Postgraduate Notes in Orthodontics-1-49

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Postgraduate Notes in .O rthodont ics DDS/MOrth Programme
These notes w ere orig inally compiled during t he fi rst MSc/MOrth Programme in Orthodont ics at t he
Univers ity of Bristo l and subseq uent ly revised in 2000, 200 2, 2005, 2008, 201 1, 2014 and 2017.
The ma in ed it ing and organ isation of t he Eight h Ed it io n w as by: Nikk i Atack
First Ed ition w ritte n by:
Nikki Atack Jonath an Sa ndy Sarah Turner
Clare Nattrass Peter Thomas
Second Edit ion re vised and updated by :
Nikki Atack Rhu McKelvey Helen Travass
Tom Hartridg e Riz Parb atani Paul Will iams
Ingrid Hosein Francis Scriven
Sanj ay Kum ar Alex Sporleder
Th ird Ed ition revised and updated by :
Nikki Atack Riz Pa rbatani Helen Travass
Ingrid Hose in Francis Scriven
Fourth Edit ion re vised and updated by :
Nikki Atack Lisa Hich ens Siti Othman
Anton ia Burgess Kate House Heidi Rowland
Matthew Clare Ann alise McN air Kath erin e Templeton
Fifth Ed it ion revi sed and updated by :
Joe Alcock Matt Clover Clare McNamara
Sa ud Al-An ezi Scott Deacon Brian Mu lgrew
Nikki Atack Tony Ireland Jonath an Sa ndy
Sinaed Ba rlow Nicky Johnston Hemendranath V Shah
Sixth Ed it io n revised and updated by :
An sa Akram Scott Deacon Mah Eng Ch ing
Nikki Atack Ba rry Hickey Jonath an Sa ndy
Chris Ba rker Kate Hou se Hemendranath V Shah
Ourvinder Chawla Tony Ireland Goldie Songra
Mich ael Dawson Clare McN amara Ju lia Scott
Seventh Ed it ion revi sed and updated by :
Ahm ed Abdu llah Kate Hou se Clare McN amara
Rana Al-G hatam Tony Ireland Hywel Naish
Nikki Atack Tim Jones Jonath an Sa ndy
Colin Chambers Jason Math aru Ju lie Williams
Eighth Ed it ion revised and updated by:
Cath erine And erson Cheong Joo Ming Joshua Robin son
Nikki Atack Yasmin Kamarud in Jonath an Sa ndy
Sukhraj Sin gh Grewal Ta ra Lee Gregory Souster
Kate Hou se Emma Mccartan Stefa nie Ta n
Tony Ireland Tarun Mittal
In addition , the fo llowing have made he lpfu l contributions and comments:
Basheer Ahmed , Christine Ashdown, Choo Soo Ching , Joanne Davi es, Neil Davey, Ph il Eden , Pau l
Ewings , Kate Garrett, Ian Hutch inson, Nico la Johnson, John Kerrigan, Helen Leach, Joseph McG ill,
Thomas Megerle, Martyn Sherriff and Jane Western .
©Child Dental Health Department, Bristol Dental Hospital , 2018
All rights rese rved, no part of the pub lication may be reproduced, stored in a retrieval system, or
transmitted , in any fo rm orb y any means, electronic, mech anica l, photocopied, recorded and/or
otherwi se, without the prior written perm ission of the publishers.
Pub lished by the Child Denta l Health Department, Bristol Denta l School, University of Bristo l.
First Edition 1998 Third Edition 2002 Fifth Edition 2009 Seventh Edition 201 5
Second Edition 2000 Fourth Edition 2005 Sixth Edition 201 2 Eighth Edition 201 8
ISBN: 978-0-9562712-3-5
Address for correspondence: Miss Nikk i Atack, Division of Child Denta l Health, University of Bristol Dental
School, Lower Maudlin Street, Bristo l, BS1 2L Y, United Kingdom
e-mail: nikk i. atack@bri sto l. ac.uk
Forward
It is a pleasure to once again introduce the latest edition of the Postgraduate Notes in
Orthodontics. This 81h edition includes some new chapters and has undergone a re-structuring
which is intended to improve the 'flow' for the reader. It is twenty years since the first edition was
published which started from humble beginnings as a way to fill the final three months of the first
MSc/MOrth postgraduate orthodontic course in Bristol. It is not as concise as originally intended
but as orthodontics evolves so does the book reflecting the changing face of our specialty.
Once again I would like to thank all the Bristol postgraduate students and staff who work hard to
keep the text current and relevant. The book's continued popularity is a testament both to the
usefulness and the hard work that is involved in the updating process.
Thank you for your continued support and I hope you continue to find the book helpful. It is
heartening to hear that it continues to be widely used both in the UK and abroad as an adjunct to
the teaching of postgraduate orthodontics.
Nikki Atack
September 2018
1
z
Contents 3
Abbreviations 6
Abbreviations for Journals 7
Useful Website Links 8
Introduction 9
What is Orthodontics? 10
Occlusion and Malocclusion 11

Occlusion 12
Development of the Occlusion 14
Malocclusion 15
Class I Malocclusions 17
Class 11/1 Malocclusions 19
Class 11/2 Malocclusions 21
Class Ill Malocclusions 24
Bimaxillary Proclination 28
Anterior Open Bite (AOB) 30
High Angle Cases 33
Deep Bites 35
Low Angle Cases 37
Asymmetries 39
Growth 43
Embryology 44
Growth Control and Growth Centres 47
Growth Rotations 50
Growth and its Relevance to Orthodontics 52
Craniofacial Syndromes 58
Clefts 61
Hypodontia 70
Impacted Upper Canines 75
Supernumeraries 80
Unerupted Permanent Incisor 83
Transpositions 85
Double Teeth 88
3
Primary Failure of Eruption 90
Ectopic Eruption of Permanent First Molars 92
Molar-Incisor Hypomineralisation (MIH) 95
lnfraocclusion of Primary Teeth 96
Aids to Diagnosis 99
Cephalometrics 100
Imaging 105
Space Analysis 108
Indices 112
lnterceptive Orthodontics 119

lnterceptive Orthodontics 120
Timing of lnterceptive Orthodontic Treatment 122
First Molars of Poor Prognosis 126
Early Loss of Primary Teeth 129
Early Treatment of Crossbites 131
Loss of Permanent Incisor 133
Treatment 1
Bone Metabolism 136
Tooth Movement 142
Anchorage 147
Extraction versus Non-Extraction 150
Extractions and Facial Profile 152
Extraction of Specific Teeth 155
Removable Appliances 161
Fixed Appliances 163
Headgear 167
Reverse (Protraction) Headgear 170
Alternative Methods for Anchorage Support and Molar Distalisation 172
Temporary Anchorage Devices (TADS) 176
Functional Appliances 180
Arch Lengthening (Anteroposterior Expansion) and Lateral Expansion 187
Correction of Skeletal Maxillary Transverse Arch Deficiency 191
Adult Orthodontics 195
Orthognathic Surgery 199
Distraction Osteogenesis 205
Archform 208
Retention 211
4
Relapse and Stability 215
Risks
Iatrogenic/Deleterious Effects of Orthodontic Treatment 222

Intra-oral Iatrogenic Damage 223
Extra-oral Iatrogenic Damage 235
Systemic Effects of Treatment ,, 237
Pain and Orthodontics 239
Periodontal Problems Related to Wear of Appliances 244
Trauma and Orthodontics 248
Risk Benefit 251
Medicolegal Aspects of Practice 256
Materials 261
Friction 262
Brackets 265
Archwires 270
Adhesives & Cements 275
Force Delivery Systems 280
Research Aspects 283

Statistics 284
Research Methodology 289
Clinical Effectiveness (Clinical Audit) 295
Clinical Governance 296
Miscellaneous 297
Temporo-Mandibular Dysfunction 298
Radiation Safety 302
Obstructive Sleep Apnoea (OSA) 304
Relevant Medical Disorders 307
Chronology of Tooth Development 314
Question and Answer Section 315
5
AFH Anterior face height
AOB Anterior open bite
AP Anteroposterior
CL Cleft lip
Cl 11/1 Class II division 1
Cl 11/2 Class II division 2
Cl Ill Class Ill
CLP Cleft lip and palate
CP Cleft palate
FA Fixed appliance
HG Headgear
LLS Lower labial segment
Mand Mandible
Max Maxilla
MMP Maxillary-mandibular plane
MnP Mandibular plane
mths Months
MxP Maxillary plane
NiTi Nickel titanium
OB Overbite
OJ Overjet
Pt Patient
PFH Posterior face height
RIG Radiographs
RCT Randomised Controlled Trial
Sk Skeletal
SM Study model
SS Stainless steel
TB Twin block
TMA Titanium Molybdenum Alloy
TMD Temporomandibular dysfunction
ULS Upper labial seglT!ent
URA Upper removable appliance
Xtn Extraction
Yr/yrs Year/Years
~ Leads to/causes/results in
t Increases
-1, Decreases/reduce
6
Journal Abbreviation
Acta Odontologica Scandinavica Acta Odonto Scand

American Journal of Orthodontics AJO
American Journal of Orthodontics Dentofacial Orthopaedics AJODO
Annals of the Royal College of Surgeons of England Ann RCSEng

Angle Orthodontist AO
Australian Dental Journal Aust Dent J
British Dental Journal BDJ

i
_BritiSh Journal of Orthodontics BJO
British Journal of Plastic Surgery Br J Plas Surg
Cleft Palate Journal CPJ
Cleft Palate Craniofacial Journal CPCJ
Dental Practice Dent Prac
Dental Update Dent Update

European Journal of Orthodontics EJO
Evidence Based Dentistry Evid Based Dent
Faculty Dental Journal FDJ
International Orthodontics 10
International Journal of Adult Orthodontics and Orthognathic Surgery IJAOOS

International Journal of Paediatric Dentistry Int J Paediatr Dent
Journal of the American Dental Association JADA
Journal of Clinical Orthodontics JCO
Journal of Clinical Periodontology J Clin Peria

Journal of Dentistry J Dent
Journal of Dental Research J Dent Res
Journal of Maxillofacial Surgery J Maxillofac Surg
Journal of Orthodontics JO
Journal of Paedodontics J Paedo
Journal of Periodontology J Peria
Journal of Oral Surgery J Oral Surg
Oral Surgery, Oral Medicine, Oral Pathology Oral Surg, Oral Med, Oral Path
Orthodontic Update Ortho Update

