Orthodontist Treating Facial and Dental Irregularities

Orthodontist Treating Facial and Dental Irregularities Including Bad Bite (Malocclusions) and Straightening Teeth.

Best Orthodontist for Treating Facial and Dental Irregularities

Facial and Dental Irregularities Including Bad Bite (Malocclusions) and Straightening Teeth

Terminologies Related to Orthodontology

Orthodontics is the field of dentistry that specializes in the diagnosis, prevention, and treatment of dental and facial irregularities (anomalies – dental and skeleton). Terms used to describe the position of teeth: • Mesioversion: A tooth in the arch more mesial than normal • Distoversion: A tooth in the arch located more distal than normal • Labioversion: An incisor or canine outside of arch towards the lips • Buccoversion: A posterior tooth outside the arch toward the cheek • Linguoversion: A tooth inside the arch from toward the tongue. • Infraversion: A tooth that has not erupted to the occlusal plane. • Supraversion: A tooth that has over-erupted • Torsiversion: A tooth rotated on its axis • Transversion (Transposition): Teeth that are in the wrong s


Malocclusion is a misalignment or incorrect relation between the teeth of the two dental arches when they approach each other as the jaws close. The term malocclusion was coined by Edward H Angle, the father of modern orthodontics. Malocclusion can also be defined as a condition that reflects an expression of normal biologic variability in the way the maxilla and mandible teeth occlude (BISHARA) or as defined by Walther & Huston as an occlusion in which there is a malrelationship between the arches in any of the planes of the spaces or in which there are anomalies in tooth position beyond the limit of normal. The World Health Organization (1987), had included malocclusion under the heading of Handicapping Dento Facial Anomaly, defined as an anomaly which causes disfigurement or which impedes function, and requiring treatment “if the disfigurement or functional defect was likely to be an obstacle to the patient’s physical or emotional well-being.”

Types of Malocclusion

Intra-Arch Malocclusion: It includes variations in individual tooth position or a group of teeth within an arch. Intra-arch malocclusions include abnormal inclination, abnormal displacement and spacing and crowding within the same arch. Inter-arch malocclusion: It comprises of malrelationship between two teeth or group of teeth of one arch to another arch. Inter-arch malocclusions can occur in the following planes; Sagittal plane, vertical plane and transverse plane of space. Sagittal Plane: This includes conditions where the upper and lower arches are abnormally related to each other in a sagittal plane. • Pre-normal occlusions: This is a condition where the lower arch is more forwardly placed when the patient bites in centric occlusion. • Post-normal occlusions: This is a condition where the lower arch is more distally placed when the patients bite in centric occlusion.

Classifications of Maloclussions

Major Classification for Malocclusion.

Vertical Plane: Includes conditions where an abnormal vertical relationship exists between the teeth of the upper and lower arch. These malocclusions include deep bite and open bite. • Deep bite: It is a condition where there is excessive vertical overlap between the upper and lower anterior. • Open bite: This is a condition where there is no vertical overlap between the maxillary and mandibular anterior teeth. Thus, space may appear between the upper and lower arch when the patient bites in centric occlusion. It can either be in the anterior or posterior region. Transverse Plane: This includes the abnormal transverse relationship between the upper and lower arches. Includes the various types of crossbites. Skeletal Malocclusions: They are the malrelations of apical bases of upper and lower arch. This can be due to the following reasons: • Abnormal relation to each other. • Abnormal relation to the skull. • Abnormal size and shape

Benefits of Malocclusion Classification

• To acquire a better understanding of the many deviations from normal occlusion. • Simplify the wide range into small groups. • Give a clue about the etiology. • Assist in the diagnosis and the selection of treatment modalities for the patient. • Assist in visualizing and understanding the problem associated with malocclusion. • Help in communicating the problem. • The similarities and differences of the various malocclusion are made easy by classification. Etiological Classification of malocclusion. There are three broad classifications of etiology of malocclusion. They are: • Moyer’s classification • White and Gardiner’s classification. • Graber’s classification

Moyer’s Classification

Heredity Neuromuscular system Bone Teeth Soft parts Development defects of unknown origin Prenatal trauma and birth injuries Postnatal trauma Physical agents. Nature of food Premature extraction of primary teeth. Thumb sucking and finger sucking. Tongue thrusting. Lip sucking and lip biting. Posture Nail biting. Prolonged use of a pacifier. Prolonged bottle feeding. Other habits Systemic diseases. Endocrine disorders. Local diseases

White and Gardiner’s Classification

Dental base abnormalities. Antero-posterior malrelationship. Vertical malrelationship Lateral malrelationship. The disproportion of size between teeth and basal Congenital abnormalities Pre-eruption abnormalities. Abnormalities in the position of developing tooth germ. Missing teeth. Supernumerary teeth and teeth abnormal in form. Prolonged retention of deciduous teeth. Large labial frenum. Traumatic injury Post-eruption abnormalities. Premature loss of deciduous teeth. Extraction of permanent teeth. Muscular Active muscle force The rest position of musculature. Sucking habits Abnormalities in the path of closure.

