BIOPROGRESSIVE THERAPY - mgumst

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BIOPROGRESSIVE THERAPY

PRESENTED BY :

Presented by: Dr. Lavesh Pandey

▪Management umbrella

▪Principles of the Bioprogressive therapy

▪Visual treatment objective or V.T.O

BIOPROGRESSIVE THERAPY

Developed by : Dr Robert Murray Ricketts

▪ It takes advantage of biological progressions including growth,

development and function and directs them in a fashion that

normalizes function and enhances aesthetic effect.

▪It accepts as its mission the treatment of the total face rather than

narrower objective of the teeth or occlusion.

Management umbrella

Management of the total practice ultimately determines the degree of

efficiency and effectiveness with which the orthodontist solves

individual patient problems.

Knowlegde of theory + skilled application of technique +

administrative efficiency = Success

Technical systems cannot function efficiently and have longevity

unless they operate under a total management system or umbrella.

The management system should increase all of the following at same

time :

A .Quality

B .Quantity

C . Effectiveness

Management umbrella

➢ PLANNING

➢ ORGANIZING

➢ LEADING

➢ CONTROLLING

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PLANNING

1.Forecast - Normal growth

2.Deveolp Objectives - Indiviual treatment objective

3.Program - Sequence of mechanics to achieve

objectives

4.Scheduling - Average time for mechanics to function

5.Budget - Fee for case

PRINCIPLES OF THE BIOPROGRESSIVE THERAPY

Ten principles have been developed in an attempt to communicate

an understanding of the mechanical procedures that bio progressive

therapy may use in developing a treatment plan , including appliance

selection and application , specific to each individual patient.

1.The use of systems approach to diagnosis and treatment by application

of the visual treatment objective in planning treatment , evaluating

anchorage and monitoring results.

In 2 year 70% of change is because of treatment and 30 % of change

are due to growth

V.T.O

Allows orthodontist to visualize the changes that should occur .

and to prescribe the necessary treatment to cause it to happen.

Helps in understanding the interrelationship of various changing parts

and the influence that one area has upon another.

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Five areas of superimposition and analysis have been selected to

evaluate the changes that have forecast to visualize the difference

between the expected growth and proposed treatment alterations.

Seven areas of evaluation are used to determine the major moves

needed to accomplish the forecast objective and to design treatment

with a priority sequence for quality results and maximum efficiency

2. Torque control throughout treatment

Most of techniques allow more freedom of movement of tooth by

using round wires .

Bio.prog therapy suggest that movement of teeth can be

more efficient and various treatment procedures more effectively

carried through when control of direction of root movement

available.

Four situation where torque control of root is necessary

• Keep roots in vascular trabecular bone during initial stages

• Place roots in dense cortical bone for anchorage

• Torque to remodel cortical bone for U/L incisor retraction

• Torque to position teeth in final occlusion

3.Muscular and cortical bone anchorage

Anchorage here is considered in terms of stabilizing the

molars and positioning teeth against movement during various stages

of orthodontic treatment.

• Upper arch –Masseter and Temporalis

Facial Type

According to lower facial height angle

cortical bone anchorage

cortical bone is more dense and laminated with very limited

blood supply therefore the physiological process is delayed and

tooth movement is slow .

• U/L molar anchorage increased by Expansion

•Tooth movement can be enhanced by understanding the position of

cortical bone .

4. Movement of all teeth in any direction with proper application of

pressure.

•Rate of tooth movement is dependent on blood supply that sustains

the physiological action that takes place within bone

•Brain lee ,suggested that the most efficient force for tooth movement

is based upon the size of the root surface of the tooth to be moved

which he called as enface root surface or the portion of root that is in

the direction of tooth movement .

• He expressed this value as 200 gm/sq.cm of root surface area

Bio prog therapy suggest as 100gm/sq.cm

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•Density of bone is also an influencing factor movement through

cortical bone require even less forces.

.016 x .016 chrome alloy archwires ,with designs ,that allow more

wire through spanning arches , sectional arches , or multiple loops

have been found to apply light continuous forces

5.Orthopedic alteration

Orthopedic forces changes the relationship of the basic supporting

for jaw structure contrasted to tooth movement in localized area .

It also affects areas associated with supporting structures like

condyles of mandible and palatal plates of maxilla Ex ; Headgear ,

RME

• Headgear according to facial type

6. Treat the overbite before the overjet correction

Most malocclusion , have a deep incisor bite relationship as in

. class II div 1 and div 2

For stability in function and retention it is vital to correct deep

bite so as to get proper overjet ,overbite and inter incisal relationship

Methods of Deep bite correction – A. Extrusion of posterior teeth

(unstable)

B. Intrusion of anterior teeth

Extrusion of Posterior teeth – 1 Vertical growth pattern

(increases anterior facial height)

2 Horizontal

(resist molar extrusion)

•Bio .prog therapy considers incisor intrusion as treatment of choice

• If deep bite is not corrected before overjet correction ?

Interference during retraction leads to limited occlusion and causes

extrusion of posteriors

• Spanning arch - Utility arch

It stabilizes the buccal occlusion and apply light continous force for

incisor intrusion

7. Sectional arch therapy

In continuous arch the force and leveraging action to move

malposed teeth comes primarily from the adjacent tooth along

the arch and , because of the short span between their brackets ,

very heavy forces of a short duration are usually applied.

In sectional arch treatment the arches are broken into sections or

segments in order that the application of force in direction and

amount will be of more benefit in efficient movements of the

teeth.

Four benefits of sectional arch treatment

1 It allows lighter continuous forces to be directed to the

individual teeth.

utility intrusion arch , class II elastic , cuspid retraction

2 More effective root control in the basic tooth movement

For intrusion – Roots of lower incisor ,

Root of cuspid need separate torque

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3. Supplements maxillary orthopedic alteration.

4 Reduces the binding and friction of the brackets along arch wire

8. Concept of overtreatment

It is necessary for the clinician not only to appreciate the changes to

bring the teeth into properly aligned functional occlusion , but to

anticipate changes that follow when all the appliances are removed

and post treatment adjustments begin to occur.

Bio prog therapy suggest four areas where the concept of

overtreatment may help :

1 To overcome the muscular forces against the tooth surfaces

• Narrow upper arches,

• Anterior open bite ,

• Upper anterior protrusion due to lip sucking.

2 Root movements needed for stability:

Deep bite ,Paralleling of roots

adjacent to extraction sites , Severe rotations

3 To overcome orthopedic rebound as heavy forces are eliminated ,

the basic supportive structures may rebound.

4 To allow settling in retention over treatment of the individual teeth

within the arches allows them to settle into a functioning occlusion.

9. Unlocking the malocclusion in a progressive sequence of

treatment in order to establish or restore more normal function

1 To describe the malocclusion and visualize the position of the teeth

in terms of what functional influences have been responsible for their

present form .

2 To describe the facial type and skeletal structure .

3 To describe the present abnormal functional influences upon dental

arches , or the lack of abnormal development by default

Ex: Upper arch expansion , Incisor protrusion correction,

TMJ problems

10. Efficiency in treatment with quality results, utilizing a concept of

prefabrication of appliances .

Allows the clinician to direct his energies in details of appliance

application, diagnosis and treatment planning.

VISUAL TREATMENT OBJECTIVE

(V.T .O)

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V.T.O

“Blue print for building a house”

▪ Its a visual plan to forecast the normal growth of the patient , so as

to establish the individual objectives for that patient .

▪Helps orthodontist to take advantage of growth .

▪ Valuable for orthodontist in self improvement.

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BURSTONE ANALYSIS

CEPHALOMETRICS FOR ORTHOGNATHIC SURGERY

[COGS ANALYSIS]

GIVEN BY CHARLES.J.BURSTONE

AT UNIVERSITY OF CONNECTICUT


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• Sample:

– From child research council of the university of

colorado school of medicine.

• Size: 30. ‘14 M’ and ‘16 F’

• Characteristic: longitudinal

• Race: cacausian

• Age: 5 – 20.

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Burstone Analysis

Hard tissue Analysis Soft tissue Analysis

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Characteristics of COGS

• The chosen landmarks and measurements can be altered by various surgical procedures.

• The comprehensive appraisal includes all of the facial bones and cranial base reference.

• Rectilinear measurements can be readily transferred to a study cast for mock surgery.

• Critical facial skeletal components are examined.

• Standard and statistics are available for variation in age and sex from 5 -20 on the basis of developmental age.

• COGS appraisal describes dental, skeletal and soft tissue variations.

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LANDMARKS USED IN COGS

• SELLA (S)

• NASION (N)

• ARTICULARE (Ar)

• PTERYGO MAXILLARY FISSURE (Ptm)

• SUBSPINALE (Pt A)

• POGONION (Pog)

• SUPRAMENTALE (B)

• ANTERIOR NASAL SPINE (ANS)

• POSTERIOR NASAL SPINE (PNS)

• MENTON (Me)

• GNATHION (Gn)

• GONION (Go)

PLANES

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Horizontal Plane:

• The base line for comparison for most the data in COGS analysis.

• Is a constructed plane called ‘Horizontal Plane’ which is a surrogate FH plane, constructed by drawing a line 7º from SN plane.

• Most measurements are made for projections either parallel or perpendicular to HP.

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• Mandibular Plane: constructed from menton to gonion.

• Nasal Floor: plane constructed from ANS to PNS.

• Occlusal Plane: is a line drawn from te

buccal groove of the permanent first molar through a point 1mm with in the incisal edge of the central incisor in each arch.

Hard Tissue Analysis

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Cranial Base:

• Ar- N:

– Skeletal base line for

corelating other

measurements.

– Relatively stable

anatomic plane.

– Can be changed by

cranial surgery or auto-

rotation of mandible.

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• Ar-Ptm:

– Determines horizontal

distance between

maxilla and mandible

posteriorly.

– More the distance

between Ar-Ptm, more

the mandible lies

posterior to maxilla.

– Male- 37.1 ± 2.8mm

– Female- 32.8± 1.9mm

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• Ptm-N:

– Determines the

horizontal end of

maxilla.

– Its less in cases of mid

facial deficiency, Class

III andCleft Palate.