Orthodonitcs & Craniofacial Research Ortho & Cranio Res
Scandanavian Journal of Dental Research Scand J Dent Res
Transactions of the European Orthodontic Society TEOS
7
British Orthodontic Society Website www.bos.org.uk
Cochrane Reviews www.cochrane.org/reviews
Department of Health www.dh.gov.uk
Healthcare Quality Improvement Partner (HQIP) www.hqip.org.uk
Nice www.nice.org.uk
Royal College of Surgeons www.rcseng.ac.uk
8
What is Orthodontics?
9
Orthodontics The branch of dentistry which is concerned with facial growth, Mitchell et al., 2007
the development of the occlusion and dentition and with the
diagnosis, interception and correction of dentofacial
anomalies and craniofacial malformations
Definition " from the Greek:
- Orth( o) = straight, true, correct
- Odontic =tooth, teeth
Occlusion " arrangement and position of teeth with upper and lower
teeth in contact in their usual position
Normal occlusion " occlusion within accepted deviation of the ideal and does Houston et al., 1992
not constitute aesthetic or functional problems
Malocclusion " tooth position or jaw position outside normal range
First description .. precise timing unknown

of malocclusion " ancient Greeks were describing irregularities of the teeth
as long ago as 400BC
First description " the Romans, notably Celsus, described the use of finger
of orthdontic pressure to move teeth
treatment
Earliest fixed .. Fauchard's Bandeau of 1726, a metallic arch tied to the
appliance labial/buccal surfaces of the teeth using fibrous ligatures
Start of 'Modern- Developed by Edward Angle:
day' orthodontics .. E-Arch (1900)
.. Pin & Tube (1910)
.. Ribbon arch (1915)
., Edgewise appliance (1925)
Developed by Raymond Begg:
.. Begg Appliance (1950)
Developed by Laurence Andrews:
.. Preadjusted Edgewise or Straightwire™ appliance (1972)
References
Houston WJB et al., 1992, A Textbook of Orthodontics, Great Britain: Wright, pp. 1-13
Mitchell Let al., 2007, An Introduction to Orthodontics, 3rct Edition, Oxford University Press, pp. 2
10
M
Occlusion
Development of the Occlusion
Malocclusion
Class I Malocclusion
Class 1111 Malocclusion
Class 1112 Malocclusion
Class Ill Malocclusion
Bimaxillary Proclination
Anterior Open Bite. (AOB)
High Angle Cases
Deep Bites
Low Angle Cases
Asymmetries
11
Normal occlusion Occlusion within accepted deviation of the ideal and does not Houston et al., 1992
constitute aesthetic or functional problems
Static occlusion Andrews 6 Keys based on 120 non-orthodontic normals: Andrews, 1972
.. correct molar relationship
.. correct crown angulation
.. correct crown inclination
.. ·tight interproximal contacts
.. absence of rotations
" flat occlusal plane
Ideal molar relationship as described by Andrews
.. distal surface of the distal marginal ridge of§. contacts
and occludes with the mesial surface of the mesial
marginal ridge of the lower 7
Bennett and McLaughlin's 7th key Bennett &
" correct tooth size Mclaughlin, 1993
In practice, orthodontically treated occlusions seldom achieve Kattner & Schneider,
all occlusal keys 1993
Functional 'Ideal' functional occlusion
occlusion " features not conclusively established Clark & Evans, 2001
.. post-orthodontic pts did not exhibit ideal occlusal Clark & Evans, 1998
relationships
Should articulators be routinely used?
.. although 13% of orthodontists in the USA routinely Utt et al., 1995
mounted pre-treatment study models, only 6.5% mounted
models at the end of treatment
.. articulation of SMs did not affect 10 orthodontists' Ellis & Benson, 2003
treatment planning decisions in a meaningful manner
Mutually protective occlusion (MPO):
- immediate but gentle disclusion of all posterior teeth in
lateral and protrusive contact with no associated non-
working side interferences
- posterior teeth protect anterior teeth in occlusion
.. alternative names are cuspid disclusion or canine
guidance
.. MPO does not convey any great advantage over other
functional occlusions
.. very few natural ideal occlusions as defined by Andrews
have an MPO
.. majority of population (91 % ) have non-working side Sadowsky & BeGole,
contacts in random samples 1980; Tipton &
Rinchuse, 1991
Should ICP coincide with retruded contact position
(RCP)?
.. general agreement that ICP should coincide with RCP,
however large disagreement as to how closely they Rinchuse, 1995
should coincide
.. potentially significant discrepancies:
- A-P discrepancy of >1.5mm Milosevic &
- lateral discrepancy of >0.5mm Samuels, 1998
.. 20% have ICP-RCP discrepancy of >2mm prior to any Egermark et al., 2003
orthodontic treatment, yet no evidence that this is harmful Utt et al., 1995
.. 40% of orthodontic pts found to have a ICP-RCP Hidaka et al., 2002
discrepancy of >2mm
" Roth attributes TMD and orthodontic relapse to a ICP- Roth, 1981
RCP discrepancy, however this is not substantiated
.. studies of post orthodontic pts have no more TMD Sadowsky & Polson,
symptoms than people with untreated malocclusions or 1984
normal occlusions
12
.. there is no link between malocclusion or functional Gesch et al., 2004
occlusion and TMD
Recommended Clark & Evans, 2001
reading
References
Andrews LF, 1972, The six keys to normal occlusion, AJO, 62;296-309
Bennett JC & McLaughlin RP, 1993, Orthodontic Treatment Mechanics and the Preadjusted Appliance,
London, Wolfe Medical Publishing
Clark JR & Evans RD, 1998, Functional occlusal relationship in a group of post orthodontic patients:
preliminary findings, EJO, 20; 102-110
Clark JR & Evans RD, 2001, Functional occlusion: A review, JO, 28;76-81
Egermark I et al., 2003, A 20 year follow-up of signs and symptoms of temporomandibular dysfunction and
malocclusions in subjects with and without orthodontic treatment in childhood, AO, 73;109-115
Ellis PE & Benson PE, 2003, Does articulating study casts make a difference to treatment planning? JO,
30;45-49
Gesch et al., 2004, Association of malocclusion and functional occlusion with signs of TMD in adults:
Results of the population-based study of health in Pomerania, AO, 74;512-520
Hidaka 0 et al., 2002, The difference in condylar position between centric relation and centric occlusion in
pretreatment Japanese orthodontic patients, AO, 72;295-301
Houston WJB et al., 1992, A Textbook of Orthodontics, Great Britain: Wright, pp.1-13
Kattner PF & Schneider BJ, 1993, Comparison of Roth appliance and standard edgewise appliance
treatment results, AJODO, 103;24-32
Milosevic A & Samuels RHA, 1998, Functional occlusion after fixed appliance orthodontic treatment: a UK
three-centre study, EJO, 20;561-568
Rinchuse DJ, 1995, A three-dimensional comparison of condylar change between centric relation and
centric occlusion using the mandibular position indicator, AJODO, 107;319-328
Roth R, 1981, Functional occlusion for the orthodontist, JCO, 15;32-51
Sadowsky C & BeGole EA, 1980, Long-term status of temporomandibular joint function and functional
occlw;;ion after orthodontic treatment, AJO, 78;201-212
Sadowsky C & Polsen AM, 1984, Temporomandibular disorders and functional occlusion after orthodontic
treatment: results of two long-term studies, AJODO, 86;386-390
Tipton RT & Rinchuse DJ, 1994, The relationship between static occlusion and functional occlusion in a
dental school population, AO, 61 ;57-66
Utt TW et al., 1995, A three-dimensional comparison of condylar position changes between centric relation
and centric occlusion using the mandibular position indicator, AJODO, 67;57-63
13
/
Stages of dental 3 recognised stages of dental occlusal development:

development .. primary dentition
" mixed dentition - the transitional phase from primary to full
permanent dentition
.. permanent dentition
Primary dentition .. usually fully erupted by the age of 2-3yrs
.. features of primary dentition:
primate spaces (50% of pts)
upper arch longer and wider than lower
OJ=2mm
OB third ht of lower incisor crown
'flush terminal plane' molars
.. a number of changes occur between the ages of 3-6yrs:
t in intercanine width
some spacing of incisors
edge-to-edge bite
'Class Ill' incisors
Mixed dentition .. transition from primary to mixed dentition begins round Fleming et al., 2008
about the age of 6yrs with the eruption of the first permanent
molars and the lower incisors
.. features of the mixed dentition:
~unit Class II molars
physiological anterior spacing e.g. midline diastema
.. occlusion accommodates the larger permanent incisors by:
permanent incisors erupting more proclined and,
therefore, on a wider arc
using the primate spaces
an t in lateral growth of the jaws
" transition from primary to permanent dentition utilises the Moyers et al., 1988
'Leeway' space, approximately 1.5mm each side in max and
2-2.5mm each side in mand
" lateral arch development occurs with the eruption of the
canines into a wider arch posiiton
Permanent " generally the permanent dentition (with the exception of third
dentition molars) is complete by the age of 14yrs
.. as a rule females reach full permanent dentition before
males
Why is it " recognising the normal Scott & Atack, 2015
important to be " spotting the abnormal
aware of normal " knowing when significant events may have happened
development? " predicting the future?
Recommended Scott & Atack, 2015
reading
References
Fleming P et al., 2008, Managing malocclusion in the mixed dentition: six keys to success. Part 1, Dent
Update, 35;607-613
Moyers RE et al., 1988, Handbook of Orthodontics, 4th Ed, Ann Arbor Michigan Year Book Medical
Publishers, pp. 127
Scott JK & Atack NE, 2015, The developing occlusion of children and young people in general practice:
when to watch and when to refer, BDJ, 218;151-156
14
Definition An appreciable deviation from normal occlusion Houston et al., 1992
Classification See section on Indices
Commonly accepted classifications:
Angle classification Angle, 1898
.. Cl I, II, Ill
Incisor classification British Standards
" Cl I Institutes, 1983
.. Cl II division 1
division 2
" Cl Ill
Aetiology " 95% of malocclusions are due to a variation of normal Proffit, 1986
(see table below) development
" 5% of malocclusions have identifiable cause
.. genetics tend to influence Sk pattern, environment Lundstrom, 1984;
influences tooth position, but both act synergistically to Dibbets, 1996
create malocclusion
Genetic influence .. Sk pattern
" some syndromes, e.g. muscular dystrophy
.. evolutionary trend to t jaw size and tooth number
.. molecular genetics of tooth morphology found MSX 1 and Mackenzie et al.,
MSX2 induces patterning in the incisor region, BARX1 1992; Sharpe,1995
and DLX2 induces patterning in the molar region
Environmental .. soft tissues - teeth in a position where there is Proffit, 1978'
influence equilibrium between forces created by the lips, tongue
and periodontal ligament (POL)
.. habits - alter resting forces on teeth Bowden, 1966
" local factors - e.g. fleshy fraenum, retained primary
tooth, missing teeth
" pathology - e.g. cleft lip and palate, lymphangioma, Mars & Houston,
odontogenic tumours 1990; Ross, 1987
.. trauma - e.g. condyle, postoperative scarring Proffit et al., 1980
.. respiration - minor influence on vertical and transverse Harvold et al., 1981;
jaw dimensions, greater effect in animals than humans; O'Ryan et al., 1982;
adenoidectomy in humans has been shown to cause a t Linder-Aronson et
in lower ant face height and a slight t in maxillary width al., 1970
Recommended Turner et al., 1997; Fleming et al., 2008
reading
AETIOLOGY OF MALOCCLUSION
HARD TISSUE SOFT TISSUE