Graber’s Classification

General factors. Congenital: These may early development of the mandibles and teeth, causing malocclusion. These include birth injuries, clefts, teratogenic effects of drugs on fetus etc. Pre-natal (trauma, maternal diet, German measles, maternal metabolism, etc.) Post-natal (birth injury, cerebral palsy, Pre-disposing metabolic climate and disease Dietary problems (nutritional deficiency) Abnormal pressure habits and functional aberrations. Abnormal sucking Thumb and finger sucking Tongue thrust and tongue sucking. Lip and nail-biting Abnormal swallowing habits (improper deglutition) Speech defects Trauma and accidents

Local Risk factors of Malocclusion

Anomalies of some teeth: Supernumerary teeth, Missing teeth (congenital absence or loss due to accidents, caries, etc.). Anomalies of tooth size. Abnormal labial frenum: mucosal barriers. Anomalies of tooth shape. Premature loss of deciduous teeth. Prolonged retention of deciduous teeth. Failure of teeth to erupt. Delayed eruption of permanent teeth. Abnormal eruptive path Ankylosis Dental caries Improper dental restoration. Misplaced teeth are causing the abnormal path of closure.

Malocclusion Classifications

Common Malocclusion Classifications

Angle classification Dewey’s modification of Angles classification Lischer’s modification of Angles classification Simon’s classification Bennett’s classification Ackerman-Profit system of classification Ballard’s incisor classification Katz premolar classification Newly proposed system