– Male- 52.8 ± 4.1mm

– Female- 50. ± 3mm

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Horizontal Skeletal Profile:

• N-A-Pg:

– Angle of convexity.

– Drawback: does not

indicate the jaw

involved.

– +ve –convex profile,

clockwise angle.

– -ve – concave profile,

counterclockwise

angle.

– Male: 3.9º ± 6.4º

– Female: 2.6º ± 5.1º

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• N-A:

– Horizontal distance

from Pt A to

perpendicular from HP

through N.

– Describes whether

anterior part of maxilla

is protrusive / retrusive

– Male:0.0 ± 3.7mm

– Female: - 2 ± 3.7mm

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N-B:

The horizontal distance of Pt B to the line perpendicular to HP through N gives N-B measurement.

Gives horizontal position of the apical base of mandible in relation to N in AP direction.

+ve value when Pt B and –ve value when Pt B is behind the perpendicular line.

Male: -5.3±6.7

Female: -6.9±4.316

• N-Pg:

• Indicates the prominence of the chin.

• Used in planning of genial augmentation or genial reduction.

• Male: -4.3±8.5mm

• Female: -6.5±5.1mm

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Vertical (skeletal and dental)

• Vertical Skeletal:

– Anterior component

– Posterior component

• Vertical Dental:

– Anterior component

– Posterior component

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Vertical skeletal

Anterior component

• N-ANS:– Represents middle

1/3rd facial height.

– Male:54.7±3.2mm

– Female:50.0±2.4mm

• ANS-Gn:– Represents lower 1/3rd

facial height.

– Male:68.6±3.8mm

– Female: 61.3±3.3mm

Posterior component:

• PNS-N:– Represents posterior

maxillary height.

– males:53.9±1.7mm


• MP-HP:– Represents posterior

facial divergence with anterior facial height.

– Males:23.0º±5.9º

– Females:24.2º±5.0º

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Vertical dental:

ANTERIOR COMPONENT

• Upper CI- NF: Represents anterior maxillary dental height.

– Male: 30.5 ± 2.1mm

– Females: 27.5 ± 1.5mm

• Lower CI-MF: represents total vertical dimension of anterior mandible.

– Male: 45.0 ± 2.1mm

– Female: 40.8 ± 1.8mm

POSTERIOR COMPONENT

• Upper 1st molar-NF: Represents posterior maxillary dental vertical height.

– Males:26.2±2mm


• Lower 1st molar-MP: Represents Posterior vertical mandibular dental height.

– Males: 35.8±2.6mm

– Females:32.1±1.9mm

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Maxilla and mandible:

Maxilla:

• PNS-ANS:– Gives the effective

length of maxilla.

– This distance with the ANS-N and PNS-N measurements gives a quantitative description of the maxilla in the skull complex

– Males:57.7±2.5mm


Mandible:

• Ar-Go (linear): – Gives quantitative

length of mandibular ramus.

– Males:52.0±4.2mm


• Go-Pg (linear):– Linear measurement of

mandibular body.

– Males:83.7±4.5mm


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• Ar-Go-Gn: (gonial angle)– Represents relation

between mandibular

ramus and body.

– Males:119.1º ±5.1º


• B-Pg:

– Describes mandibular

chin prominence with

respect to mandibular

denture base.

– Males:8.9±1.7mm


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Dental:

• Occlusal plane angle:

– Angle formed between OP plane and HP. If the teeth

overlap anteriorly to produce an overbite,the OP can be

drawn as a single line.

– If an anterior openbite is pesent then,Op passes through

a point 1 mm within the incisal edge the two Op must be

drawn and measured seperately for the angle with HP.

– Each OP is assessed as to its steepness or flatness

– Vertical facial and dental height must be assessed to

determine which OP should be corrected.

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• Increased OP-HP may be associated with skeletal openbite,lip incompetence,increased facial height and retrognatic mandible.

• Decreased OP-HP seen in deep bite, decreased facial height.

• Male:6.2 º±5.1º

• Females:7.1º±2.5º

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• AB-OP (linear):

– Gives relationship of

maxillary and

mandibular apical

bases to OP.

– Males:-1.1±2mm

– Females: -0.4±2.5mm

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• Upper CI- NF (angle):

– This is constructed

from a line drawn from

the incisal edge of

incisors through the tip

of the root to the point

of intersection with NF.

– Males:111.0º±4.7º


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• Lower CI-MP (angle):

– Represents the

angulation of lower CI

to MP.

– Determines the

procumbency/recumbe

ncy of the incisors.

– Males:95.9º±5.2º


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Soft Tissue Analysis.

• Treatment Planning for patients who require orthognathic surgery should include both a hard tissue and soft tissue cephalometric analysis.

• Soft tissues such as neck, nose, and lips must be considered in determining whether prognathism or retrognathism of the jaw exists.

Legan HL, Burstone CJ. Soft tissue cephalometric analysis

for orhtognathic surgery. J Oral Surg 1980: 38 : 81-87. 30

• Burstone, previously developed a system of soft tissue analysis for planning treatment for patients requiring orthodontic treatment (1958).

• This analysis was reduced to its most relevant measurements and new measurements were added which were significant to the surgical patient.

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• The means and standard deviations were derived from a population of 40 white adults(20 men and 20 women) between the ages of 20 and 30.

• All were orthodontically untreated patients with class I occlusions and had a vertical facial proportions that were determined to be within normal limits. (N-ANS / ANS-Me was

between 0.75 and 0.85)

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Mesurement Landmarks Mean S.D

Facial Form

•Facial Convexity angle

G-Sn-Pg’ 12 4

•Maxillary Prognathism

G-Sn (HP) 6 3

•Mandibular Prognathism

G-Pg’ (HP) 0 4

•Vertical Height ratio G-Sn/Sn-Me’

(HP)

1 ---

•Lower face - Throat angle

Sn-Gn’-C 100 7

•Lower Vertical Height-Depth Ratio

Sn-Gn’/C-Gn’ 1.2 ---

Soft tissue analysis- Adult Standards

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Mesurement Landmarks Mean S.D

Lip Position and Form

•Nasolabial Angle Cm-Sn-Ls 102 8

•Upper lip protrusion Ls to (Sn-Pg’) 3 1

•Lower lip protrusion Li to (Sn-Pg’) 2 1

•Mentolabial Sulcus Si to (Li-Pg’) 4 2

•Vertical lip-Chin Ratio

Sn-Stms/Stmi-Me’ 0.5 ---

•Maxillary incisor Exposure &

•Interlabial Gap

Stms – 1

&

Stms-Stmi

2

2

2

2

Soft tissue analysis- Adult Standards

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Facial Form

• Facial Convexity Angle

( G-Sn-Pg’)

• Describes overall horizontal soft tissue profile of the patient.

• G – Sn – Pg’.

• 12+4

• A clockwise angle is positive (+) and a counterclockwise angle is negative (-).

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• As the positive angle increases, the profile becomes more convex, suggesting a class II skeletal and dental relationship and vice-versa.

• However, the angle of facial convexity is not specific as to the location of the deformity.

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• Maxillary and Mandibular Prognathism

• A line perpendicular to the horizontal plane (HP) is dropped from glabella and the relationship of the maxilla and the mandible are related to it.

• It helps to determine whether the problem is in maxilla or mandible.

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• Maxillary Prognathism (G-Sn II HP)

• The distance from the line perpendicular to HP to Subnasale is measured.

• Describes the amount of maxillary excess or deficiency in the anteroposterior

dimension.

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• A negative number suggestive of maxillary retrusion, whereas a large positive number connotes maxillary procumbency.

• Mean – 6+3mm.

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• Mandibular Prognathism (G-Pg’ II HP)

• The position of pogonion is also measured parallel to HP from the perpendicular line dropped from glabella.

• This measurement gives an indication of mandibular prognathism or retrognathism.

• Mean – 0+4mm.

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• Vertical Height Ratio

(G-Sn/Sn-Me I HP)

• In the vertical dimension, the anterior facial proportionality is assesed by taking the ratio of middle-third facial height to lower-third facial height measured perpendicular to HP.

• The ratio must be approximately 1:1

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• A ratio of less than one would connote a disproportionately larger lower third of the face.

• A vertical maxillary excess, vertical macrogenia, or a combination of these deformities can be assesed.

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• Lower Face-Throat Angle (Sn-Gn’-C)

• It is formed by the intersection of the lines Sn-Gn’ and Gn’-C.

• An application of this angle is critical in planning treatment to correct anteroposterior facial dysplasias.

• Mean- 100+7

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• An obtuse angle should warn the clinician not to use those procedures which will reduce the chin prominence.

• Class III patients who have short, heavy throats and an obtuse lower face-throat angles should not have mandibular set backs.

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• Alternatives such as maxillary advancement, a mandibular subapical surgery, mandibular setback with advancement genioplasty.

• Compromised tooth position can also be attempted.

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• Lower Vertical Height-Depth Ratio

• Sn-Gn’/C-Gn’

• Is useful in determining the feasibility of reducing or increasing the prominence of chin.

• Mean-1:2

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• The ratio of the distances subnasale to gnathion and cervical point to gnathion is normally a little larger than 1.

• In other words, if this ratio becomes much larger than 1, the patient has a relatively short neck, and the anterior projection of the chin should not be reduced.

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Lip Position and Form

• Nasolabial Angle(Cm-Sn-Ls)

• Is an important measurement in assessing anteroposterior maxillary dysplasias.

• Although the angle takes into account the inclination of the nose, it is useful in evaluating the position of the upper lip.

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• Mean- 102 ±8

• An acute nasolabial angle will often allow us to surgically retract the maxilla or retract the maxillary incisors, or both.

• An obtuse angle suggests a degree of maxillary hypoplasia and calls for a maxillary advancement or orthodontic proclination of maxillary incisors.

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• Anteroposterior Lip Position

• Is evaluated by drawing a line from subnalsale to soft tissue pogonion.

• The amount of lip protrusion or retrusion is measured as a perpendicular linear distance from this line to the most prominent point of both lips.