Dental Local
Local e.g. tooth number/size/shape digit sucking
ectopic position (}) · lip habit
early/delayed loss tongue habit
frenum
General e.g. tooth size pathology e.g. scarring
extensive hypo/hyperdontia natural aging process
Skeletal General
Local e.g. alveolar insufficiency genetic - homeobox genes
lip morphology
General e.g. genetics - cranial base length, respiration
saddle angle pathology e.g. CLP, trauma
Pathology e.g. trauma
Head & neck syndromes
15
References
Angle EH, 1898, Classification of malocclusion, Dent Cosmos, 41 ;248-264
Bowden BD, 1966, A longitudinal study of the effects of digit- and dummy-sucking, AJO, 52;887-901
British Standards Institutes, 1983, Glossary of Dental Terms (BS4492) BSI London
Dibbets JMH, 1996, Morphological associations between the Angle classes, EJO, 18;111-118
Fleming PS et al., 2008, The aetiology of malocclusion: A contemporary view, Ortho Update, 1;16-21
Harvold EP et al., 1981, Primate experiments on oral respiration, AJO, 79;359-372
Houston WJB et al., 1992, A Textbook of Orthodontics, Great Britain: Wright, 1-13
Lundstrom A, 1984, Nature versus nurture in dento-facial variation, EJO, 6;77-91
Linder-Aronson Set al., 1986, Mandibular growth direction following adenoidectomy, AJODO, 89;273-284
Mackenzie A et al., 1992, Expression patterns of the homeobox gene, Hox-8, in the mouse embryo
suggest a role in specifying tooth initiation and shape, Development, 115;403-420
Mars M & Houston WJB, 1990, A preliminary study of facial growth and morphology in unoperated male
unilateral cleft lip and palate subjects over 13 yrs of age, CPJ, 27;7-10
O'Ryan FS et al., 1982, The relation between nasorespiratory function and dentofacial morphology: a
review, AJO, 80;403-410
Proffit WR et al., 1980, Early fracture of the mandibular condyles: frequently an unsuspected cause of
growth disturbances, AJO, 78;1-24
Proffit WR, 1978, Equilibrium theory revisited: factors influencing position of the teeth, AO, 48;175-186
Proffit WR, 1986, On the aetiology of malocclusion. The Northcraft lecture, 1985 presented to the British
Society for the Study of Orthodontics, Oxford, April 18, BJO, 13;1-11
Ross RB, 1987, Treatment variables affecting facial growth in complete unilateral cleft lip and palate, CPJ,
24;5-77
Sharpe PT, 1995, Homeobox genes and orofacial development, Connect Tissue Res, 32;17-25
Turner SR et al., 1997, The role of soft tissues in the aetiology of malocclusion, Dent Update, 24;209-214
16
Definition By incisor relationship: British Standards
.. the lower incisal edge lies on or below the cingulum Institutes, 1983
plateau of the palatal surface of the upper incisors
Incidence .. 60% Todd & Lader, 1988
Features Skeletal
.. usually Sk Cl 1, may be mild Cl 2 or Cl 3, with
dentoalveolar compensation
" vertical and transverse anomalies may be found e.g.
AOB, crossbites
Soft tissues
" favourable
Dental
" most common problem is crowding, usually due to local
factors
" spacing
" bimaxillary proclination
" vertical anomalies, e.g. AOB
" transverse anomalies, e.g. crossbites, scissorbites
Facial growth
.. usually favourable but AOB tend to worsen as
dentoalveolar compensation is already at its limits
Treatment .. orthodontic management alone is usually required
options
Crowding .. managed by creation of space from Xtns or arch
expansion
Spacing " consider whether to:
i) open spaces and place prostheses
ii) close space with appliances
Bimaxillary " see section on Bimaxillary Proclination
proclination
Vertical .. see sections on Low/High Angles cases, AOB and Deep
anomalies Bites
Transverse .. see section on Arch Lengthening and Lateral Expansion
anomalies Crossbite - a discrepancy in buccolingual relationship of the
upper and lower teeth
Buccal crossbite - buccal cusps of lower teeth occlude
buccal to buccal cusps of upper teeth
" managed by maxillary expansion but before planning
treatment consider if there is a displacement (favourable)
or true asymmetry e.g. skeletal (unfavourable) and Gill et al., 2004
manage appropriately
" can be treated with: Agostino et al., 2014
i) URA with midline screw/coffin spring
ii) Quadhelix
iii) RME McNally et al., 2005
iv) AW expansion in FA
v) Expansion arch (attached in molar tubes)
vi) Surgical assisted expansion
Lingual crossbite (scissorbite) - buccal cusps of lower
teeth occlude lingual to lingual cusps of upper teeth
" need mandibular expansion and maxillary contraction
" if severe may need surgery
References
Agostino Pet al., 2014, Orthodontic treatment for posterior crossbites, Cochrane Database Syst Rev,
CD000979
17
Gill D et al., 2004, The management of transverse maxillary deficiency, Dental Update, 31 ;516-523
McNally MR et al., 2005, A randomized controlled trial comparing the quadhelix and the expansion arch for
the correction of crossbite, JO, 32;29-35
Todd JE & Lader D, 1988, Adult Dental Health, HMSO, London
18
.. lower incisor edges lie palatal to the cingulum plateau of Institute, 1983
the upper incisors
" upper incisors are proclined or of average inclination, with
ant OJ
.. Cl II intermediate the upper incisors are slightly
retroclined with an t OJ; this can be a confusing definition
and is rarely used
Incidence .. Class 11/1: 20% Todd & Lader, 1988
" Class II intermediate: 10% - upper incisors are 'upright', Williams & Stephens,
OJ 4-6mm (not commonly used and can confuse) 1992
Aetiology ., Sk base relationships, usually Cl 2
., habits, e.g. thumb-sucking
., soft tissues, e.g. lower lip trapping behind upper incisors,
short upper lip
Features Skeletal
" 76% have Sk 2 base, if Sk 1, incisor relationship is
usually due to a habit
" t cranial base angle ---> mandibular retrognathia Hopkins et al., 1968
.. longer cranial base ---> prognathic max
., may have small mand and large max
., average or -!, lower face height
Soft tissues
.. lip pattern important in maintaining a stable result, short
upper lip ---> OJ t will be less stable
.. lower lip may have caused malocclusion, e.g. trapping
behind upper incisors or lip-tongue seal
Dental
. Cl II incisor relationship with proclined or average upper
incisors
. OJ is t
" OB is usually deep and often incomplete (adaptive
anterior oral seal - tongue to lower lip)
" buccal segments usually Cl II, may have crossbites
(buccal/lingual)
Mandibular position
" ensure pt is not habitually posturing, treat to centric
relation
.. consider the profile
Facial growth
" variable
.. can expect favourable growth but if pt rotates posteriorly Bjork & Skieller,
will not help buccal segment correction (20% of pts) 1972
//
Reasons for Risk of trauma
treatment .. 45% t risk with OJ>9mm in 12yr olds Todd & Dodd, 1983
" early treatment has small t in risk but not clear if this is Batista et al., 2018
cost effective
Improvement in aesthetics
" some improvement in self concept with early OJ t O'Brien et al., 2003
Reducing bullying
.. 12.8% pts referred for treatment are bullied Seehra et al., 2011
Relief of gingival trauma
Treatment .. orthodontic camouflage
options .. orthodontic decompensation and orthognathic surgery
19
Aims for " dental camouflage
orthodontics " some mandibular growth
alone " some restraint of maxillary growth
" forwards mandibular rotation
" combination of above
Favourable " small ANB difference
features for " no dental compensation
orthodontics " growing pt
alone " cessation of habit (if present)
" greater component of OJ being proclination of ULS Burden et al., 1999
Treatment aims General - adjusted as necessary
" relieve crowding
" level and align the arches
" ..!- OB and correct edge - centroid relationship {lower Houston, 1989
incisor edge should lie anterior to the upper root centroid)
., J, OJ
., correct the buccal segment relationships
Orthodontic URA
treatment options " simple tipping achieves desired movements
" if maxillary incisors are proclined
" canines mesially angulated
.. if lower incisors already lie anterior to upper root
centroid
Functional appliances
., in growing pts
FA/FA
., if bodily tooth movement is required
" if Sk problem allows camouflage
Orthognathic surgery
.. when too severe for orthodontics alone, ANB>9°
.. in non-growing pts
Timing of Treatment can be performed during:
treatment " primary dentition - NOT stable as pattern of growth re-
establishes later
.. mixed dentition - growth modification to be started 1-
3yrs before peak adolescent growth spurt BUT transition
to permanent dentition can be difficult to manage
" permanent dentition
References
Balista KBSL et al., 2018, Orthodontic treatment for prominent upper front teeth (Class II malocclusion) in
children, Cochrane Database Syst Rev, CD003452
Bjork A & Skieller V, 1972, Facial development and tooth eruption. An implant study at the age of puberty,
AJO, 62;339-383
Burden DJ et al., 1999, Predictors of outcome among patients with Class II Division 1 malocclusion treated
with fixed appliances in the permanent dentition, AJODO, 116;452-459
Hopkins GB et al., 1968, The cranial base as an aetiological factor in malocclusion, AO, 38;250-255
Houston WJB, 1989, Incisor edge-centroid relationships and overbite depth, EJO, 11; 139-143
O'Brien K et al., 2003, Effectiveness of early orthodontic treatment with the Twin-block appliance: a
multicenter, randomized, controlled trial. Part 2: psychosocial effects, AJODO, 124;488-494
Seehra J et al., 2011, Bullying in orthodontic patients and its relationship to malocclusion, self-esteem and
oral health-related quality of life, JO, 38;247-56.
Todd JE, Dodd T, 1985, Children's Dental Health in the United Kingdom, 1983: A Survey Carried Out by
the Social Survey Division of OPCS, on Behalf of the United Kingdom Health Departments, in Collaboration
with the Dental Schools of the Universities of Birmingham and Newcastle, Stationery Office
Williams A & Stephens CD, 1992, A modification to the incisor classification of malocclusion, BJO, 19;127-
130
20
.. lower incisor edges lie palatal to the cingulum plateau of Institute, 1983
the upper incisors
.. upper incisors (and usually lowers) are retroclined, with
minimal OJ although maybe t
Incidence '" range 10-18%
Aetiology '" high concordance in twin studies suggesting autosomic Markovic, 1992
dominant with incomplete penetrance or polygenic model
'" axial inclinations of incisors is such that the lower incisor