Angle Classification The first classification of malocclusion was first published in 1890 by Edward H. Angle. The classifications are based on the relationship of the mesiobuccal cusp of the maxillary first molar and the buccal groove of the mandibular first molar. Edward Angle, who is considered the father of modern orthodontics, believed that the anteroposterior dental base relationship could be evaluated reliably from the first permanent molar relationship, as its position remained constant following eruption. In the case where the first molars of either the mandible and maxillary were missing, the canine relationship is used. Normal Occlusion. According to the Angle’s classification, the mesiobuccal cusp of the maxillary first molar is aligned with the buccal groove of the mandibular first molar. Based on the canine relationship, the maxillary canine occludes with the distal half of the mandibular canine and the mesial half of the mandibular first premolar. Importance of normal occlusion includes mastication, speech, appearance, and stability. Six keys to normal occlusion were put forward by Andrews in 1970, after studying models of 120 patients with ideal occlusion. The six keys include: Molar inter-arch relationship Mesio-distal crown relationship Labio-lingual crown inclination Absence of rotation Tight contacts The curve of Spee. Class 1 Malocclusion. In class, I malocclusion (Neutrocclusion), the mesiobuccal cusp of the maxillary first permanent molar occludes with the mesiobuccal groove of the mandibular first permanent molar. Class II Malocclusion. The distobuccal cusp of the maxillary first molar lies within the buccal groove of a mandibular first molar. Class II Malocclusion has 2 divisions to describe the position of anterior teeth; Division I and Division II. Class II Division 1 There are proclined upper incisors. Presence of abnormal muscle activity. There are disproportionate overjet and deep overbite. The mandible may be deficient and chin underdeveloped. V-shaped upper arch, narrow in the canine region and broad between the molars. Short upper lip with failure in the anterior lip seal. The muscle imbalance is as a result of a hyperactive buccinator and mentalis muscle and an altered tongue. that accentuates the narrowing of the upper dental arch. Class II Division 2 The upper incisors teeth showed lingual inclination and may be overlapped by the superior lateral incisor’s teeth. Deep overbite. The upper arch usually broad. Normal upper lip and lip seal, with the deep mental groove. The mandible is of normal size. Class III Malocclusion A malocclusion where the molar relationship shows the mesiobuccal cusp of the maxillary first permanent molar occludes posteriorly (distally) to the mesiobuccal groove of the mandibular first molar. The line of occlusion is not indicated but irregular, depending on the facial pattern, overcrowded teeth and space needs. This class can be further classified into two division; True class III (skeletal) and Pseudo class III (false or postural). True class III (skeletal): This class is of genetic origin and is due to: Disproportionate large mandible Anteriorly placed mandible. Smaller than the normal Retro positioned maxilla Pseudo-class III: It occurs as a result of anterior movement of the mandible during jaw closure, thus also known as postural or habitual class III malocclusion. It can be due to the following causes Presence of occlusal prematurity which may deflect the mandible anteriorly. Premature loss of deciduous posteriors A child with enlarged adenoids. Prevalence of Malocclusion in Angle’s Classification Class I normal occlusion: 30%. Class I malocclusion: 50-55%. Class II malocclusion: 15% Class II malocclusion: 15%. Class III malocclusion < 1%. More class II in whites and more class III in Asians. Class III and open bite are more frequent in African than European populations Advantages of Angle’s Classification It is widely used for educational purpose. It requires no instrumentation. An easy and practical method. Easy to communicate. Disadvantages of Angle’s Classification Angle classified malocclusion only in the anterior and posterior plane, and not in the transverse and vertical plane. He considered the first permanent molars as focal points in the skull which was not found so. The classification cannot be applied, if the first molars were to be extracted or missing. The classification cannot be applied to deciduous dentition. Angle’s classification does not highlight the etiology of malocclusion. The classification cannot differentiate between skeletal and dental malocclusions. Individual tooth malposition was not considered in Angle’s classification. Dewey’s Modification of Angle’s Classification. Dewey’s modification of Angle’s divided class I into five subtypes and class III into three subtypes. Class I modification: Type 1: Class I malocclusion with bunched or crowded anterior teeth Type 2: Class I with protrusive maxillary incisors. Type 3: Class I malocclusion with anterior crossbite Type 4: Cass I molar relation with posterior crossbite. Type 5: The permanent molar is positioned mesially due to the early extraction of a second deciduous molar or second premolar. Class III modification: Type 1: The upper and lower dental arches when viewed separately are in normal alignment. But when the arches are made to occlude the patient shows an edge to edge incisor alignment, suggestive of forwarding movement of the mandible. Type 2: The mandibular incisors are crowded and are in lingual relation to the maxillary incisors. Type 3: The maxillary incisors are crowded and are in crossbite about mandibular anterior Lischer’s Modification of Angle’s Classification. Neutrocclusion: This is the same as Angle’s class I malocclusion Distocclusion: This is the same as Angle’s class II malocclusion. Mesiocclusion: Same as Angle’s class III malocclusion. Buccocclusion: Known as the buccal placement of a tooth or group of teeth. Linguocclusion: lingual placement of a tooth or a group of a tooth or a group of teeth Supraocclusion: when a tooth or group of teeth have erupted beyond the normal level. Infraocclusion: when a tooth or group of teeth have not erupted to a normal level Mesioversion: mesial to the normal position Distoversion: Distal to the normal position Transversion: Transposition of two teeth Axiversion: Abnormal axial inclination of a tooth Torsiversion: Rotation of a tooth around its long axis Simmon’s Classification. The Simmon’s classification is a craniometric form of classification. This classification was based on abnormal deviations of dental arches from their normal position concerning three planes, i.e., the Frankfort horizontal plane, the orbital plane, and the midsagittal plane. The Frankfort horizontal plane or eye-ear-plane: This plane is used to classify malocclusions in the vertical plane. It connects the margin of the external auditory meatus to the infra-orbital margin. When the dental arch or part of it is closer than normal to Frankfort plane, it is called