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• Upper Lip Protrusion {Ls to (Sn-Pg’)}

• Mean - 3+1mm

• Lower Lip Protrusion {Li to (Sn-Pg’)}

• Mean – 2+1mm

• Retracting or protracting the incisors surgically or orthodontically or advancing or reducing the prominence of chin, or both, can achieve concordant lip position.

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• Mento-Labial Sulcus { Sl to (Li-pg’)}

• Measured from the depth of sulcus perpendicular to the Li-Pg’ line.

• A sulcus of 4mm is average in providing a pleasing lower lip to chin contour.

• Mean – 4+2mm

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• Factors that can affect the lower lip inclination and deepen the mentolabial sulcus.

• Flared lower incisors.

• Extruded upper incisors.

• Flaccid lower lip tone.

• Abnormal morphology of the lip.

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• To Reduce a deep Mentolabial Sulcus.

• Upright the lower incisors.

• Intrude the maxillary incisors.

• Cheiloplasty to retract the lower lip.

• Bony Chin. ( Can affect the depth of sulcus)

• Advancement Genioplasty will deepen and Reduction Genioplasty will aid in reducing excessive sulcular depth.

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• Vertical Lip-Chin ratio.

• Sn-Stms/Stmi-Me’ (HP)

• The lower third of the face (Sn-Me’) can be divided into thirds; the length of the upper lip, or Sn-Stms should be approximately one third the total.

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• The distance Stmi-me’ should be about two thirds.

• In other words, the ratio should be 1:2.

• When this ratio becomes smaller than one half, often a vertical reduction genioplasty

should be considered.

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• Maxillary Incisor Exposure(Stms-1)

• A Key factor in determining the vertical position of maxilla.

• 2mm of maxillary incisor exposure with the lips at rest is desirable.

• This will also correspond in general with a pleasing smile.

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• Patients with vertical maxillary excess tend to show a large amount of upper incisor with lips in repose.

• The patients that show an excess exposure of tooth may just have a short upper lip also. So, Treatment approach should be accordingly.

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• Treatment modalities orthodontically is to establish a large curve of spee.

• Conversely, patients with a long face that also have open bites may have an acceptable tooth-to-lip relationship but may need superior repositioning of the posterior portion of the maxilla.

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• Patients with vertical maxillary deficiency tend not to show maxillary teeth with lips relaxed and may have incisors at a level superior to the upper lip, giving an edentulous look.

• Orthodontically, extruding the maxillary teeth or surgically positioning the maxilla inferiorly will be a useful treatment approach.

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• Interlabial Gap {Stms-stmi (HP)}

• Vertical distance between the upper lip to the lower lip in repose, has been shown by Burstone to be fairly ideal at a range of from just lightly touching to approximately 3mm apart.

• Mean – 2+2mm

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biblography:

• Cephalometrics for orthognathic surgery.

– Charles J Burstone, DDS,MS; Randal B.

James, DDS; H Legan, DDS; G A Murphy,

DDS; Louis A. Norton DMD, Farmington, Conn.

– Journal of Oral Surgery, Vol 36, Aug 1978.

• Soft tissue cephalometric analysis for

orhtognathic surgery.

– Legan HL, Burstone CJ. J Oral Surg 1980: 38

: 81-87.

Thank you…

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Good morning1

DEVELOPMENT OF

dentition and

OCCLUSION2


CONTENTS

➢ Introduction

➢Prenatal Dental Development

➢The mouth of neonate – Pre-dentate period

➢Eruption of teeth

➢The Primary teeth and occlusion

▪ Development of teeth

▪ Development of occlusion

➢The mixed Dentition period

▪ First transitional period

▪ Inter-transitional period

▪ Second transitional period

➢Permanent teeth and occlusion

➢Assessment of dental age3

CONTENTS

➢Dentitional and occlusal development in Young Adult

➢Andrew’s six keys of occlusion

➢Occlusion and mandibular movements

➢Factors affecting occlusal development

➢Role of genetics in occlusal development

➢Clinical implications

▪ Normal versus ideal occlusion

▪ Occlusal adaptive mechanisms

➢Conclusion

➢References4

What is “occlusion” ?

Mosby’s dental dictionary (Zwemer;1998) defines occlusion as

”a static morphological tooth contact relationship”

Acc. to Ash and Ramfjord , occlusion may be defined as ”the

contact relationship of the teeth in function or para

function”.

Acc. to Angle, occlusion is “the normal relation of the

occlusal inclined planes of the teeth when the jaws are

closed”.

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➢ The term occlusion , however, refers not only to contact

at an occlusal interface but also to “ all those factors

concerned with the development and stability of the

masticatory system and with the use of the teeth in oral motor behaviour ”

➢ In most instances , malocclusion and dentofacial

deformity are not caused by some pathological process ,

but by moderate distortions of normal development.

➢ Therefore , knowledge of the process of occlusal

development is necessary for the practice of

orthodontics.

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DEVELOPMENT OF DENTITION

➢Humans are having two sets of teeth

Deciduous dentition Permanent dentition7

PRENATAL DENTAL

DEVELOPMENT

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Prenatal Dental DevelopmentInitiation Of Odontogenesis

• First sign of tooth development - third embryonic week – thickening of epithelial lining

• At sixth week - Epithelial thickenings coalesce -dental lamina

Dental lamina9

Prenatal Dental DevelopmentInitiation Of Odontogenesis

Bud stage Cap stage Bell stage Advanced

bell stage

Initiation Proliferation Histo-differentiation Morpho-differentiation

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Prenatal Dental Development

➢ Sequential pattern▪ CI-LI-C-M1-M2

▪ Postnatal variations – 25 %

➢Spatial pattern▪ The prenatal dental arch progressively changes shape

▪ 6-8 week- Flat antero-posteriorly

▪ 4th month - Elongation of Ant. Segment - Catenary curve

➢Spacing ▪ Inter-dental spacing is relatively constant during this period.

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Prenatal Dental Development➢Tooth Fields

▪ Interdental spaces are shared by

neighbouring tooth fields.

▪ Tooth germ together with the space

mesial and distal to it within the dental

arch is called tooth field

▪ Greatest level of occupancy of a tooth

field by a tooth germ is about 80 % for

the first deciduous molar and lateral

incisor.

▪ More occupancy of the field by the

lateral incisor leads to its concomitant

rotation and displacement.

#Van der linden FPGM et al .Tooth size and position before birth . J Dent

Res 1972;51:71-74 12

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Mouth of the neonate

Predentate period

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Predentate Period

Gum pads➢Cover the alveolar process at birth

➢Pink, firm, covered by dense fibrous periosteum

➢Segmented to indicate sites of developing teeth

➢Transverse groove divides into ten parts

➢Dental groove demarcates the labio-buccal and the lingual portions

➢Lateral sulcus between the canine and the first molar is used to estimate the inter-arch width

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Predentate Period

➢Size of the gum pads at birth may be determined by (Leighton) :

▪ State of maturity of infant at birth

▪ Size at birth as expressed by birth weight

▪ Size of developing primary teeth

▪ Purely genetic factors

➢ Maxillary arch▪ Horse shoe shaped

▪ Complete overjet labially and bucally

➢ Mandibular arch ▪ Lies posterior to the maxillary arch when the gum pads

contact

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Predentate Period

➢Neonatal jaw relations

▪ No precise ‘Bite’ or jaw relation

▪ Ant. open bite incidence

➢Dental Arch Width

▪ pre-eruptive:

• significant increase between

6 weeks and 1 year

16

Predentate Period Precociously erupted primary teeth

➢Natal teeth

➢Neonatal teeth

➢ Pre-erupted teeth

➢ Etiology

▪ Superficial position of tooth germ

▪ Febrile incidents, hormonal stimulation, heredity

• Increased rate of eruption

▪Osteoclastic activity

➢ Associated with syndromes

• Chondro-ectodermal dysplasia

17

Predentate Period Self correcting anomalies

➢Retrognathic mandible

▪ Differential and forward growth

➢ Anterior open bite

▪ Eruption of primary incisors

➢ Infantile swallowing pattern

▪ Introduction of solid food in diet

18

.

4

CALCIFICATION

▪ Stages of tooth development given by Nolla

▪ He arbitrarily divided the tooth development in 10 stages

▪ Development of a tooth is compared with drawings

▪ Stage 2 – initial calcification

▪ Stage 6 – beginning of eruptive movements

▪ Girls are more advanced in

calcification of permanent teeth than

boys

# Nolla CM.The development of the permanent teeth. J Dent Child 1960; 27 :254-26619

ERUPTION OF TEETH

20

ERUPTION OF TEETH

➢ It is a developmental process that moves a tooth from it’s crypt position

through the alveolar process into the oral cavity and to occlusion with it’s

antagonist

➢ Physiologic tooth movements leading to tooth eruption can be divided into 3

phases

1. Pre - eruptive phase

2. Eruptive phase

3. Post - eruptive phase 21

➢ERUPTIVE PHASE

Begins with the root formation and the tooth moves from its position

within the jaw bones to its functional position in occlusion. The principal

direction of movement is occlusal.

➢PRE - ERUPTIVE PHASE

Consists of the movements of the developing tooth germs within the

alveolar process before root formation. During this phase, the growing teeth

move in various directions to maintain their position in the expanding jaws.

➢POST - ERUPTIVE PHASE

Consists of tooth movements which

▪Maintain the position of the erupted teeth while the jaws continue to

grow

▪Compensate for occlusal and proximal wear22

Theories of tooth eruption

➢Root elongation theory

▪ Suggests that proliferating root impinges on a fixed base, the

cushion-hammock ligament, thus converting an apically

directed force into occlusal movement.

▪ Evidence against - A series of experiments where rootless

teeth have erupted into functional occlusion.

➢Pulp constriction theory

▪ Suggests that a propulsive force is generated by extrusion of

pulp through three mechanisms : firstly growth of dentin,

secondly interstitial pulp growth and thirdly, hydraulic effects

within the vasculature

▪ Evidence against - The work of Merzberg and Schour, who

removed the pulp of rodent incisors and found that the

eruption rates were unaffected. 23

Theories of tooth eruption➢Hydrostatic pressure theory

▪ Teeth move in their sockets in synchrony with arterial

pulse, thus local volume changes may produce limited

tooth movement.