edge cannot be maintained on the upper incisor crown -7
deep OB, reduced OJ
'" 'strap-like' lower lip may retrocline maxillary and
mandibular incisors (bimaxillary retroclination) -7 deep
OB, reduced OJ
'" high resting lip pressure against maxillary central incisors Lapatki et al., 2002
'" lower lip may procline .f.
Features Skeletal
'" usually mild Sk 2 base, can be Sk 1 or Sk 3
'" t cranial base angle -7 mandibular retrognathia Hopkins et al., 1968
'" longer cranial base -7 prognathic max
'" max short, broad and forward relative to mand -7
tendency for scissorbite
'" i lower face height
'" i gonial angle
'" i MMP angle
Soft tissues
'" high resting lower lip line (due to i lower face height)
'" typically strap-like lower lip
.. marked labia-mental fold
'" high masseteric muscle forces lngervall &
Thilander, 1974;
Dental Sciote et al., 2012
'" retroclined upper and lower incisors
'" .f.'s often proclined, mesially tipped and mesiolabially
rotated (low~r lip fails to control shorter crown)
'" t interincisal~ngle
'" OB is usually deep
'" OJ is reduced usually
'" extruded upper incisors
'" buccal segments usually Cl 11
.. scissorbite common in premolar region due to transverse
discrepancy
.. crown-root angle may be decreased
.. incisors may be thin with a poorly defined cingulum Robertson & Hilton,
1965
Facial growth
.. variable
'" usually can expect favourable growth
Reasons for .. improve facial aesthetics
treatment .. remove traumatic bite - trauma to palate, stripping of
upper palatal gingiva, recession of lower labial mucosa
.. improve tooth alignment, in particular of the .f.'s
Treatment '" leave and observe
options .. orthodontics alone
.. orthodontic decompensation and orthognathic surgery
21
Favourable .. small ANB difference
features for " growing pt
orthodontics only
.. relieve crowding
.. level and align the arches
., -J., OB - correct edge-centroid relationship (lower incisor Houston, 1989
edge should lie anterior to the upper root centroid)
-t interincisal angle, often requiring intrusion and Mills, 1973
palatal root torquing of upper incisors
., correct the buccal segment relationships
Orthodontic URA
treatment options ., to t OB with anterior bite plane - limit incisor eruption and
allow lower molars to erupt
" aid correction of buccal segment with EOT
" convert pt to a Cl 11/1 malocclusion and manage
accordingly, e.g. with functional appliance
" correct scissorbite with a contraction plate
Modified functional appliances
" in growing pt
., use cantilever springs behind the upper incisors to Dyer et al., 2001
procline the maxillary incisors and correct the sagittal
relationship with same appliances
FA/ FA
.. if bodily tooth movement is required, very likely to need
torque to upper incisors
.. Sk problem allows dental camouflage
., avoid Xtns in low MMP angle cases as space closure can Bjork & Skieller,
be difficult 1972
" carefully consider Xtn decision, if Xtn necessary take 5s
rather than 4s to minimise lingual movement of LLS
., when too severe for orthodontics alone, ANB>9°
" non-growing pts
Timing of Treatment can be performed during:
treatment " mixed dentition
- prevention of a deep OB can be achieved with a URA
" permanent dentition
Stability and " can consider proclining the LLS, as it has been trapped Mills, 1968
retention " proclination of LLS after intrusion of ULS has been Selwyn-Barnett,
suggested as stable treatment as lower incisors would 1996
take up positions previously occupied by uppers, however
this stability however has been questioned Canut & Arias, 1999
" consider fixed retention and pericision of rotated ;?_ Edwards, 1970
Recommended Mills 1973; Houston, 1989
reading
References
AJO, 62;339-383
Canut JA & Arias S, 1999, A long term evaluation of treated Class II division 2 malocclusions: A
retrospective study model analysis, EJO, 21 ;388-386
Dyer FM et al., 2001, The modified twin block appliance in the treatment of Class II division 2
malocclusions, JO, 28;271-280
Edwards JG, 1970, A surgical procedure to eliminate rotational relapse, AJODO, 57;35-46
Houston WJB, 1989, Incisor edge-centroid relationships and overbite depth, EJO, 11 ;139-143
lngervall B & Thilander B, 1984, Relation between facial morphology and activity of the masticatory
muscles, J Oral Rehabilitation, 1;131-147
22
Lapatki BG et al., 2002, The importance of the level of the lip line and resting lip pressure in Class II,
division 2 malocclusion, J Dent Res, 81 ;323-328
Markovic MD, 1992, At the cross-roads of orofacial genetics, EJO, 14;469-81
Mills JRE, 1968, The stability of the lower labial segment. A cephalometric survey, Dent Pract, 18;293-306
Mills JRE, 1973, The problem of overbite in Class II, division 2 malocclusion, BJO, 1 ;34-48
Robertson NRE & Hilton R, 1965, Feature of the upper central incisors in Class II division 2, AO, 35;51-53
Sciote JJ et al., 2012, Human masseter muscle fiber type properties, skeletal malocclusions, and muscle
growth factor expression, J Oral & Maxillofac Surg, 70;440-448
Selwyn-Barnett JB, 1996, Class II division 2 malocclusion: A method of planning and treatment, BJO,
23;29-36
23
., lower incisal edges lie anterior to the cingulum plateau of Institute, 1983
the palatal surface of the upper incisors
Incidence .. 5% Todd & Lader, 1988
., incidence of anterior cross bite 10% Chestnut et al., 2004
Aetiology " genetics - due to Sk pattern
., pts with CLP may present with a Cl Ill malocclusion
Features Skeletal
" usually Sk 3 base relationship
" -J, cranial base angle ---> forwards position of mand Hopkins et al., 1968
" maxillary retrusion is the most common contributing Guyer et al., 1986
factor, affecting 60% of all cases
., sometimes a short cranial base
., max short, small and narrow relative to mand which tends
to be broad, therefore, crossbites likely
" obtuse gonial angle
" normal or t MMP angle and lower face height
" transverse Sk discrepancy often a feature Chen et al., 2008
Soft tissues
" not involved in aetiology but encourage dentoalveolar
compensation
" lower lip may be full and pendulous
Dental
" Cl Ill molar relationship, tendency to or full reverse OJ, t
OB, AOB may exist
" incisors compensate for Sk base, i.e. proclined maxillary,
retroclined mandibular incisors
" max probably crowded, mand unlikely to be so Lin, 2007
" in 'pseudo' Cl Ill there is bilateral Cl I buccal occlusion
and majority of teeth are in anterior crossbite
Displacements
.. likely to be a displacement in order to obtain posterior
occlusion due to edge-to-edge incisor contact or to
unsatisfactory transverse buccal segment relationship
Facial growth
" tends to be unfavourable i.e. backwards growth rotation,
t vertical growth
Treatment .. growth modification
options .. orthodontic camouflage
.. orthodontic decompensation and orthognathic surgery
Orthodontics " dental compensation
alone aims .. development of A. point
.. Sk maxillary protrusion
.. backwards mandibular rotation to t prominence of B
point
.. combination of above
Favourable .. good OB
features for . can pt reach edge to edge in centric relation? - although
orthodontics only this is not completely reliable as it can be affected by
amount of incisor compensation
. low SNA - want to bring A point forwards
.. low lower face height - want to rotate mand downwards
and backwards ---> t lower face height
.. no dental compensation
.. low SNB or normal SNB
.. pt past peak growth
24
" once corrected for crowding and displacements, want
molar relationship less than Y, unit Cl Ill
.. relieve crowding
" level and align the arches
" t OB and OJ
.. correct the buccal segment relationships
Orthodontic URA
treatment options .. if 1-2 incisors are in crossbite and positive OB
Anterior cross elastics
" if 3-4 incisors in crossbite, minimal crowding Reynolds, 1978
" used in combination with disclusion with the use of GIC or Tzatzakis &
composite molar build-ups Gidarakou, 2008
2x4 appliance Hagg et al., 2004
" used if pseudo Cl Ill case
.. mixed dentition
.. may be superior to URA in terms of cost effectiveness Wiedel et al., 2015
and treatment time
FA/ FA alone
" if tooth control is needed, minimal Sk problem ANB>0°
'Orthopaedic' treatment
In a review of 'orthopaedics' in Cl Ill cases Dermaut & Aelbers,
" 50% of studies showed stimulation of max growth 1996
" 90% showed inhibition of mandibular prominence
" small changes seen, ? clinical relevance
Protraction HG (see section on Protraction HG)
.. can be used if pt shows favourable Sk features, is about
8yrs (before posterior max suture closes) and ANB<-2°, in McNamara, 1987
conjunction with URA in mixed dentition or FA
.. facemask treatment results not influenced by RME so Vaughin et al., 2005
should only be considered if constricted max present
.. early orthopaedic treatment with protraction HG is Mandall et al., 2010
skeletally and dentally effective in the short-term
" facemask treatment was skeletally effective in pts under Mandall et al., 2012
10yrs old (3yr follow up), although only overall change in
ANB value was statistically significant; 70% of pts still
presented with a positive OJ in facemask group at 3yrs
.. no clinically significant psychosocial benefit of early Mandall et al., 2012,
treatment 2016
.. Sk change was not maintained after 6yrs but 68% of pts Mandall et al., 2016
maintained +ve OJ
., pts were also less likely to be offered orthognathic surgery Mandall et al., 2016
if had facemask treatment (36% compared with 66% of
control group)
.. meta-analysis of effectiveness of protraction HG Kim et al., 1999
concluded it was less effective on pts >1 Oyrs; longer
treatment plans if palatal expansion not used; induced
greater ULS proclination
Chin caps
., ---t lingual tipping of LLS and clockwise rotation of mand Thilander, 1963
.. not recommended for open bite, significant reverse OJ or Ko et al., 2004
compensated lower incisor cases
., effective at reducing mandibular prognathism before Sugawara et al.,
puberty but this is then lost with continual growth 1990; Sugawara &
Mitani, 1997
Functional appliances
.. FR3 can be used, results unpredictable
" reverse TB effective in Cl Ill early treatment but long-term Seehra et al., 2012
stability uncertain and depends on future growth
25
Bone Anchored Maxillary Protraction/Bollard Plates De Clerk, 2010; Hino
