The characteristics of malocclusion ;

a modern approach to classification

and diagnosis

Ackerman proffit 1969

history
As early as 18th century system to classify
malocclusions started
John hunter, carabelli were first to
describe jaw abnormalities
Edge to edge, overbite ,these terms are
taken from carabelli system of
classification
Lefoulon of france coined the term
orthodontics
Angles system of classification came in
20th century
Mb cusp of max first molar relation to
mandibular 1st molar
It is still most commonly used’
It has many drawbacks ..CALVIN CASE..
Was critic of angles system of classification
Drawback of angles system
Angles system considered only anterio-
posterior relationship of jaws ,,, but it is a
3D phenomenon
Angle does not considered the teeth
relation to the face
Angle does not recognized difference
between malocclusion with same
distomesial relationship
Angle does not included the diagnosis
history
Norman in 1912 told that we should
classify malocclusion in all 3 planes
because it is a 3d phenomena ,, , but the
British society of orthodontics rejected his
thought
Simon later on followed thought of
Newman and formed gnathostatic model
and classified malocclusion in 3 planes
Analogous and homologous malocclusion

Analogous malocclusion….having only the

same mesiodistal molar relation same other
characteristics are different
Homologous malocclusion…..having all
characteristics same
We can treat all homologous malocclusion with
same treatment plan
But we can not treat all analogous malocclusion
with same treatment plan
Example …class 2 div 1 and div II
Angles system did not tell how complex is
the problem
But still used because of its simplicity
And because most of the orthodontic
referral cases generally have anterior
posterior discrepancy
To overcome the drawbacks and to
complete the angles classification
ackerman and proffit developed a system
of classification
They used
Angles classification + venn diagram
5 groups considered in venn diagram
1st alignment and symmetry
2nd profile
3rd lateral /transverse/buccolingual
4th saggital/antero-posterior
5th vertical descrepancies
conclusion
Method based on 5 descriptive characteristics
and defining 9 groups of malocclusion
overcomes the drawbacks of angles system of
classification
Influence of dentition on profile is considered
All 3 planes are considered
According to author this classification is better
for communication between orthodontists and
help in better treatment planning
Treatment response as an aid in diagnosis
and treatment planning
As cephalometrics is evolving and
various new techniques are evalving basic
objective of orthodontics is getting
blurred and more rigid treatment plan are
framed
Before treatment planning we should
know what we have to treat and what are
the goal we have to achieve
objective
According to author we have to achieve
Optimal proximal contact
Optimal occlusal contact
With acceptable facial esthetics , function, with
reasonable stability

There is nothing called as IDEAL in nature

therefore we should use words optimal ,
acceptable, normal when talking about goal to
achieve
Functional esthetics and stability go
together?
Auther contradicted the above statement
and told we can achieve functional
stability and esthetics with or without
each other
When we extract 2nd premolar and close space there is
unavoidable marginal discrepancy between 1st molar and 1st pm.

We cant achieve ideal….we can achieve optimal…

reasonable,,,, acceptable

There is no place for rigidity in treatment plan in orthodontics

which focus on achieving ideal

Some orthodontic systems based on cephalometric are

suggesting rigid treatment plans and they are not successful
ever time in achieving it
We should keep space for uncertainty in treatment plan
Why space for uncertainty in treatment
plan?
Because in most of the cases in orthodontics we do
not know the etiology or cause of the problem..

Ifwe are uncertain about the etiology how can we

be certain about the treatment results and get
perfect results

Whether malocclusion is due to genetic influence

on jaw morphology or due to neuromuscular
influence on jaw relation ship treatment is
same……but results may not be same
 Therapeutic diagnosis
Here author says that we can use
treatment response as a diagnostic criteria
if we are not certain about itiology
Diagnosis
confermed
Initial Results are
diagnosis is observed
made

Initial diagnosis
is wrong
 Example

Thmb Correction of
Anterior Correct
sucking open bite
openbite diagnosis
habbit
braking
appliance
given

No result

Another cause is
suspected ex
Tongue thurst
All interceptive procedures in orthodontics use therapeutic
diagnosis method

If
tongue guard, lip bumper are successful in treating
malocclusion .initial diagnosis is confirmed

This shows id diagnosis is uncertain results cant be certain

therefore there is allways a room for error in orthodontics

Author says that we should use this therapeutic diagnosis

knowledge to identify correct diagnosis in future because
therapeutic diagnosis is not a substitute for established diagnosis
Extract or not to extract
To satisfy acceptable esthetics and reasonable
stability one extracts the teeth
Calvin case 1907 told no matter how badly
teeth are mal aligned they can be made to align
in normal place in dental arch
So malalignment should not be the basis of
extractions

But if alignment is causing facial protrusion and

bad esthetics then we can extract a teeth
Some say that if we treat malpoistioned
teeth without extraction stability would
not be there..
But in how many extraction cases doctor
can say with assurance that after
extraction stability would be there … 50
percent
Growth prediction
In growing children growth prediction is
considered in treatment planning and growth
changes are necessary to obtain an optimal
treatment result.
Precise prediction of growth is not possible
therfore scope of error is allways there
Soft tissues,chin,nose,eruption of incisor in
anterio-posterior direction all can show various
variations which we can not predict…therefore
end result we cant be 100 percent sure.
Ex.
Early class III cases keep on growing
even after completion of treatment
Even simple cases show relapse after some
time
According to author Since we are nit sure
about the future results we should see the
treatment response as a tool
Ex
classII div 1 case
If we give functional appliance
.headgears and harness growth…..if
results are positive we should modify
growth.
If results are not positive then we should
go for other methods and may go for
extractions to get class I relationship
 Patient factor
in borderline cases evaluation of response to treatment can begin with the very
first phase of treatment.

While applying separators in a “crowded” case, one can determine whether all of
the contacts are tight.

Do most of the separators stay in, or do they fall out in a few days because
ofsufficient space between the teeth?

 How sore do the teeth get from the separators?

When one fits the bands, how difficult is it to seat all of the bands?

When one is working in the patient’s mouth, how tight is the labial and buccal
musculature?
Does the tongue protrude over the teeth?
demonstrate significant tooth-size discrepancies between the right and left
sides? During the seating of bands, how hard can the patient bite?

At the next visit one can check the patient’s oral hygiene. One can also observe

whether the patient deformed the arch wires and whether he is a grinder
or clencher.

This can often be determined from wear facets on the lingual

surfaces of the maxillary anterior bands.

 All these factors are likely to influence the course of treatment.

From this frame of reference, much of orthodontic treatment is based on a

type of therapeutic diagnosis.

 Ifa case is treated successfully (occlusally and

facially) without extractions and remains stable, we assume that a correct
decision was made and that some of the causes of the problem were also eliminated
If non extraction case is proceeding with
difficulty, adversely affecting facial esthetics then
we can think that extraction might resolve the
problem,
When extraction cases are selected on this basis
results are more stable and
successful…..extraction spaces fill rapidly in such
cases and esthetics are very well improved
We can even decide extract or not to extract teeth
after the initial alignment and leveling, if in
doubt
conclusion
A definitive treatment plan can be formed
only after a definitive diagnosis is made. In
many orthodontic problem it is not possible
to make a definitive diagnosis.then
thereputic diagnosis can be helpful as a tool
to find out proper diagnosis
As proper diagnosis is one obtained then we
can think of acceptable facial
esthetics,normal function,and reasonable
stability