▪ Evidence against - Surgical excision of a growing root

and associated tissue eliminates the periapical

vasculature without stopping eruption.

➢ Bone remodeling theory

▪ Suggests that selective deposition and resorption of bone

brings about eruption of tooth.

• Evidence supporting - In experiments where tooth germ is

removed but the follicle is left in position, the eruptive

pathway still forms in bone thus proving the dental follicle

and not bone as the major determinant in tooth eruption.

24

.

5

Theories of tooth eruption

➢Periodontal ligament traction theory▪ The periodontal membrane plays an important role in the

tooth eruption. Two causative agents with in the

periodontal ligament which can generate eruptive force.

• Collagen contraction

• Fibroblast traction

▪ Evidence supporting – Changes are induced in the

shape and orientation of PDL fibroblasts by a transition

from impeded to unimpeded eruption.

25

FACTORS AFFECTING

ERUPTION

➢Factors regulating and affecting eruption

▪ Heredity

▪ Socioeconomic status

▪ Racial differences

▪ Nutritional influence

▪ Mechanical disturbance

▪ Localised pathosis

26

Deciduous dentition

27

Deciduous dentition

➢Begins at around 6 months of age with the

eruption of lower central incisors.

➢Completed after all the 2nd molars have attained

occlusion i.e. usually around 2.5 years of age.

➢ Little changes take place in the deciduous

dentition between 2.5 to 5 years of age.

28

Deciduous dentitionDevelopment Of Primary teeth

➢Calcification▪ Central incisor- 14 week

▪ 1st molar- 15 1/2 weeks

▪ Lateral incisor- 16 week

▪ Canine- 17 week

▪ 2nd molar- 18 week

➢Genetic control ▪ Morphology, rate and sequence of growth, pattern

of calcification, mineral content of teeth

29

Deciduous dentition:Development of Primary teeth

➢ Eruption

➢Sexual differences▪ Males - early eruption till 15 month

▪ Females - surpass after 15 months

30

.

6

Deciduous dentitionDevelopment of Primary teeth

➢Developmental anomalies▪ less frequent

▪ fewer than 1% incidence of congenitally missing teeth.

➢Primary tooth resorption▪ Important contribution to permanent tooth eruption

▪ Due to pressure from the erupting permanent successor

though it may occur even its absence

▪ Hastened by inflammation and occlusal trauma

▪ Delayed by splinting and absence of permanent successor

31

➢Ankylosis▪ Primary teeth more likely to be involved as compared to permanent

▪ Teeth fused to alveolar bone and their eruption prevented

▪ Particularly molars

▪ Lower teeth twice as upper

▪ Often bilaterally

▪ Trauma or excessive pressure said to be the cause

▪ Osseous bridging and fusion of bone occuring during rest periods of resorption of dentin

▪ Posterior open bite due to involved tooth being “submerged ”.

32

Deciduous dentition: Development of occlusion

➢Neuromuscular considerations

▪ Sequential inter-dentation begins in the front as the

incisors erupt

▪ Teeth guided into occlusal position by muscular

functional matrix during very active growth of the facial

skeleton.

▪ Low cusp ht. and ease of wear of occlusal surfaces

also contribute to this adaptability

▪ Muscle behaviour is adaptive to skeletal morphology

▪ Acc . to a study by Leighton ,abnormal sucking habits

either largely cause the skeletal differences or

contribute to them.33


➢Arch form▪ In maxilla

• Ovoid in shape

• Role of tongue

• Increased intercanine width by 6 mm between 3-13 yrs

• Increased Intermolar width of 2 mm between 3-5 yr34


➢Arch form▪ In mandible

▪Ovoid shape

▪ Increased intercaninewidth by 3.7 mm between3-13 yrs

▪ Increased Intermolarwidth of 1.5 mm between3-5 yr

35


➢Arch length and

circumference

▪ Small amount of decrease

• mesial migration of second

primary molars during eruption

• proximal caries

36

.

7


Spacing➢Usually generalised inter-dental spacing

➢According to Baume▪ Closed dentition

▪ Spaced dentition

• Generalized- Physiologic Pressure from the

tongue (Barber)

• Localized – Primate spaces (anthropoid/

simian spaces)

• Primate spaces• 87% of maxillary arches between lateral incisor

and canine

• 78% of mandibular arches between canines

and first primary molars37


➢ Flush terminal plane

▪ The lower second molar is wider mesio-distally than maxillary second molar

▪ The distal surfaces of upper and the lower second molars are in one plane

▪ Favorable for the eruption of the first permanent molars into a normal relation

Occlusal relations

38


➢ Mesial step

▪ Distal surface of lower

more mesial to upper

▪ Eating habit, Attrition and

growing mandible

▪ Favourable

39


➢ Distal step

▪ Distal surface of lower

more distal to upper

▪ Sucking habits

▪ Prognostically

unfavourable

40


➢ Acc. to a study by Bishara et al , the distribution of terminal plane relationships was found to be:

Distal step - 10%

Flush terminal plane - 29%

Mesial step of 1-0 mm -42%

Mesial step > 1-0 mm -19%

# Samir E Bishara – ‘Changes in molar relation between deciduous and

permanent dentition –a longitudinal study . Am J Orthod 1988;93:19-28 41


➢Over bite

▪ Vertical Incisor overlap

▪ Average - 1- 2mm

▪ Decreases steadily ; a reflection of skeletal maturation

▪ Foster study

• Ideal- 19%

• Reduced- 37%

• Openbite-24%

• Excessive overbite- 20%

# Foster TD , Hamilton MC : Occlusion in the primary dentition . Br Dent J 1969

;126 : 76-79 42

.

8


➢ Overjet▪ Horizontal overlap

▪ Normal :- 0-4 mm in primary dentition

▪ Decreases steadily

▪ Foster study

• ideal – 28%

• excessive – 72%

# Foster TD , Hamilton MC : Occlusion in the primary dentition . Br Dent J

1969 ;126 : 76-79 43

Normal signs of Deciduous

dentition

➢ Spaced anteriors

➢ Primate spaces

➢ Shallow overbite and overjet

➢ Straight terminal plane

➢ Class - I molar and cuspid relationship

➢ Almost vertical inclination of anterior teeth

➢ Ovoid arch form

44

Self correcting anomalies of Deciduous

dentition

➢ Anterior deep bite

▪ Cause - Incisors more upright

▪ Correction

• Forward and downward growth of mandible

• Attrition of incisal edges

• Eruption of permanent molars

45

Self correcting anomalies of Deciduous

dentition

➢ Primate spaces

▪ Early mesial shift

➢ Flush terminal plane

▪ Early mesial shift

▪ Late mesial shift

➢Physiologic spaces

▪ Permanent incisor accommodation

46

MIXED DENTITION PERIOD

47

Mixed dentition

➢Period of both primary and permanent

dentition

➢Those permanent teeth that follow into

place in the arch once held by a primary

teeth are called SUCCESSIONAL TEETH

- Incisors, cuspids and bicuspids)

➢Those teeth that erupt posteriorly to the

primary teeth are termed as

ACCESSIONAL TEETH48

.

9

Mixed dentition

➢Clinical importance

▪ Utilization of arch perimeter

▪ Alignment of permanent incisors.

▪ Space for cuspids and premolars.

▪ Adjustment of the molar occlusion.

▪ Adaptive changes occur in occlusion during the

transition from deciduous dentition to permanent

▪ Orthodontic intervention

49

Eruption of permanent teeth

➢Sequence

➢Maxillary

6-1-2-4-3-5-7 or 6-1-2-4-5-3-7

➢Mandibular

6-1-2-4-3-5-7 or 6-1-2-3-4-5-7

➢This includes 40-50 % of all children

# Lo RT , Moyers Re . Studies in the etiology and prevention of Malocclusion .I .

The sequence of eruption of permanent teeth. Am J Orthod 1953;39:460-750

Mixed dentition

➢ First transitional

period :-

▪ Emergence of first

permanent molars.

▪ Exchange of

deciduous incisors

with permanent

incisors.

▪ Establishment of

occlusion51

Mixed dentition First transitional period

➢1st molar eruption▪ Mandible

• Guided into its occlusal position by distal surface of 2nd primary molar

• Mesial and lingual path of eruption

▪ Maxilla• Forward direction of maxillary growth

• Space created posteriorly

• Distal and buccal path of eruption

52


➢Factors affecting first molar

eruption

• Congenital absence of tooth itself

• Congenital absence of premolars

• Distal caries of deciduous 2nd molar

• Early loss of deciduous 2nd molar

• Developmental disturbances

53


➢Molar adjustment

▪ Early mesial shift• Closure of primate spaces and other

inter-dental spaces from the rear

• Controversy - alternative theory

• primate spaces closed by eruption of

incisors without loss of perimeter

▪ Late mesial shift-• Mesial migration of first permanent molar

after loss of second deciduous molar

using leeway space.

5 Yr

7 YrJ Dent Res 1950; 29:331-7

54

.

10


Leeway space

➢The difference between the mesio-distal width

of the primary canine,1st molar,2nd molar and

their permanent successors.

➢ In Maxillary arch

▪ 1.5 mm per side

➢In Mandibular arch

▪ 2.5 mm per side

55


Occlusal changes➢ Flush terminal plane of primary dentition class l molar

relation of permanent molars ▪ Achieved by

• Late mesial shift

• Greater forward growth of mandible

• Combination of both

➢Two most common paths are

▪ From a flush terminal plane to class I

▪ From a mesial step to class I

➢A distal step in primary dentition results most likely in class II occlusion in permanent dentition

56

s

57


➢Incisor eruption

▪ Mandible

• Central incisors usually follow

mandibular first molars

• Erupt labially to their normal balanced

position between tongue and lip and the

facial musculature

• Lateral incisor eruption - Crowding

58


➢Incisor eruption▪ Maxilla

• Usually follow mandibular centrals or erupt concurrently with mandibular laterals

• More labial eruption than primary incisors

• Lateral incisors

• Erupt more labially than centrals

59


➢Incisor liability

▪ The difference between the amount of space needed

for the incisors and the amount available for them

▪ 6-7 mm

▪ It causes a transitory stage of mandibular incisor crowding

at age 8 – 9

▪ Normal development feature

60

.