.. use of miniplates to infrazygomatic crest and lower canine et al., 2013
region with Cl Ill intermaxillary force application to the max
(girls: 11yrs, boys: 12yrs) -t highly significant amount of
max advancement; less mand changes were seen
.. light Cl Ill elastics to miniplates
.. disadvantages: flaps need to be raised for insertion and
removal, prominence of hooks must be precise (too
prominent will traumatise mucosa, too close to bone will
prevent placement of elastics)
Orthodontics and .. when too severe for orthodontic camouflage
orthognathic .. DO NOT extract teeth in the lower arch in a growing pt in Jacobs & Sinclair,
surgery options case surgery is required at a later date 1983
.. orthodontic decompensation of the lower arch is more Artun et al., 1990
difficult if Xtn have been undertaken
Recommended Watkinson et al., 2013; Mandall et al., 2016
reading
References
Artun Jet al., 1990, Stability of mandibular incisors following excessive proclination: a study in adults with
surgically treated mandibular prognathism, AO, 60;99-106
British Standards Institute, 1983, Glossary of Dental Terms (BS4492) BSI London
Chestnut I et al., 2004, The orthodontic condition of children, Children's dental health survey, Department
of Health, 2004
Chen Fetal., 2008, Dental arch widths and mandibular-maxillary base widths in Class Ill malocclusions
from ages 10 to 14, AJODO, 133;65-69
De Clerk H, 2010, Dentofacial effects of bone-anchored maxillary protraction: A controlled study of
consecutively treated Class Ill patients, AJODO, 138;577-581
Dermaut LR & Aelbers CMF, 1996, Orthopaedics in Orthodontics: Fiction or reality. A review of the
literature - Part II, AJODO, 110;557-671
Guyer EC et al., 1986, Components of class Ill malocclusion in juveniles and adolescents, AO, 56;7-30
Hagg U et al., 2004, A follow-up study of early treatment of pseudo Class Ill malocclusion, AO, 74;465-472
Hino CT et al., 2013, Three-dimensional analysis of maxillary changes associated with facemask and rapid
maxillary expansion compared with bone anchored maxillary protraction, AJODO, 144;705-714
Jacobs JD & Sinclair PM, 1983, Principles of orthodontic mechanics in orthognathic surgery cases, AJO,
84;399-407
Kim JH et al., 1999, The effectiveness of facemask therapy: A meta-analysis, AJODO, 115;675-685
Ko YI et al., 2004, Determinants of successful chincup therapy in skeletal class Ill malocclusion, AJODO,
126;33-41
Lin J J-L, 2007, Creative orthodontics, blending the Damon system and TADS to manage difficult
malocclusions, Taiwan, Yong Chieh Co ISBN: 978-986-83331-1-6
Mandall Net al., 2010, Is early Class Ill protraction facemask treatment effective? A multicentre RCT: 15
month follow up, JO, 37;149-161
Mandall Net al., 2012, Is early Class Ill protraction facemask treatment effective? A multicentre RCT: 3
year follow up, JO, 39; 176-185
Mandall Net al., 2016, Early class Ill protraction facemask treatment reduces the need for orthognathic
surgery: a multi-centre, two-arm parallel randomized, controlled trial, JO, 43;164-175
McNamara JA, 1987, An orthopedic approach to the treatment of Class Ill malocclusion in young patients,
JCO, 11 ;598-608
Reynolds IR, 1978, The anterior crossbite: a simple method of treatment, BDJ, 144;143-146
Seehra Jet al., 2012, A comparison of two different techniques for early correction of Class Ill
malocclusion, AO, 82;96-101
Sugawara Jet al., 1990, The long-term effects of chin cap therapy on skeletal profile in mandibular
prognathism, AJODO, 98;127-133
Sugawara J & Mitani H, 1997, Facial growth of skeletal malocclusion and the effects, limitations and long
term adaptation to chin cap therapy, Seminars in Orthodontics, 3;244-254
Thilander B, 1963, Treatment of Angle Class Ill malocclusion with chin cap, TEOS, 39;384-398
Tzatzakis V & Gidarakou IK, 2008, A new clinical approach for the correction of anterior crossbites, WJO,
9;355-365
26
Vaughn GA et al., 2005, The effects of maxillary protraction therapy with or without rapid palatal expansion:
a prospective, randomized clinical trial, AJODO, 128;299-309
Watkinson Set al., 2013, Orthodontic treatment for prominent lower front teeth (Class II malocclusion) in
children, Cochrane Database Syst Rev, CD003451
Wiedel AP et al., 2015, Stability of anterior crossbite correction: a RCT with a 2 year follow-up, AO, 80; 189-
195
27
Definition The proclination of the upper and lower dental arches Keating, 1986
Aetiology " dentition adapts to the Sk and soft tissue pattern
Incidence " most common in Afro-Caribbeans and Oriental
populations
Features Skeletal Keating, 1985; Carter
" Sk bimaxillary protrusion (prognathic jaws) & Slattery, 1988
" t ANB, due to maxillary protrusion; mild Cl 2
" long, more prognathic max and mand
" short posterior cranial base
" smaller upper and posterior face height
" divergent facial planes
Soft tissues - in Afro-Carribeans: Connor & Moshiri,
" convex facial form 1985
" t lip length therefore more everted
" tongue thicker and longer Adesina et al., 2013
" lips more protrusive (flaccid/full/everted) in black females Fonesca & Klein,
than white females 1978
Dental
.. dental bimaxillary proclination Carter & Slattery,
.. proclined LLS compensates for ANB difference 1988
" tendency for t OB or AOB
" larger dental arch length due to proclined teeth
" steeper mandibular plane (divergent facial planes)
" normal molar relationship
" may have superimposed malocclusion
Why treat?· " to improve facial aesthetics, i.e. flatten profile Carter & Slattery,
" to reduce t OJ 1988
" to enable lip competence
Treatment " assess each malocclusion on its own merits
considerations " premolar Xtns appropriate for crowded cases Carter & Slattery,
.. avoid Xtns for incisor retraction alone, as relapse prone 1988
and risks reopening of spaces
.. do not extract in spaced cases
" joint orthognathic approach may be needed
" Xtn of four premolars can be effective in t the soft tissue Bills et al., 2005
procumbency in bimaxillary protrusion cases
" 5.2 mm of 21/12 retraction to 2.4 mm of upper lip
retraction
" round AW to allow tipping of teeth
Relapse " long-term stability is unpredictable, depends on lip pattern Keating, 1986
adapting to incisor retraction, i.e. lower lip covering more
of 21/12, and becoming competent
" interincisal angle during treatment relapsed by 20% in a
treated Caucasian sample
" t relapse rate as teeth occupy a position of balance
between pressure of tongue on one side and lips/cheeks
on the other so if moved may shift equilibrium
Recommended Keating,1985, 1986
reading
References
Adesina BA et al., 2013, Assessment of the impact of tongue size in patients with bimaxillary protrusion, Int
Orthod, 11 ;221-32
Bills DA et al., 2005, Bimaxillary dentoalveolar protrusion: traits and orthodontic correction, AO, 75;333-339
Carter NE & Slattery DA, 1988, Bimaxillary proclination in patients of Afro-Caribbean origin, BJO, 15;175-
184
Connor AM & Moshiri F, 1985, Orthognathic surgery norms for American black patients, AJO, 87;119-134
Fonseca RJ & Klein WD, 1978, A cephalometric evaluation of American Negro women, AJO, 73;152-160
28
Keating PJ, 1985, Bimaxillary protrusion in the Caucasian: a cephalometric study of the morphological
features, BJO, 12;193-201
Keating PJ, 1986, The treatment of bimaxillary protrusion. A cephalometric consideration of changes in the
inter-incisal angle and soft tissue profile, BJO, 13;209-220
29
Definition Condition where there is no contact and no vertical overlap of Houston et al., 1996
the lower incisor crowns by the upper incisor crowns when
mand is in full occlusion
Incidence " 2-4% of children O'Brien, 1993
" 4% of adults Todd & Whitworth,
1972
.. more common in Africans (5%) and Afro-Caribbeans Noar & Portney, 1991
Aetiology Genetic
Environmental
" habits (if prolonged into mixed and permanent dentition) Fletcher, 1975
" abnormal tongue function (endogenous or adaptive
tongue thrust)
., trauma/pathology affecting condyle
., pathological e.g. CLP, acromegaly, trauma
., neurological disturbances
" muscular dystrophy
" iatrogenic e.g. extrusion of molars during treatment
" respiration - minor influence on vertical and transverse Linder-Aronson,
jaw dimensions, greater effect in animals than humans 1972; Harvold et al.,
1981
Classification .. classification based on the appearance of the mand Kim, 1974
- dentoalveolar: mand appears normal
- Sk: mand appears abnormal
Features Great variability in dental and skeletal morphology in pts with Cangialosi, 1984
open bites
Skeletal AOB
Extra oral features:
.. long face
" lip incompetence
.. steep FMP angle
.. marked antegonial notch
" t AFH, ,), PFH with reduced UFH:LFH
Intra oral features:
" mild crowding with upright incisors
" may occlude only on 7s if severe
.. gingival hypertrophy due to mouth breathing
" maxillary, occlusal and palatal planes tilt upwards,
mandibular occlusal plane canted downwards
Dental AOB (most commonly due to digit-sucking habit)
Extra oral features:
" no unusual features
Intra oral features:
" arches will have features related to the AOB aetiology,
e.g. thumb-sucking may procline upper incisors, depress
and retrocline mandibular incisors
" open bite limited to incisor region, often asymmetrical
" maxillary arch may be narrow, presence of crossbites
" tilting of max plane and ant displacement
., 'Fish mouth' appearance
" severity depends on: age, intensity, frequency, duration
(t6hrs)
Swallow/Abnormal tongue function
" have tongue-thrust type swallow to form lip seal
Cephalometric .. maxillary palatal plane normal, occlusal plane canted Dung & Smith, 1988
features of " may have ,J, dentoalveolar height anteriorly, may be
skeletal open bite excessive posteriorly
30
Treatment 1. stop any habits
options 2. orthodontic
3. orthognathic approach
4. combination of treatment
'The greater the skeletal elements contribute to the aetiology, Mizrahi, 1978
the poorer the prognosis for treatment'
Treatment of . incisors are already maximally erupted, therefore cannot
Skeletal Open extrude further
Bite .. do not distalise molars, extract distally as this allows Mizrahi, 1978; Aras,
reduction in MMP 2002
.. combined orthodontic/surgical approach - usually Le Fort I
to impact the max posteriorly allowing a forward rotation
of mand
.. T ADs to intrude the buccal segments Park et al., 2004