attraction. When the dental arch or part of it is farther away from the Frankfort plane, it is called abstraction. Raphe median or midsagittal plane: This plane is used to describe malocclusion in the transverse direction. When a part or whole of the arch is far from the plane, it is known as distraction. If the dental arch is closer to the plane, it is known as a contraction. Orbital plane: This plane lies perpendicular to the Frankfort plane, dropped down from the bony margins of the orbital bone, directly under the pupil of the eye. According to Simon, the orbital plane should pass through the distal third of the upper canine, also known as Simon’s law of canine. The orbital plane is also used to describe malocclusion in a sagittal or anteroposterior direction. When the dental arch or part of it is directed away from the orbital plane, it is known as protraction. If the dental arch is closer or placed more posteriorly to this plane, it is called retraction. Bennetts Classification Bennett’s classification is based on etiology. Class I describes the abnormal position of one or more teeth due to local factors. Class II: It is the abnormal formation of a whole or part of an arch due to developmental defects of bone. Class III defines the abnormal relationship between upper and lower arches, and between either arch and facial contour and correlated abnormal formation of either arch. Ackerman-Profit System of Classification. The Ackerman and Profit classification were proposed in 1960 to address the limitations of Angle’s classification. This system includes Angle’s classification and five characteristics of malocclusion within a Venn diagram. Salient features of Ackerman-Profit system include: It is classified based on five characteristics Alignment Transverse relationship. Profile Class Bite depth (Vertical plane) Incision protrusion is taken into consideration The transverse and vertical discrepancies can be considered in addition to the anteroposterior malrelations. The influence of dentition on the profile. Crowding and Arch asymmetry can be evaluated. Advantages of Ackerman and Profit classification. Explained the different complexities of malocclusion The profile of the patient is given Differentiation between skeletal and dental problems are made All the three-dimensional problems are evaluated Aids incomplete diagnosis and treatment planning. The arch length problems are evaluated. Disadvantages of Ackerman and Profit Classification This classification is based on static occlusion only Etiological factors are not taken into consideration. Ballard’s Classification A classification of malocclusion based on an incisor. Treatment is often primarily aimed at correcting this relationship. Based on the incisors, it is grouped into class I incisor, class II incisor and class III incisor. Katz Premolar Classification. Katz classification is grouped into three divisions, namely; Premolar class I, Premolar class II and Premolar class III. Premolar class I: The most anterior upper premolar fits exactly into the embrasure created by distal contact of most anterior lower premolar Premolar class II: The most anterior upper premolar is occluding mesial of the embrasure created by the distal contact of the most anterior lower premolar Premolar class III: The most anterior upper premolar is occluding distal of the embrasure created by the distal contact of the most anterior lower premolar. The measurement has a (-) sign Advantages This classification system provides a quantitative treatment objective that is required to attain a perfect buccal occlusion. In cases of deciduous and mixed dentition, emphasis shifts from the permanent first molars to the region of utmost importance e. deciduous molar region. This system offers some flexibility regarding finishing a case in functional class II or class III buccal occlusion, at the same time, keeping buccal interdigitation as the prime goal. Disadvantage There is no consideration for aesthetics and facial balance. Measurement is not possible if the premolars are missing, malformed or supernumerary. Severely rotated and ectopically erupted premolars conditions. Orthodontic Treatment. The number of adult patients receiving orthodontic treatment is increasing daily all over the world. Many patients seeking treatment are dissatisfied with either the appearance of their teeth or their ability to chew or a combination of both. Depending on the differences in the size of teeth or possible jaw imbalances, treatment options include: Braces Braces are comprised of brackets that are affixed to teeth and wires that are passed through slots in the brackets. They are used to correct “bad bites” or malocclusion. Clear Aligners Aligners are transparent, thin, plastic-like trays, designed to fit an individual’s teeth. Users are responsible for wearing and removing their aligners. The number of aligners needed to correct bad bites or misaligned teeth depends on the patient’s orthodontic profile and its correction. Retainers Retainers are used to allow the newly formed bone to harden around the teeth. There are two types of retainers, removable and fixed retainers. Both types of retainers keep teeth in their new positions after an “active” orthodontic treatment is completed. Elastics Elastics are tiny rubber bands that provide extra force to a tooth or teeth in ways that braces alone cannot help so that teeth move into their ideal positions. The configuration of the elastics can be vertical or diagonal, depending on the individual’s need. Patients are responsible for placing and removing their elastics In more complex cases, especially in adults, treatment may require a combination of dental braces and surgery. Surgery should not be an option for malocclusion treatment, but when treatment is delayed beyond the time when growth modification is possible, surgery is often the only possible solution. Advantages of Early Orthodontic Treatment Easy cooperation between children and young patients. Reduced risk of periodontal trauma (crossbites and guiding eruption into attached gingiva). Reduced risk of tooth trauma (protruded teeth) Growth modification (sagittal, transverse, asymmetric jaw growth). References Abdulnabi, Y., Albogha, M., Abuhamed, H., & Kaddah, A. (2017). Non-surgical treatment of anterior open bite using miniscrew implants with posterior bite plate. Orthodontic Waves, 76(1), 40-45. doi: 10.1016/j.odw.2016.11.006 Millett, D., Cunningham, S., O’Brien, K., Benson, P., & de Oliveira, C. (2018). Orthodontic treatment for a deep bite and retroclined upper front teeth in children. Cochrane Database Of Systematic Reviews. doi: 10.1002/14651858.cd005972.pub4 Minato, M., Kataoka, T., Fujiki, T., Yamashiro, T., & Takano-Yamamoto, T. (2007). Orthodontic treatment of an open bite case with congenitally missing teeth using premolar autotransplantation. Orthodontic Waves, 66(3), 99-105. doi: 10.1016/j.odw.2007.06.004 Shrestha, R. (2018). Deep Bite in Orthodontics. Orthodontic Journal Of Nepal, 7(2), 62. doi: 10.3126/ojn.v7i2.20173