11


➢Incisor liability adjustment

▪ Inter-canine arch growth - 3 to 4 mm

( 2 mm average )

▪ Inter-dental (Developmental) spacing -

2 to 3 mm

▪ More anterior position of permanent

incisors as they erupt - 1 to 2 mm

61

Mixed dentition Inter-transitional period

➢Between the 1st and 2nd transitional

period.

➢Stable phase

➢Contains both sets of dentition.

▪ Permanent 1st molars and incisors.

▪ Deciduous canines and deciduous 1st and

2nd molars.

62

Mixed dentition

➢ Second

transitional period

▪ Emergence of

Bicuspids, cuspids,

2nd molars

▪ Establishment of

occlusion

63

Mixed dentition Second transitional period

Mandible➢Most favorable and the most common

eruption sequence

▪ 6-1-2-3-4-5-7

➢ Eruption of cuspids first

▪ Maintenance of arch perimeter

▪ Prevention of lingual tipping of

incisors

64


➢ If tooth size-space available ratio is

poor , the cuspid may be stopped in its

eruption by the first molar or the

primary molar may be hastened in its

exfoliation

➢1st Bicuspids▪ Rarely any difficulty

▪ Sometimes show rotation due to

uneven resorption of primary molar

roots

65


➢2nd bicuspids▪ Last lower succedaneous teeth to erupt

▪ Extreme variation in calcification and development schedule

▪ Often congenitally missing

▪ Eruption complication

• Mesial migration of 1st molar

• Poor tooth size - space available ratio

• Premature exfoliation of 2nd primary molar

▪ First molar must not be allowed to move mesially untill the second bicuspid has attained its proper position in the arch

66

.

12


Maxilla

➢Sequence of eruption

▪ 6-1-2-4-5-3-7 or 6-1-2-4-3-5-7

➢1st bicuspid▪ Minimal difficulty in eruption

▪ Nearly the same size as its predecessor

67


Maxilla

➢2nd bicuspid▪ Easy eruption

▪ Larger mesio-distal width

of primary predecessor

permits easy eruption in

its place in the arch

68


➢Cuspid

▪ More difficult and tortuous path of eruption than any other tooth

▪ Uses leeway space for acomodation

▪ Favourable sequence

• Cuspid before 2nd molar

▪ In case of short arch length

• labioversion with a decided mesial inclination

69 70

Impacted maxillary cuspids

➢Frequently impacted

➢Females more than males.

➢Reasons :-

▪ High initial position in the crypt

▪ Deviated path of eruption

▪ Lack of guidance from maxillary lateral incisor

▪ Lack of space

▪ Congenital absence of lateral incisor

▪ Presence of supernumerary teeth


2nd molars➢Last teeth to erupt before 3rd molar

➢Mandible

▪ If precede 2nd bicuspid, the 1st molar may tip mesially

▪ Erupts typically before maxillary second molar

➢Maxilla

▪ Eruption of maxillary second molar ahead of the mandibular second molar is said to be symtomatic of a developing class ll malocclusion

# Lo RT , Moyers Re : Studies in the etiology and prevention of malocclusion.I.

The sequence of eruption of the permanent dentition . Am J Orthod 1953 39 :

460-467 71

Mixed dentition Self correcting anomalies

➢Ugly Duckling Midline diastema

(Broadbent phenomena)

72

.

13

Mixed dentition

Self correcting anomalies

➢Mandibular anterior crowding

▪ Increased inter-canine width

▪ Tongue pressure

• Labial movement and change in inclination of

incisors

73

Mixed dentition

Self correcting anomalies

➢End on molar relation▪ Late mesial shift

• Leeway space

74

PERMANENT

DENTITION

75

PERMNENT DENTITION

Factors determining the tooth’s position

➢Mesial drift▪ strong inherent tendency of the teeth to

move mesially even before they appear in the oral cavity

➢Anterior component of force ▪ Axial inclination of permanent teeth are

such that some of the forces of chewing produce a mesial resultant through the contact points of the teeth

▪ Result of muscle forces acting through the inter-cuspation of the occlusal surface.

▪ Counteracted by proximal contacts of the

teeth and by the musculature of the lips

and cheeks.76

Permanent dentition

Arch Width➢ Width increase involves alveolar process growth

➢ Maxillary alveolar processes diverge while the

mandibular processes are more parallel

Maxilla➢ Maxillary width increases are much greater and

they can be more easily altered in treatment

➢ Mid-palatal suture can be reopened with RME –

large amount of actual widening

Mandible➢ Widening the basal bony width – deposition on

lateral borders of corpus mandibularis

➢ Little help to clinician to widen the arch

77

Permanent dentitionSafety valve mechanism

➢Mandibular inter-canine arch width completed

▪ Girls – 9 years

▪ Boys – 10 years

➢Maxillary inter-canine arch width completed

▪ Girls – 12 years

▪ Boys – upto 18 years

➢Differences in increase in maxillary dimensions – pubertal growth spurts - in girls form 10 ½ - 12 years and from 12-18 years in boys

➢Maxillary inter-canine arch width increase serves as a

‘safety valve’ for the dominant horizontal basal mandibular growth during growth spurts. 78

.

14

Permanent dentition

Arch Circumference or perimeter➢Maxilla

▪ Typically increases slightly

▪ Angulation of incisors and greater increase in width - Preservation of circumference

➢Mandible▪ Reduction

• Late mesial shift

• Mesial drifting tendency

• Lingual positioning of incisors due to differential mandibulo-maxillary growth

• Original tipped position of incisors and molars

79

Permanent dentition

Overjet and overbite

➢Mixed to permanent dentition

▪ Overbite

• Increases followed by decrease

• Great variability

• Correlated with a number of facial dimensions ( eg . Ramus height )

▪ Overjet

• Reflection of antero-posterior skeletal relationship

• Sensitive to abnormal lip and tongue function

# Fleming HB .An investigation of the vertical overbite during the eruption of the

permanent dentition . Angle Orthod 1961;31:53-62 80

Assessment of dental age

➢Which teeth have erupted ?

➢The amount of resorption of the primary

teeth

➢The amount of development of the

permanent teeth.

81 82

DENTAL AGE - 6

➢Near simultaneous eruption

of permanent mandibular

central incisors, maxillary 1st

molars and mandibular 1st

molars.

83

DENTAL AGE - 7

➢Eruption of maxillary central incisors

followed by mandibular lateral incisors.

➢Root formation of maxillary lateral incisor

advanced.

➢Premolars and canines in stage of crown

completion.

84

DENTAL AGE - 8

➢Eruption of maxillary

lateral incisors

➢Delay of 2-3 years

before any more

permanent teeth erupt.

.

15

85

DENTAL AGE - 9

➢Primary canines,1st and 2nd

deciduous molars present

➢Root development of maxillary canines and all second premolars is just beginning

➢One third of the root of the mandibular canines and all of the first premolars have been completed.

86

DENTAL AGE - 10

➢Completion of one half of the root development

of mandibular canine, mandibular 1st premolar

and maxillary 1st premolar

➢Completion of roots of mandibular incisor teeth

➢Near completion of roots of maxillary laterals.

87

DENTAL AGE - 11

➢Near simultaneous

eruption of mandibular

canine , mandibular 1st

premolar and maxillary 1st

premolar.

Dental age – 12

88

➢Eruption of maxillary

canine, maxillary and

mandibular 2nd premolar.

➢Second permanent molars

in both the arches are

nearing eruption.

89

DENTAL AGE – 13 , 14 , 15

➢Progressive completion of

roots of permanent teeth.

➢ If 3rd molar is present

crown formation is

complete.

Dentitional and occlusal changes in young

adults

➢3rd molar development

▪ Most variable in calcification and eruption

▪ Role of 3rd molar in crowding

▪ Impacted mandibular third molars

• seen more frequently with skeletal class II particularly when mandible is short and acutely angled

90

.

16


adults

➢Dimensional changes

▪ Decrease in arch perimeter during the late adolescent and

young adult period

➢Occlusal changes▪ Decrease in overjet and overbite in 2nd decade

• Forward growth of mandible

▪ Changes in Sagittal relationships

• Mesial drifting tendency

• Inter-proximal wear

• Continuing growth of mandible

▪ 3rd molar eruption

91

Dentitional and occlusal changes in

young adults

➢Resorption of permanent teeth

▪ Idiopathic resorption of one or more teeth – by the

end of the second decade

▪ Frequency increasing with age

▪ Orthodontic treatment - increased severity and

number of resorbed teeth

92


young adults

➢Arrangement of teeth in the jaws

▪ Intra arch tooth alignment

• Relationship of teeth with in the dental arch

• Teeth seen in varying degree of inclination

• Lateral view – curve of spee

• Frontal view - curve of wilson

• Proximal view

93


young adults▪ Curve of spee

• First described by Von Spee in

1928

• Inclination of teeth in lateral view

• Antero-posterior curvature of the

occlusal plane

• The average value 2.5 – 3 mm

94


young adults

▪ Curve of Wilson

• In frontal view • Posterior teeth

• Maxillary arch - Slight buccal inclination

• Mandibular arch - Lingual inclination

• Medio-lateral or transverse curvature of the

occlusal plane

95


young adults

▪ In the proximal view

• Maxillary arch

• Anterior teeth - mesially inclined

• Posterior teeth - Distally inclined

• Mandible – oblique backwards

96

.

17


adults

➢Inter arch tooth alignment

• Relationship of teeth in one arch to those in other arch.

• Every tooth occludes with two opposing teeth except mandibularcentral incisors and maxillary third molars ; this one to two relationship leads to distribution of masticatoryload over the entire arch.

• Occlusal contacts occur mainly through two types

• Cusp to fossae relationship

• Cusp to embrasure relationship 97

Andrews six keys to normal occlusion

➢These are a set of six characteristics that

were consistently present in collection of

120 casts of naturally optimal occlusion ,

identified by Dr. Lawrence F Andrews

#Andrew L.F. The six keys to normal occlusion . Am J Orthod.1972 ; 62 : 296-302. 98

Key I : Interarch Relationships

➢ The mesio-buccal cusp of the

permanent maxillary first molar

occludes in the groove between the

mesial and middle buccal cusps of the

permanent mandibular first molar –

originally given by Angle

➢ The distal surface of the disto-buccal

cusp of the upper first permanent first

molar occludes with the mesial surface

of the mesio-buccal cusp of the lower

second molar

99

Key II : Crown Angulation

➢The mesio-distal tip of the

long axis of the crown

➢Measured as the angle

formed between the long

axis of the crown and a line

bearing 90 degrees from the

occlusal plane.