. lack of evidence on how to treat Cozza et al., 2004
Treatment of .. stop habit Borrie et al., 2015
Dental Open Bite .. change in tongue posture with tongue crib/spurs ?success Huang et al., 1990;
.. no treatment for endogenous tongue thrusts Taslan et al., 2010
.. active orthodontic treatment should aim to prevent
extrusion of molars and restrict vertical development of
the post max, therefore avoid intermaxillary elastics
.. intrusive HG - high pull HG and transpalatal arch mainly
for Cl II pts to intrude 6's and prevent dropping of palatal Firouz et al., 1992
cusps
.. buccal intrusion split and high-pull HG
" FA and vertical anterior elastics
.. curve of Spee in lower arch
.. chin cup treatment little help
. magnets in bite blocks not much help, difficult to
distinguish between the effects of the bite blocks and the Katra et al., 1989
magnets, may cause crossbites to develop
" Kim mechanics: use multiloop wires/rocking chair NiTi
with t curve of Spee in max, reverse in mand to tip molar Kim, 1987;
teeth backwards and vertical elastics to close the bite Kucukkeles et al.,
" change was mainly dentoalveolar, similar to natural 1999
dentoalveolar compensation Chang & Moon, 1999
" retrospective study (small sample: 32) compared Begg,
Edgewise and Andresen appliances, some with chin caps Arat & Iseri, 1992
- found that FA groups had mand rotation downwards and
backwards whilst functional appliance group rotated
forwards and upwards BUT difficult to analyse the results
as unusual cephalometric assessment used
.. in Cl II div 1 cases with proclined incisors, retraction of
incisors t OB Sarver & Weissman,
1995
" use of TADs: can be used to intrude buccal teeth which
may help to t OB Kravitz et al., 2007;
different treatment modalities have been investigated Causley, 2014
" Lentini-Oliveira et al.,
however due to limitations in the studies the results should
be interpreted with caution 2014
Stability
" < 0.5mm relapse over 2yrs post Kim mechanics (OB t by Kim et al., 2000
4mm during treatment) ,
.. most accurate predictor is the arhount of OB at start of Kim, 1974
treatment
. correlation between FMP and OB unreliable
.. surgical correction reported to have 43% relapse rate Denison et al., 1989
.. no single parameter gives prediction of stability Lopez-Gavito et al.,
1985
Relapse Attributed to: Burford & Noar, 2003
" unfavourable growth
.. soft tissue factors (unfavourable tongue posture)
31
., resumption of digit habit
., inappropriate orthodontic tooth movement e.g. incisor
extrusion
" surgery that has increased the PFH (e.g. mand procedure
only to close AOB)
Other useful Predictors of problem cases Dung & Smith, 1988
papers ., no cephalometric predictors exist, 300 pts examined; OB
depth indicator (ODI) and extent of AOB at start of
treatment were the best predictors of success
Recommended Dung & Smith, 1988; Burford & Noar, 2003; Lentini-
reading Oliveira et al., 2014
References
Aras M, 2002, Vertical changes following orthodontic extraction treatment in skeletal open bite subjects,
EJO, 24;407-416
Arat M & Iseri H, 1992, Orthodontic and orthopaedic approach in the treatment of skeletal open bite, EJO,
14;207-215
Barrie FR et al., 2015, Interventions for the cessation of non-nutritive sucking habits in children, Cochrane
Database Syst Rev, CD008694
Burford D & Noar JH, 2003, The causes, diagnosis and treatment of anterior open bite, Dent Update,
30;235-41
Cangialosi T J, 1984, Skeletal morphologic features of anterior openbite, AJODO, 85;28-36
Chang YL & Moon SC, 1999, Cephalometric evaluation of the anterior open bite treatment, AJODO,
115;29-38
Cousley RR, 2014, Molar intrusion in the management of anterior openbite and 'high angle' Class II
malocclusions, JO, 41 Suppl 1:s39-46
Cozza Pet al., 2004, An orthopaedic approach to the treatment of Class Ill malocclusions in the early mixed
dentition, EJO, 26;19'1-'199
Denison TF et al., 1989, Stability of maxillary surgery in openbite versus non openbite malocclusions, AO,
59;5-10
Dung DJ & Smith RJ, 1988, Cephalometric and clinical diagnoses of open bite tendency, AJODO, 94;484-
490
Firouz M et al., 1992, Dental and orthopedic effects of high-pull headgear in treatment of Class II, division 1
malocclusion, AJODO, 102;197-205
Fletcher BT, 1975, Etiology of fingersucking: review of literature, J of Dentistry for Children, 42;293-298
Harvold EP et al., 1981, Primate experiments on oral respiration, AJO, 79;359-372
Houston WJB et al., 1996, Class 1 malocclusions. In: A Textbook of Orthodontics, 2nd ed. Oxford: Wright
Huang GJ et al., 1990, Stability of anterior openbites treated with crib therapy, AO, 60;17-24
Kalra Vet al., 1989, Effects of a fixed magnetic appliance on the dentofacial complex, AJODO, 95;467-478
Kim YH, 1974, Overbite depth indicator with particular reference to anterior open-bite, AJODO, 65;586-611
Kim YH, 1987, Anterior openbite and its treatment with multiloop edgewise archwire, AO, 57;290-321
/Kim YH et al., 2000, Stability of anterior openbite correction with multiloop edgewise arch wire therapy; a
cephalometric follow up study, AJODO, 118;43-54
Kravitz ND et al., 2007, The use of temporary anchorage devices for molar intrusion, JADA, 138;56-64
Kucukkeles Net al., 1999, Cephalometric evaluation of open bite treatment with NiTi arch wires and
anterior elastics, AJODO, 116;555-562
Lentini-Oliveira DA, et al., 2014, Orthodontic and orthopaedic treatment for anterior open bite in children,
Cochrane Database Syst Rev, CD005515
Linder-Aronson S, 1972, Effects of adenoidectomy on dentition and nasopharynx, TEOS, 1972; 177-86
Lopez-Gavito G et al., 1985, Anterior open-bite malocclusion: a longitudinal 10-year postretention
evaluation of orthodontically treated patients, AJO, 87;175-186
Mizrahi E, 1978, A review of anterior open bite, BJO, 5;21-27
Noar JH & Portnoy S, 1991, Dental disease status of children in a primary and secondary school in rural
Zambia, Int Dent J, 41 ;142-148
O'Brien M, 1993, Children's Dental Health in the United Kingdom, London: HMSO
Park HS et al., 2004, Treatment of open bite with microscrew implant anchorage, AJODO, 126;627-36
Sarver DM & Weissman SM, 1995, Nonsurgical treatment of open bite in nongrowing patients, AJODO,
108;651-659
Taslan Set al., 2010, Tongue pressure changes before, during and after crib appliance therapy, AO,
80;533-539
Todd JE & Whitworth A, 1972, Adult Dental Health in Scotland 1972, London: HMSO
32
Definition ., Frankfort mandibular planes angle (FMPA), the angle Dung & Smith, 1988
made by the Frankfort horizontal (orbitale-porion) and the
mandibular plane (Go-Me), is t
., normal = 27 ± 5°, ~ high angle is > 1 SD above normal
Aetiology " t anterior lower face height (ALFH) or i posterior face Houston, 1988
height (PFH) which result in a backwards growth rotation
Relevance of t May have the following:
FMPA to ., dentoalveolar compensation (i.e. retroclined LLS) Betzenberger et al.,
orthodontics " crowding 1999
" reduced/incomplete OB or AOB
" marked ANB discrepancy
" i muscular forces Proffit et al., 1983
., gummy smile/VME (vertical max excess)
Treatment Related to features above:
principles " do not procline LLS to normal values
" do not aggravate growth rotation, i.e. avoid Cl II traction Houston, 1988
and bite opening functional appliances
" maintain OB if reduced, e.g. sectional arches to pick up
high canines
" avoid Cl II traction which may extrude lower molars
" use transpalatal arch with high pull HG to avoid upper
molar palatal cusps dropping down
" extracting more distally in arch i MMPA during treatment Aras, 2002
.. space closure does not occur quicker in high angle cases Ireland et al., 2016
then in low angle cases
., caution with bonding Ts
Treatment of AOB see section on AOB
Predictors Anatomical predictors
" Bjork's 7 structural signs help to predict type of growth Bjork, 1969
rotation (see section on Growth Rotations)
" others have investigated these further and found that only Skieller et al., 1984
in severe cases were they found to be of use
., pre-treatment lat cephs cannot predict future growth Leslie et al., 1998
rotations
Cephalometric predictors Dung & Smith, 1988
" many have been used:
- SN-MP angle > 40°
- OB Depth Indicator (ODI)
- Occlusal/MnP angle > 22°
- UFH I LFH ratio< 0.7
- PFH I AFH (Jarabak) ratio< 58%
- OB
- MMP ·angle > 32°
" only degree of OB present at start of treatment and ODI Kim, 1974
found to show any relationship to difficulty in treatment
" 191 subjects with SN I MnP > 40°: 50% had normal OB, Betzanberger et al.,
30% had deep OB and 20% had AOB 1999
Miscellaneous " Jarabak ratio= PFH:AFH, 59 - 63 is normal; if:::: 64 =>low Jarabak & Fizzell,
angle case, deep OB;:<::: 58 =>high angle case, i OB 1972
" Sassouni analysis useful for assessing facial heights Sassouni, 1969
References
Aras A, 2002, Vertical changes following orthodontic extraction treatment in skeletal open bite subjects,
EJO, 24;407-416
Betzenberger D et al., 1999, The compensatory mechanism in high-angle malocclusions: A comparison of
subjects in the mixed and permanent dentition, AO, 69;27-32
Bjork A, 1969, Prediction of mandibular growth rotation, AO, 55;585-599
33
Dung DJ & Smith RJ, 1988, Cephalometric and clinical diagnoses of open bite tendency, AJODO, 94;484-
490
Houston WJB, 1988, Mandibular growth rotations - their mechanisms and importance, EJO, 10;369-373
Ireland AJ et al., 2016, Effect of gender and Frankfort mandibular plane angle on orthodontic space
closure: a randomized controlled trial, Ortho & Cranio Res, 19;74-82
Jarabak JR & Fizzell JA, 1972, Technique and treatment with the light wire edgewise appliance, Mosby
Year Book, St Louis
Kim YH, 1974, Overbite depth indicator with particular reference to anterior open-bite, AJODO, 65;586-611
Leslie LR et al., 1998, Prediction of mandibular growth rotation: Assessment of the Skieller, Bjbrk, and
Linde-Hansen method, AJODO, 114;659-667
Proffit WR et al., 1983, Occlusal forces in normal- and long-face adults, J Dent Res, 62;566-571
Sassouni VA, 1969, A classification of skeletal facial types, AJO, 55;109-123
Skieller Vet al., 1984, Prediction of mandibular growth rotation evaluated from a longitudinal implant
sample, AJO, 86;359-370
34
Definition .. t overlap, beyond average (2-4mm), of the upper incisors
with the lower incisors
.. complete to tooth/soft tissue or incomplete
Aetiology Skeletal Bjork & Skieller,
" anterior growth rotation due to -!- anterior lower face 1972
height (ALFH) or t posterior face height (PFH)
Soft tissue
" high lower lip line (due to-!- anterior lower face)
.. t mentalis muscle activity (strap-like)
.. t masseteric forces lngerval & Thilander
1974; Sonnesen &
Dental Bakke,2005
.. excessive eruption of incisors esp. lower incisors
.. resting tongue position and swallow will determine
whether OB is complete or incomplete
.. retroclination of incisors by muscle activity
Indications for Primary dentition
treatment " deep OB may occur in 1° dentition, however treatment is
likely to relapse if treated early therefore rarely indicated
Early permanent dentition
.. trauma to soft tissues palatal to max incisors or labial to
mand incisors
.. traumatic OBs associated with poor OH (IOTN 4f) Naini et al., 2006
Planning .. Age - extrusion in adults unstable
considerations " Soft tissues - smile line, should show 2-4mm at rest
.. A-P skeletal - growth modification or surgery
" Vertical skeletal
- short face - extrusion of buccal segments
- long face - avoid extrusion of buccal segments
Aims .. relative intrusion of incisors
.. absolute intrusion of incisors
.. proclination of LLS Eberhart et al., 1990
Methods of OB No one treaJment method is superior Millett et al., 2018
reduction URA
.. URA with anterior bite plane in growing pts to
accommodate tin vertical dimension±-!- FA
" Dahl appliance
" functional appliance: MOA allows eruption of lower
posterior teeth
FAs
" bond incisor brackets more incisally
" SS full thickness archwires - to level bracket slots; tip in
canine brackets, especially distoangular 3, will cause
incisor extrusion in light aligning wires; as canines
upright, incisors will reintrude: vertical 'round tripping'
.. incorporate 7s giving t vertical post anchorage
" upper t curve of Spee (COS) and lower reverse COS,
can consider using 'counterforce' Niti AW (these can
distort archform with prolonged use)
.. Tip-Edge - anchor bends, intrude labial segments
.. lingual appliance
Segmental archwires - i.e. Ricketts' utility arch & Burstone's
intrusion arch (segmental mechanics)
Auxiliaries
.. bite turbos
" microscrews, can be used to intrusde labial segments Semi;;1k &
Turkkahraman, 2012
35
" low pull HG
" Cl II elastics
" fixed intermaxilliary traction e.g. Advansync
" use of TADs
" 3 point landing followed by premolar extrusion
" segmental surgery, e.g. Kole procedure
Stability The following have been suggested:
" good inter-incisal angle - occlusal stop Mills, 1973
" edge-centroid relation - no evidence this is more stable Houston, 1989
" long-term retention Mills, 1968
Recommended Millet et al., 2018
reading
References
AJO, 62;339-383
Eberhart BB et al., 1990, The relationship between bite depth and incisor angular change, AO, 60;55-58
Houston WJ, 1989, Incisor edge-centroid relationships and overbite depth, EJO, 11 ;139-43
muscles, J Oral Rehabil, 1;131-147
Millett DT et al., 2018, Orthodontic treatment for deepbite and retroclined upper front teeth in children,
Cochrane Database Syst Rev, CD005972
Mills JRE, 1968, The stability of the lower labial segment, Trans Br Soc Study Orthod;11-24
Mills JRE, 1973, The problem of overbite in Class II, division 2 malocclusion, BJO, 1;34-48
Naini FB et al., 2006, The aetiology, diagnosis and management of deep overbite, Dent Update, 33;326-
336
Sem§1k NE & Turkkahraman H, 2012, Treatment effects of intrusion arches and mini-implant systems in
deepbite patjents, AJODO, 141 ;723-733
Sonnesen L & Bakke M, 2005, Molar bite force in relation to occlusion, craniofacial dimensions, and head
posture in pre-orthodontic children, EJO, 27;58-63
36
Definition .. Frankfort mandibular planes angle (FMPA), the angle
made by the Frankfort horizontal (orbitale- orion) and the
mandibular plane (Go-Me), is decreased
.. =
normal 27 ± 5°, ~ low angle is >1 SD below normal
Aetiology .. J, anterior lower face height (ALFH) or t posterior face
height (PFH) which result in a forwards growth rotation
. anterior growth rotation (counterclockwise) most common Bjork & Skieller,
(average -7°) 1972
Relevance of {, May have the following features:
FM PA to " square face with hypertrophic masseters (Type II muscle) Hunt et al., 2006
orthodontics " proclined LLS
" increased/complete OB ± palatal trauma
.. t muscular forces lngerval & Thilander
1974; Sonnesen &
Bakke, 2005
Treatment Related to features above:
principles .. avoid mandibular Xtns as space closure can be difficult,
however space closure during FA treatment is affected by Ireland et al., 2016
gender and active growth but not by FMPA
.. can procline LLS beyond normal values (ideal angle for
LLS is 120° - FMPA)
.. ways to reduce OB:
" J, OB if increased e.g. URA with anterior bite plane in
growing pts ± J, FA
" functional appliance e.g. MOA allows eruption of Naini et al., 2006
lower posterior teeth; trim upper TB and do not crib
lower 6's
., FAs - upper t curve of Spee (COS) and lower
reverse COS, segmental archwires i.e. Rickets &
Burstones, Bite Turbos, microscrews, low pull HG,
Class II elastics, lingual appliances
( " banding Ts possibly extrudes 6's and 5's Clifford et al., 1999
" in adults no residual growth remaining therefore J, OB
via incisor intrusion or proclination
" 5° proclination reduces overbite by 1mm Eberhart et al., 1990
" surgery to reduce OB - i.e. 3 point landing followed by
premolar extrusion or Kole segmental surgery
" Tip-Edge anchor bends
" lingual appliance - acts as bite opening appliance
Predictors Bjork's 7 structural signs help to predict type of growth Bjork, 1969
rotation (see section on Growth Rotations)
Miscellaneous .. =
Jarabak ratio PFH:AFH, 59 - 63 is normal; if ;:o: 64 => low Jarabak & Fizzell,
angle case; deep OB; :o:; 58 =>high angle case, J, OB 1972
" Sassouni analysis useful for assessing face heights Sassouni, 1969
References
AJO, 62;339-383
Bjork A, 1969, Prediction of mandibular growth rotation, AO, 55;585-599
Clifford PM et al., 1999, The effects of increasing the reverse curve of Spee in a lower archwire examined
using a dynamic photo-elastic gelatine model, EJO, 21 ;213-222
Eberhart BB et al., 1990, The relationship between bite depth and incisor angular change, AO, 60;55-58
Hunt N et al., 2006, Northcraft Memorial Lecture 2005: muscling in on malocclusions: current concepts on
the role of muscles in the aetiology and treatment of malocclusion, JO, 33; 187-197
muscles, J Oral Rehabil, 1;131-47
Ireland AJ et al., 2016, Effect of gender and Frankfort mandibular plane angle on orthodontic space
closure: a randomized controlled trial, Ortho & Craniofac Res, 19;74-82
37
Jarabak JR & Fizzell JA, 1972, Technique and treatment with the light wire edgewise appliance, Mosby
Year Book, St Louis
Naini FB et al., 2006, The aetiology, diagnosis and management of deep overbite, Dent Update, 33;326-
336
Sassouni VA, 1969, A classification of skeletal facial types, AJO, 55;109-123
Sonnesen L & Bakke M, 2005, Molar bite force in relation to occlusion, craniofacial dimensions, and head
posture in pre-orthodontic children, EJO, 27;58-63
38
Definition Dissimilarity of parts on either side of a straight line or plane,
or about a centre or axis; clinically: imbalance or Chia et al., 2008
disproportionality between left and right side of face
Incidence " common
" most people have asymmetry in the face and dentition,
this is usually mild
" lay people only notice cnetreline discrepancy >2mm Johnston et al., 1999
Aetiology Developmental (1 51 and 2nd arch structures) Bishara et al., 1994;
" hemimandibular elongation/hyperplasia Chia et al., 2008
" hemifacial microsomia/hypertrophy/atrophy (Parry-
Romberg syndrome)
" achondroplasia
" torticollis
" unilateral CLP
Environmental
" intra-uterine pressure
" condylar hyper/hypoplasia
" excessive condylar growth
., habits
Pathological
" tumours a17d cysts, e.g. osteochondroma
.. infection
.. condylar resorption
Trauma
" condylar fractures ± ankylosis Proffit et al., 1980
Functional
" mandibular deviations e.g. premature contacts
Local factors e.g. retained/missing teeth
Classification Skeletal Bishara et al., 1994
" maxillary, mandibular or combination with muscular
Muscular
" masseteric hypertrophy
" craniofacial atrophy
.. cerebral palsy
Functional
., mandibular displacement due to constricted max,
premature contact
" TMJ dysfunction
Dental
., retained/missing teeth
" habits e.g. thumb-sucking
Clinical Skeletal
examination .. vertical - assess cant of maxillary plane relative to
interpupillary plane
" transverse - look from top of pt's head for deviation of
chin point in relation to facial midline
" AP
Soft tissue
.. transverse - assess bilateral symmetry and for deviation
of the dorsum and tip of the nose and the philtrum
Dental - check for displacement on closure and examine in
both centric occlusion and relation:
., vertical - assess open bites
" transverse - examine crossbites, buccolingual tooth
position, relationship of the dental midlines with respect to
each other and to the facial midline
.. AP - assess buccal segment relationships
39
., localized factors - missing teeth etc
., check lower centreline in relation to chin point; if
coincident then likely to be skeletal in origin
Supplementary R/Gs
records .. lateral cephalogram little value for symmetry evaluation
" DPT shows condyles, bony and dental structures of jaws
.. PA skull good for assessing right and left
Photographs
Laser scanning/stereophotogrammetry
., acquiring 3D images using multiple photographs of same
object at different angles
" can quantify facial morphology and detect changes in
growth and development of face
., non-invasive and reproducible ~ enable monitoring of
facial asymmetry as image comparison possible through
software
Study casts
.. demonstrate arch asymmetries
Face bow record
., with study models demonstrates relationship of jaws in all
3 planes
Technetium isotope scan
.. R/Gic procedure with short-lived gamma-emitting isotope
which shows 'hot' spots of active growth
.. useful to assess condylar activity
" false negatives common, so interpret results with caution
( CT/Cone Beam CT/MRI
.. MRI can demonstrate soft tissue asymmetry
Sievers et al., 2012
.. 3D CT reconstruction can be very useful