➢The gingival portion of the

long axis of crown is more

distal than the incisal portion

100

Key III : Crown inclination

➢ Labio-lingual or bucco-lingual

inclination

➢ Measured as the angle formed

by a line which bears 90 degrees

to the occlusal plane and a line

that is tangent to the bracket

side

101

Key III : Crown inclination

➢ Most maxillary incisors have a

positive inclination; mandibular

incisors have a slightly

negative inclination

➢ For posterior teeth a

progressively minus inclination

is seen from canine through

the second molars

102

.

18

Key IV: Rotations

➢Absence of rotations.

103

Key V: Tight Contacts

➢Contact points should abut unless a discrepancy exists in mesio-distal crown diameter.

104

Key VI : Flat occlusal plane or curve of spee

➢The depth of the curve of Spee ranging from a flat plane to slightly concave surface

➢Inter-cuspation of teeth is best when the plane of occlusion is relatively flat

105

Seventh key to occlusion

➢Acc. to McLaughlin and Bennett , tooth size is the seventh key to occlusion.

➢Evaluation of tooth size discrepancy -Bolton’s analysis.

➢Acc. to Bolton , a mean ratio of 91.3 ( ie . total mandibular versus maxillary tooth size) will result in ideal overbite - overjetrelationships as well as posterior occlusion.

106

Occlusion and mandibular

movements

➢Protrusive movements

▪ Incisal guidance

➢Lateral movements

▪ Canine guidance

▪ Group function

107

Incisal guidance

➢Determined primarily by

lingual surface of maxillary

anteriors and controls the

posterior disclusion during

protrusion.

➢ In normal occlusal

relationship protrusive

contacts occurs only on the

guiding inclines of anterior

teeth.

108

.

19

Incisal guidance

➢Reasons

▪ Incisors are located far away from TMJ

thus, creating less amount of stresses

on them.

▪ Gliding type of movement is more

adaptive to the incisors due to their

favorable anatomy.

109

Canine guidance

➢When mandible moves laterally contact

occurs only between the canines thus ,

discluding posteriors and incisors.

110

Canine guidance

➢Reasons▪Good crown to root ratio of canines.

▪Hard compact bone surrounding the tooth.

▪Location far away from TMJ receiving less amount of

stresses.

▪Many receptors in PDL of canines.

➢Prevents the breakdown of periodontal fibers of

posteriors and incisors.

➢Cannot be possible in periodontally

compromised canines or missing canines

111

Group function

➢Working side contacts extend posteriorly involving

premolars and mesiobuccal cusp of first molar.

➢Can be achieved when canine guidance is not

possible.

112

Mutually protected occlusion

➢Anterior and posterior teeth function differently

➢The posterior teeth function more effectively in stopping the mandible during closure, whereas anterior teeth function most effectively in guiding the mandible during eccentric movement.

➢Posterior teeth should thus contact slightly more heavily than anterior teeth in centric relation.

➢ This condition is described as mutually protected occlusion.

113

FACTORS AFFECTING OCCLUSAL DEVELOPMENT

➢General factors▪ Heredity

▪ Skeletal factors

▪ Muscle factor

➢Local factors▪ Aberrant

developmental

position of teeth

▪ Supernumerary

teeth

▪ Hypodontia

▪ Oral habits

▪ Localized soft

tissue anomalies114

.

20

Role of genetics in occlusal

development

➢Occlusal characteristics could be inherited in two

major ways

▪ An inherited disproportion between the size of

the teeth and the size of the jaws, which

would produce crowding or spacing

▪ An inherited disproportion between size or

shape of the upper and lower jaws, which

would cause improper occlusal relationships.

➢The more independently these characteristics

are determined, the more likely that disproportions could be inherited.

115

Role of genetics in occlusal

development

➢There is dental anthropological evidence that

population groups that are genetically

homogeneous tend to have normal occlusion.

However, in heterogeneous populations the

incidence of jaw discrepancies and occlusal

disharmonies is significantly greater.

➢The influence of inherited tendencies is

particularly strong for mandibular prognathism.

116

Clinical implications

➢Normal versus ideal occlusion

▪Normal occlusion implies more than a

range of anatomically acceptable values.

▪ It also indicates physiological adaptability

and the absence of recognizable

pathological manifestations.

117


➢Ideal occlusion is a state in which no

neuromuscular adaptation is needed because no

occlusal interferences are present

• The concept of an ideal occlusion refers both to an

esthetic and physiological ideal

• It is a hypothetical formula which does not and

cannot exist in man

118


➢Occlusal adaptive mechanisms

119

Conclusion

➢Occlusion , good or bad, is the result of an

intricate and complicated synthesis of

genetic and environmental relationships at

work throughout the early developmental

stages of childhood and young adulthood.

➢Understanding the concepts has thus got

far reaching implications in diagnosis,

treatment planning and prognosis of

malocclusion.120

.

21

References➢ Robert Meyers. Handbook of orthodontics

➢ Samir E. Bishara . Textbook of Orthodontics

➢ William R. Profitt .Contemporary orthodontics: fourth

edition

➢ Wheelers dental anatomy

➢ Woelfel , Scheid .Dental anatomy

➢ A.R. Ten Cate . Oral histology – development, structure

and function

➢ Berkovitz ,Holland and Moxham .Oral anatomy,histology,

embryology

➢ Ramfjord SP. Occlusion

➢ McLaughlin , Bennett and Trevisi – Systemized

orthodontic treatment mechanics

121

References

➢ Andrew L.F. The six keys to normal occlusion . Am J

Orthod. Vol. 62; 1972: 296-302.

➢ Samir E. Bishara .Changes in molar relationship

between deciduous and permanent dentition – a

longitudinal study. Am J Orthod. 1988; 93:19-28.

➢ Lo RT , Moyers Re : Studies in the etiology and

prevention of malocclusion . I. The sequence of eruption

of the permanent dentition . Am J Orthod 1953 39 : 460-

467

➢ Fleming HB .An investigation of the vertical overbite

during the eruption of the permanent dentition . Angle

Orthod 1961;31:53-62

➢ Functional occlusion for orthodontist . JCO 1981;jan 32-

51122

References

➢ Foster TD , Hamilton MC : Occlusion in the primary

dentition . Br Dent J 1969 ;126 : 76-79

➢ Nolla CM.The development of the permanent teeth. J

Dent Child 1960; 27 :254-266

➢ Van der linden FPGM et al .Tooth size and position before

birth . J Dent Res 1972;51:71-74

123

Thank you124

.

1

Hard tissue Analysis


Contents

Mc Namara Analysis

Quadrilateral Analysis

Bjork Analysis

Jaraback Analysis

PA Ceph Analysis

Mc’Namara’s Analysis

1984, American journal of Orthodontics.

This analysis is derived in parts from the

principles of the cephalometric analysis of

Ricketts (1960; 1972;1981)

Harvold ( 1974)

Woodside (1975)

The construction of Nasion perpendicular & pt. A are

presumed to be original.

Composite normative standards based on 3

cepholometrics sample are provided

1.Lat ceph of the children comprising the

Bolton Standards-

-longitudnally followed up from 6-18yrs

-retraced and digitized by Behrents &

Mcnamara

2. Group of untreated children from Burlington

orthodontic centre

- longitudinally followed up from 6-20 yrs.

3. Ann Arbor sample of 111 young adults

- Good to excellent profile

- Class I occlusion

- Good skeletal balance

average age of females-26yrs 8 mths

average age of males - 30 yrs 9 mths

In an effort to create a clinically useful analysis

the craniofacial skeletal complex is divided

into-

Maxilla to cranial base

Maxilla to mandible

Mandible to cranial base

Dentition

Airway

.

2

Maxilla to cranial base

The position of maxilla relative to cranial base

is evaluated in two ways;

Soft tissue profile

Skeletal relationship of Point A to the N

perpendicular

Soft tissue evaluation

Both the nasolabial angle and the cant of

upper lip should be examined

Average angle= 102 (SD.8) : males & females

Acute angle-

Dentoalveolar protrusion

Orientation of the

base of the nose

Upper lip is examined relative to vertical orientation of

the face

Average angle=14(SD-8.2)

The upper lip should have forward cant.

A vertical or retruded lip orientation is contraindication for any

mechanics that would distalize maxillary dentition

Hard tissue evaluation - distance between Na

perpendicular & pt. A.

Ideal mixed dentition

= 0mm

❑ Ideal adult female

= 1 mm

Maxilla to mandible

Anterior – Posterior direction

The determination of maxillary and

mandibular length can be determined using a

method developed by Harvold

Midfacial length- Condylion to Pt. A

Effective mandibular length- Condylion to

Gnathion

A linear relationship exists between

The effective length of the

midface and that of mandible

any given midfacial length

corresponds to an effective

mandibular length within a

given range.

.

3

Maxillo mandibular relationship=

M.L - M.F.

Ideal max. mand differences;

Small= 20 - 30 mm

Medium =25 – 27 mm

Large = 30 – 33 mm

Vertical dimensions

The clinical appearance of the relationship

between the upper and lower jaws is affected

to a great extent by lower facial height

The lower anterior facial height is measured from

ANS to Menton

Increase in LAFH

- downward &

backward position of

chin

❑ Decrease in LAFH

❑ - autorotation of chin in

a forward &upward

direction

An increase or decrease

in LAFH can have

profound effect on the

horizontal relationship

of mandible to maxilla

Other measures of Vertical Dimensions:

Mandibular plane angle

Facial axis of Ricketts.

.