Management Diagnose aetiology of asymmetry, aim to minimise maxillary Bishara et al., 1994
cant during growth, especially in craniofacial microsomia
Skeletal
.. mild Sk asymmetries may be managed by orthodontics
alone, e.g. hybrid functional appliances in growing pts,
although pt must be aware of compromise
.. severe Sk asymmetries difficult to treat, treatment timing
depends whether growth is excess or deficient; require
joint orthognathic approach or distraction osteogenesis
.. >4mm mand asymmetry may be noticed McAvinchey et al.,
2014
Soft tissue
., augmentation/reduction surgery involving bone grafts and
implants may be needed
Functional
., occlusal adjustments may correct minor deviations
" habitual displacements may need an occlusal splint for
diagnosis and deprogramming
" severe deviations will need orthodontic treatment, often
involving maxillary expansion
Dental
" missing teeth can be managed with appropriate Xtn
patterns or restorative approach
" asymmetric buccal segment relationships can be
managed with asymmetric Xtn patterns and asymmetric
mechanics
.. asymmetric transverse relationships may need
asymmetric torque
Recommended Bishara et al., 1994; Chia et al., 2008
reading
References
Bishara SE et al., 1994, Dental and facial asymmetries: a review, AO, 64;89-98
40
Chia MSY et al., 2008, The aetiology, diagnosis and management of mandibular asymmetry, Ortho Update,
1;44-52
Johnston CD et al., 1999, The influence of dental to facial midline discrepancies on dental attractiveness
ratings, EJO, 21 ;517-522
McAvinchey Get al., 2014, The perception of facial asymmetry using 3-dimensional simulated images,
AO, 84;957-965
Proffit WR et al., 1980, Early fracture of the mandibular condyles: frequently an unsuspected cause of
growth disturbances, AJO, 78;1-24
Sievers MM et al., 2012, Asymmetry assessment using cone beam CT. A Class I and Class II patient
comparison, AO, 82;410-417
41
42
Embryology
Growth Control and Growth Centres
Growth Rotations
Growth and its Relevance to Orthodontics
43
3 stages of Ovum
development .. 0-8 days in utero (IU)
.. fertilised ovum -t rapid mitosis -t morula -> blastocyst -t
implantation
Embryonic period
.. from 2nd to 121h week IU
.. subdivided into:
presomite period from 8-20 days IU
1° germ layers formed:
Endoderm - forms gastro-intestinal systems
Ectoderm - forms cutaneous and neural systems, infolding of
ectoderm forms -t
Mesoderm - forms cardiovascular system, bone, muscle,
connective tissue and ectomesenchyme which originates
from edges of neural tube (neural crest cells), migrates
throughout head and neck region
somite period from 21-31 days IU, basic patterns of main body
systems/organs formed
postsomite period from 4-10 weeks IU, rapid organ growth,
development of external features, head growth dominates
Fetal period
.. from 3-9mths
.. head development exceeds rest of body
.. reproportioning of body components occurs
.. organogenesis/tissue differentiation not features
Role of neural .. NCC are a multipotent cell population that is largely Noisa & Ravio, 2014
crest cells (NCC) responsible for forming the vertebrate head
in the head .. NCC are capable of differentiating into various somatic
cell types, including melanocytes, craniofacial cartilage
and bone, smooth muscle and peripheral nervous cells
" NCC from: Thorogood &
1. anterior neural fold forms much of epidermis of Ferretti, 1992
forehead and frontonasal regions, epithelium of 1°
palate and nasal cavities
2. posterior neural fold forms epidermis of maxillary and
mandibular regions, 2° palate and dorsum of tongue
" NCC migration discovered via:
1. 3 H labelled thymidine NCC
2. cell mapping in chimaeric embryos
.. pre-migration NCC are pluri-potential
.. specific differentiation regulated by environmental factors
" interaction with maxillary/mandibular ectoderm necessary
for chondrogene~is/osteogenesis
" NCC invade pharyngeal arches -t ectomesenchyme
(week 4)
Patterning " regulatory genes known as homeobox genes exist Holland, 1988
.. homeobox genes are a large family of genes first
described in Drosophilia Melanogaster (fruitfly)
" all homeobox genes contain specific highly conserved
region of 180 nucleotide base pairs
" homeobox genes encode a 60-amino acid sequence
(homeodomain) which binds to DNA mediating
transcription
.. Hox genes best studied homeobox genes but few are Whiting, 1997
expressed in the head, restricted to posterior cranial
region, abnormal ectopic expression in anterior structures
-t craniofacial dysmorphologies
44
.. Non-Hox homeobox genes expressed in abundance in
craniofacial region
.. product of these genes bind to downstream genes and
regulate expression
.. specific genes for each axial level of embryo and are
transmitted to corresponding brachia! arch via NCC
" no Hox gene expression in max and mand, Dix genes
responsible for patterning of jaws
Landmark dates Facial development
" begins 4th week IU
Ossification of calvarium
.. begins 3th week IU
" intramembraneous ossification
" 8 centres
Ossification of cranial base
" begins 3rd mth IU
., endochondral ossification
Ossification of max
., begins 7th week IU
., 2 centres
Ossification of mand
., begins 5th week IU
" 2 centres by bifurcation of inferior dental nerve
1° palate/lip fusion
.. 5th week IU
" classically thought to be 'fusion' of frontonasal and
maxillary processes
., now thought to be due to 'fusion' of maxillary processes
with frontonasal process submerged beneath these
2° palate
., vertical shelf development from maxillary processes
initially 5th week IU
.. shelf elevation 7 _3th week IU
" fusion occurs initially posteriorly to 1° palate then Ferguson, 1988;
continues posteriorly, finally to nasal septum 1995
" complex interaction for elevation:
- t synthesis of EGF and TGFp
- internal shelf forces
i. proteoglycan content of extracelluar fluid
ii. Type I collagen ? contraction
iii. differential cell proliferation
iv. t vascularity
- tongue movement
Teratogens " Vit. A/retinoids
induces ectopic Hox and homeobox gene expression Whiting, 1997
" alcohol
t programmed cell death and suppresses prechordal Smith et al., 2014
plate outgrowth, thereby -J, neuroectoderm and neural
crest induction and causing holoprosencephaly
" ionising radiation
damages DNA and t programmed cell death
" methotrexate and anti-convulsive drugs
interfere with folate metabolism --? birth defects including Hartridge et al., 1999
oral clefts
.. others
hypoxia, hyperthermia
45
Basis of Theories
craniofacial .. deficiency in number/migration of NCC
malformations .. reduced cell division resulting in fewer cells
.. t cell adhesion, number of NCC normal but fewer reach
areas of face
.. defect in interaction between NCC and epithelium
Recommended Moore et al., 1993; Meikle, 2002; Cobourne 2004, 2007
reading
References
Cobourne MT, 2004, The complex genetics of cleft lip and palate, EJO, 26;7-16
Cobourne MT, 2007, Familial human hypodontia - is it all in the genes? BDJ, 25;203-208
Ferguson MWJ, 1988, Palate development, Development, 103 suppl;41-60
Ferguson MWJ, 1995, Development of the face and palate, CPCJ, 32;522-524
Hartridge T et al., 1999, The role of folic acid in oral clefting, BJO, 26;115-120
Holland PWH, 1988, Homeobox genes and the vertebrate head (review), Craniofacial Development,
103;17-24
Meikle M, 2002, Craniofacial Development, Growth and Evolution, published by Bateson Publishing, ISBN
09542338 08
Moore KL et al., 1993, The Developing Human: Clinically Orientated Embryology, 5th Ed
Noisa P & Raivio T, 2014, Neural crest cells: From developmental biology to clinical Interventions, Birth
Defects Res C Embryo Today, 102;263-274
Smith SM et al., 2014, Neural crest development in fetal alcohol syndrome, Birth Defects Res C Embryo
Today, 102;210-220
Thorogood P & Ferretti P, 1992, Heads and tails: recent advances in craniofacial development, BDJ,
173;301-306
Whiting J, 1997, Craniofacial abnormalities induced by the ectopic expression of homeobox genes,
Mutation Research, 396;97-112
46
Definition of .. location at which independent (genetically controlled)
growth centre growth occurs e.g. synchondroses (not to be confused
with centres of ossification which occur in each bone e.g.
at the cranial sutures)
.. growth centres are also growth sites
Definition of .. location at which growth occurs
growth site .. growth sites are not always growth centres, e.g. cranial
sutures - growth occurs in response to stimulus
Definition of .. an t in size and number - development implies an t in Houston et al., 1993
growth specialisation of function
What initiates .. principally somatotrophin hormone (growth hormone)
growth? released from the pituitary gland
What controls the Genetic control
extent and timing .. highly conserved homeobox genes provide the genetic
of growth? "blue print" for growth and development
.. these genes are the same in all animals and are highly
conserved
" gives rise to family resemblances - a disturbance of these
genes can cause chromosome defects such as Trisomy
21 (Down's syndrome)
Environmental factors
" psychological stress in emotionally deprived children
inhibits the release of growth hormone although the
precise mechanism is unknown
" Moss's functional matrix theory 'growth of the face occurs Moss & Salentijn,
as a response to functional needs and is mediated by the 1969
soft tissue in which the jaws are embedded' e.g. the orbit
grows as a result of eye growth, brain growth causes
increase in cranium size
Theories of .. Sutural theory (Sicher)
craniofacial " Cartilaginous theory (Scott)
growth " Functional matrix theory (Moss) - capsular and periosteal
matrices
Evidence for each Sutural theory
component .. old school of thought: the sutures had innate growth
potential and that the sutures pushed apart the bones ~
ant in size
" this was disproved by transplanting a suture, no sutural Ryoppy,1965
growth was produced
" however when a suture is stretched ~ growth showing
that there is some external environmental force
" sutures do not grow actively, they respond with passive
deposition of bone between stretched edges of sutures
Cartilaginous theory
" suggests the primary determinant of growth is the
cartilage
" transplanting a nasal septum cartilage into other tissues Copray, 1986
produces some growth of the septum indicating some
innate growth potential exists
" removing the nasal septum from rabbits produces a Sarnat, 1976
retrusive midface - however this could be due to the
traumatic surgery
" transplanting a condyle produces no condylar growth Ronning & Koski,
1969
.. in 75% of cases no impairment in growth is seen following Profitt et al., 1980
a condylar fracture in growing children
47

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Skeletal 2 Skeletal 1 Skeletal 3

Occlusion and Malocclusion 11

lnterceptive Orthodontics 119

Iatrogenic/Deleterious Effects of Orthodontic Treatment 222

Research Aspects 283

Question and Answer Section 315

Acta Odontologica Scandinavica Acta Odonto Scand

American Journal of Orthodontics Dentofacial Orthopaedics AJODO

Annals of the Royal College of Surgeons of England Ann RCSEng

Australian Dental Journal Aust Dent J

British Dental Journal BDJ

British Journal of Plastic Surgery Br J Plas Surg

Cleft Palate Journal CPJ

Cleft Palate Craniofacial Journal CPCJ

Dental Practice Dent Prac

Dental Update Dent Update

Faculty Dental Journal FDJ

International Journal of Adult Orthodontics and Orthognathic Surgery IJAOOS

Journal of Clinical Periodontology J Clin Peria

Orthodontic Update Ortho Update

First description .. precise timing unknown

Stages of dental 3 recognised stages of dental occlusal development:

HARD TISSUE SOFT TISSUE

Pathology e.g. trauma

Head & neck syndromes

.. 3D CT reconstruction can be very useful

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