4

Mandible to cranial base

Distance from

pogonion to the Na

perpendicular

Mixed dentition:

-8mm to -6mm

Adult female

-4mm to 0mm

Adult male

-2mm to 4mm

Dentition

Relating the upper incisors to maxilla

A-P position

Ideal distance=

4-6 mm

Advantage over Ricketts

In instances of malrelationships between

maxilla and mandible,serious error may result

if the position of upper incisor is determined

by any measurement that uses the mandible as

reference point.( A-Pog line)

Advantages over Steiner

It is valid only if the maxilla is in a neutral

position A-P relative to cranial base.

Retrusive position of the maxilla relative to

Na- upper incisor appear more flared

Protrusive position- upper incisors appear

more retrusive.

Vertical position:

Incisal edge of upper incisor should lie 2-3mm

below the upper lip at rest.

Upper lip should be at gingival margin while

smiling

Some adjustments may be needed to interpret the meaning of these measurements according to the functional state of the lip musculature and axial inclination of the tooth prior to treatment

Retruded and upright incisors- more gingival tissue is seen.

Following either functional or orthognathic theraapy- a hypotonic lip may become more active, thus changing functional state.

.

5

Relating lower incisors to mandible

A-P position

Ideal distance is 1- 3mm

Vertical position:

Evaluated on the basis of existing LAFH

Excessive curve of spee

intrusion of incisors

or

eruption of molars……????

LAFH excessive or normal

- lower incisors intruded

❑ Inadequate- extrusion or eruption of buccal

segment

Airway Analysis

Upper pharynx-

Post outline of the soft

palate to the closest point on

pharynx

Normal= 15-20mm

<2 – airway impairment

Lower Pharynx

Point of intersection of the post border of

tongue & the inf border of the mandible to the

closest point on post. Pharyngeal wall.

Normal=11-14mm

Smaller than av-

-Little consequences

Greater than av.-

-Possible ant. Positioning

Of tongue

Strengths

Considers changes in midfacial,mandibular, lower ant facial height.

Advantageous over ricketts and steiners on AP positioning of upper incisors to maxilla

It allows interpretation of changes in growth pattern

Linear measurements primarily so that treatment planning for surgery is simplified

Drawbacks

Na perpendicular to Pt. A

Position of N

Position of Pt A

Linear changes are more affected by error in magnification than angular measuremnts

The Quadrilateral

Analysis

-An individualized skeletal assessment

-Developed by- Rocco. J.Di Paolo 1969

.

6

Quadrilateral

The four measures:

Maxillary base length,

Mandibular base length

ALFH & PLFH

Forms the basis for the

quadrilateral analysis of

lower face

The quadrilateral analysis, concerns itself

primarily with the skeletal configurations of

the individual dentofacial complex in both the

horizontal and vertical dimensions, regardless

of dentoalveolar relationship.

It provides an individual skeletal assessment of

each case.

Analysis

Skeletal assessment

Dental assessment

Concepts of lower facial proportionality

In a balanced facial pattern there is a 1:1 proportionality that exists between the maxillary base length and mandibular base length; also the average of ALFH & PLFH equals the denture base.

Skeletal analysis

Two horizontal facial planes are used:

Palatal plane – (ANS- PNS)

Mandibular Plane – (Go- Gn)

Maxillary base length

mean= 50.9

S.D = 2 mm

Mandibular base

length

Mean = 50.0mm

SD = 2mm

Locating point J

.

7

Anterior lower facial

height

Mean = 60mm

SD – 3.5mm

Posterior lower facial

height

Mean = 39.4mm

SD= 2.2 mm

Anterior upper facial

height

Measured from

projection of Pt.A onto

palatal bone to Nasion

on cranial base

Mean = 49.2mm

SD- 2.3 mm

A proportional relationship exists between

anterior upper facial height and ant lower facial

height.

This proportion is 45:55 and is in agreement

with the original work of Wylie & Johnston.

Angle of facial

convexity

the angle that is formed

by ALFH & ALFH at

the projection of Pt.A

onto the palatal plane.

168-178

SD -3.2

This angle relates the quadrilateral to the

cranial base and upper face.

It is a means of establishing a skeleta profile

assessment.

It focuses on possible areas of skeletal

discrepancies, such as posture of lower facial

complex, cranial base deflections, and denture

base discrepancies.

Dental Assessment

Point A line

Line from Pt. A parallel

to AFH

Measure the distance

between

most ant. Point on

incisors to this line

Average = 5 (SD- 1)

.

8

Point B line

A line from Pt. B

parallel to AFH

Indicates mandibular

incisor position

Av- 2mm

Pogonion line

A line drawn tangent to

pogonion & parallel to

AFH

Indicates chin excessive

/ deficient

Before any dental assessment can be made, a

thorough knowledge of the skeletal pattern of

the patient is essential.

Only then can we relate incisor positioning

with the skeletal pattern that has been

established

Advantages

It informs the clinician of discrepancies

between the sizes of upper and lower jaw.

By using an analysis of vertical proportionality,

we can determine which jaw is normal

It determines the direction & extent of skeletal

dysplasia in millimeter measurement which is

more understandable in surgical orthodontics

than angular measurements.

Bjork Analysis

Sample

Size and age

Group I- 20 twelve years old

Group II- 322 twelve years old

Group III- 281 high school graduates

Race – Scandinavian

Sex- males

It mainly tells about growth pattern .

Takes in account posterior angles

Saddle angle

Articulare angle

Gonial angle

.

9

Saddle Angle- N-S-Ar-

angle between ant

cranial base and post

cranial base

Mean value- 123+ 5

Articular Angle- may be

altered by Orthodontics.

143+6

Bite is opened by extrusion of the post teeth

or distalization- angle increases

Large angel- retrognathic profile

Small angle- prognathic profile

Gonial Angle-

Mean value- 128+ 7

Sum of the posterior angle-

Sum of the three angles, saddle, articulare, and

gonial angle is 396 +6

If it is greater than 396- vertical growth

If it is smaller - horizontalJaraback Analysis

Jarabck 1972

.

10

Sample

Origin – some of the measurements were

taken from B’jork cephalometric analysis

Size- not specified

Race- not specified

Sex- not specified

Age- not specified.

This analysis is mainly concerned with growth

pattern.

For this purpose two measurements are taken

into consideration

Facial height

Gonial angle

Facial height

It is an appraisal of face

in vertical dimension

Determination of AFH

& PFH and use the

result to arrive at a

figure which suggests

direction of growth

AFH

Linear measurement

from Na- Me.

PFH

Linear measurements

from S- Go

Ratio is-

Posterior facial height x 100

Anterior facial height

Mean value= 62-65%

Higher percentage- great PFH & horizontal

growth

Small percentage – short PFH & vertical growth

Gonial Angle

Angle formed by intersection of a line tangent

to post border of ramus and mandibular plane

(Go-Me)

Large angle- posterior rotation of the mandible

Small angle- anterior rotation of the mandible

Determines degree of inclination of ramus to

mandibular plane & growth pattern

.

11

For accurate analysis,

gonial angle is divided

into UGA & LGA by a

line drawn from Na to

Go.

UGA-

Mean 52- 55

LGA

Mean 70-75

Large UGA- horizontal growth pattern

large LGA- vertical growth pattern

The gonial angle has marked influence on

direction of growth, profile changeand the

position of the lower incisors

The magnitude is determined by the relation

between AFH & length of ramus

Increase in AFH- angle is obtuse

Decrease in AFH- acute angle

Posterioanterior

Cephalometry

In cases of dentoalveolar &facial asymmetries

Dental & skeletal crossbite

Functional mandibular displacement.

Methods of Analysis

Ricketts Analysis

Grummons Analysis

Grayson analysis

Hewitt Analysis

RICKETT’S FRONTAL ANALYSIS

Nasal width: importance of attaining normal respiration in the

orthodontic patient.

Used in combination with the palatal plane in clinical diagnosis,

The nasal cavity can be altered with extraoral traction.

Measured from N.C.-N.C.( widest points in nasal capsule)

Increases 0.5mm per yr

.

12

Mandibular width:Basal mandibular width is described by points just below the

trihedral eminence, called Ag (antegonial tubercle).

Stable area undistorted by muscle attachments

Maxillary width:

About a 10mm distance from J point to the fronto-lateral facial line is

desirable.

Symmetry:Symmetry is evaluated by relating point

A and pogonion to the midsagittal

plane,.

A midline plane is dropped through the

top of the nasal septum or crista galli,

perpendicular to the line through the

centers of the zygomatic arches,

asymmetries can be located within the

maxilla or in mandible or in

combination. Thus this information assists

in the diagnosis of unilateral conditions and

severe midline deviations.

Symmetry:Symmetry is evaluated by relating point

A and pogonion to the midsagittal

plane,.

A midline plane is dropped through the

top of the nasal septum or crista galli,

perpendicular to the line through the

centers of the zygomatic arches,

asymmetries can be located within the

maxilla or in mandible or in

combination. Thus this information assists

in the diagnosis of unilateral conditions and

severe midline deviations.

Denture relations in the frontal

Molar width:

In the denture pattern a primary

interest is the lower molar width

relative to the skeleton. In this

molars are evaluated related to

basal bone near its position. The

lower molar measurement

changes with age.

Intermolar width:

It is measured from buccal

surface of the first permanent

molars transversely.

Intercuspid width:

The width between the tips of

the lower cuspids is assessed.

These teeth also changes

relationship during the time of

eruption, requiring the

appraisal of age effects in any

evaluation.

.

13

Denture symmetry:

Similar to basal midlines, the denture

midline is assessed from points

between the upper and lower central

incisor roots. And central sagittal

plane should falls on all these

midlines.

.

Upper to lower molar relation:

Width differences

between upper and

lower molars are useful

in identifying actual and

potential crossbites.

The measurements is

made at most

prominent buccal

contour of each tooth.

The average value is

1mm.

Grummons analysis

Duane. C. Grummons

Martin A. Kappeyne Van De Coppello (1987 jco)

Comparative and quantitative PA ceph analysis: not

related to normative data

2 forms of this analysis: Comprehensive

Summary

The information gathered can be correlated with lat ceph

data to complete a three dimensional facial assessment.

Construction of horizontal planes

Medial aspect of ZF suture

Centers of ZA

Medial aspect of jugal process

Parallel to Z plane

through menton

Construction of mid sagital

reference line

Cg through ANS to chin area

perpendicular to Z plane

Key reference line-

closely follows the visual plane

subnasale & the mid points

between the eyes

MSR- centre of cervical vertebrae

–possible head rotation

In cases of anatomic variations in

upper & middle facial region……

Location of Cg???...

- midpoint of the Z plane through ANS

Upper facial asymmetries???

- midpoint of Z through

mid point of Fr-Fr line

.

14

What may appear as asymmetry on film may

be quite different from patient’s actual

asymmetry if the head to tip or rotate to

conform to the cephalostat…

Extend Z plane and compare the distance

between Z& cranial borders.

To ensure correct head tilt when taking the

radiograph, check the patient from the side to

see FP is close to horizontal.

Mandibular morphology

Left & Right triangles are formed- Co-Ag-Me

Split by ANS-Me line

Linear values

Angles

Anatomy can be measured

Quite sensitive to head

rotation

Volumetric Comparison

2 volumes (polygon) are calculated from the area defined

by Co-Ag- Me &the intersection with a perpendicular

from Co-MSR

Superimposition done

by computer

Maxillo mandibular comparison of

asymmetry

Perpendiculars to MSR from J & Ag

Connecting lines from Cg- J& Ag

Linear asymmetries

Vertical offset & linear distance is measured from MSR-

Co,NC,J,Ag,Me

Maxillo-mandibular relation

Buccal cusps of upper 1st molars along the

perpendiculars

Ag plane, MSR, & ANS-Me

Are drawn to depict the dental

Compensations for any skeletal

Asymmetries.

.

15

Frontal vertical proportions

Upper facial ratio-

Cg-ANS/Cg-Me

❑ Lower facial ratio

ANS-Me/Cg-Me

❑Maxillary ratio

ANS-A1/ANS-Me

❑ Total maxillary ratio

ANS-A1/Cg-Me

Mandibular ratio

B1-Me/ ANS- Me

Total mandibular ratio

B1-Me/Cg-Me

Maxillo mandibular ratio

ANS-A1/B1-Me

Advantages

It provides a practical,

functional method of

determining the

locations and amount of

facial asymmetry

It includes volumetric

comparison

Limitations

Head rotation and

improper construction

of MSR can reduce the

effectiveness of this

analyses.

The measurements are

subjected to distortion

from projection

technique.

Grayson AnalysisBarry Grayson; Fred Bookstein 1983

Landmarks are identified in different frontal planes at

selected depth of the craniofacial complex and

subsequent skeletal midlines are constructed

The analysis enables visualization of midlines and

midpoints in third (sagital dimension)

The midlines and midpoint may be combined and warped

midsagiatl plane can be outcome of this analysis

The analysis is performed on 3 different

acetate tracing papers using the same PA ceph

Separate acetate tracings are made on the same

radiograph, corresponding to structures of the lateral

view

.

16

Tracing 1. A. Orbital rims B. pyriform aperture

C. Maxillary & Mandibular incisors. D. Inferior

border of symphysis

In this 1st drawing, the

anatomy of the most

superficial aspect of the

craniofacial complex, as

indicated by plane A, is

presented.

Tracing 2. A. Greater and lesser wing of

sphenoid. B. lat cross section of the zygomatic

arch. C, coronoid process . D. Maxillary and

Mandibular first molars. E body of the

mandible F mental foramina

These structures are

located on or near the

deeper coronal plane

B

Tracing 3 A. Superior surface of the petrous

portion of the temporal bone B. Mandibular

condyles with outer border of ramus C.

mastoid process, corresponding to plane C

Midline construction for all the 3 planes

The result is a segmented construction of

these midlines, whose angles express the

degree of asymmetry of the structures in this

specific plane.

If the 3tracings are sperimposed, the

phenomenon of warping within craniofacial

skeleton can be observed.

In most asymmetric patients, the craniofacial

asymmetry will appear less severe in the most

post and in the deep lying cranial structures.

.

17

Advantages

3 dimensional multiplane cephalometric

analysis integrating information from both the

PA and basilar cephalometric radiographs.

The study of structures in various coronal and

transeverse planes makes it possible to

measure and record the three dimensional

relationship of anatomic structures to one

another.

Hewitt Analysis

It is performed by dividing the craniofacial

complex in constructed triangles, the so called

triangulation of face.

The different angles, triangles and component

areas can be compared for both the left and

right side.

Cranial base

Lat. Maxillary region

Upper max region

Middle max region

Lower max region

Dental region

Mandibular region

.

1

1

Loops in Orthodontics


Contents

⚫ Introduction

⚫ Hiistory

⚫ Types of loops

⚫ T-loop

⚫ K-loop.

⚫ M-loop

⚫ Omega loop

⚫ Vertical loop

⚫ K -sir loop

⚫ Opus loop

⚫ Rickets loop

⚫ Box loop

⚫ Bull loop.

⚫ Tear drop

⚫ Triangular loop.

⚫ L-loop.

⚫ Balista loop.

⚫ Rectangular loop.

⚫ L-loop

⚫ Most of the time ,due to anatomic limitations in the oral cavity, it is

not usually possible to devise an intraoral mechanism to deliver a

force whose line of action passes through a tooth's center of

resistance. Equivalent force systems, comprised of forces and

moments, are instead applied to brackets bonded to the tooth's

crown to achieve translatory movement.

⚫ Two approaches can be used to apply the force systems

necessary to trigger the biologic phenomena that result in space-

closing movement of individual teeth or groups of teeth (“en

masse”).

⚫ 1.Sliding mechanics

2. Loop mechanics – a) Segmental and b) Continues.

Introduction.

⚫ Force: is defined as an act upon a body that

changes or tends to change the state of rest or

the motion of that body.

⚫ The correct unit to express forces are

Newtons (N). However, in orthodontics forces

have been commonly expressed in grams.

4

1gm = 0.00981 N (or) 1N = 101.937gm

Basics of the biomechanics.

5

⚫ A force is a “vector”.

⚫ Vector quantities are characterized by having both magnitude &

direction.

⚫ The magnitude of vector represents its size.

⚫ Direction is described by the vector’s line of action, sense & point of

origin (point of application).

⚫ In order to indicate all of these features, force vectors are

represented as arrows. The length of the arrow is proportional to

the magnitude of the force.


6

Line of action

Sense/DirectionOrigin or

point of application

The point of application of a force is indicated by the origin of the arrow.

This is simply the point of contact between the body being moved and

the applied force.

Direction is indicated by the body of the arrow itself and the arrowhead.

Without the head of the arrow, the body alone indicates the line of

action. The sense is determined by which end we put the arrowhead on.


.

2

7

Points Of Application:

Orthodontic forces are commonly applied at the

crowns of a tooth.

1) centre of mass

2) centre of gravity

3) centre of resistance.

⚫ Centre of a mass: is a single point within it

where all of its mass is concentrated.

8

⚫ A tooth in the oral cavity is not a free body

because its supporting periodontal tissues

restrain it. The analogous centre of mass for an

in vivo tooth is referred to as the “centre of

resistance” of the tooth.

⚫ It can be defined as a point at which resistance

to tooth movement is concentrated.

9

Centre of gravity

Centre of resistance⚫ The centre of resistance of single rooted tooth lies

approximately six-tenth of the distance between the

apex of the tooth and crest of the supporting

alveolar bone. ( PROFFIT )

⚫ It lies at 66% of the root length from apex towards

alveolar crest. ( BURSTONE)

• The centre of resistance of multirooted tooth lies just

above the furcation.

• The centre of resistance of whole dentition lies

between the premolar roots.

⚫ If a force is applied to a free body & the force

does not act through the centre of resistance, it

causes the body to rotate.

⚫ Rotation is the movement of a body where no

two points on the body move the same amount

in same direction.

⚫ Moment: The tendency to rotate is called a

moment.

⚫ Moments can be symbolized by curved arrows.

12

.

3

13

⚫ Moment of a force: about a specified point is a measure

of the potential of that force to rotate the body, upon

which the force acts, about the particular point.

⚫ It is defined as the product of the force times the

perpendicular distance from the point of force application

to the centre of resistance. It is measured in units of gm-

mm.

14

d

Mf = F x d

M

The direction of moment is foundby following the line Of actionaround the centre of resistancetoward the point of origin.

F

15

• Counterclockwise moments are said to be -ve

• Clockwise moments are considered +ve.

AJODO 1984

⚫ Moment may be referred differently in orthodontics, rotation or 1st order tooth

movement, tipping or 2nd order tooth movement, torque or 3rd order tooth

movement.

16

1st order 2nd order 3rd order

17

⚫ When a body rotates, there is a point located either internal or external to

the body around which the body turns.This point is termed the “centre of

rotation”.

⚫ Center of rotation may be defined as a point about which a body appears to

have rotated, as determined from its initial and final positions.

Centre of rotation

18

⚫ Couple: is a pair of equal & opposite non-collinear

forces acting on a body.

⚫ A couple always results in a pure moment, with the

tendency to rotate around the centre of resistance.

X gm

X gm

.

4

19

⚫ The moment of a couple is equal to the magnitude of one of the forces

multiplied by the perpendicular distance between them.

⚫ The two forces cancel out any tendency for the center of resistance of

the object to move, but the moment created by the two forces does not

cancel each other.

20

Classification of anchorage

This classification helps in the design of mechanics plans that

are individualized for specific patient needs

21

⚫ Type A Anchorage:

This category describes the critical maintenance of the posterior

tooth position. 75% or more of the extraction space is needed for

anterior retraction .

22

Type B Anchorage:

⚫ This category describes relatively symmetric space closure with

equal movement of the posterior and anterior teeth to close the

space. This is often the least difficult space closure problem.

23

Type C Anchorage:

⚫ This category describes “noncritical” anchorage. 75% or more of the

space closure is achieved through mesial movement of the posterior

teeth. This could also be considered to be "critical" anterior

anchorage.

⚫ In friction mechanics during space closure in cases in which wirewith large rigidity is used, friction will develop in the system withpossible cessation of canine/anterior teeth movement and lossanchorage.

⚫ During space closure, where an wire with a low load-deflectionrate is used, the wire will deform and undesirable side effects onother teeth will be seen.

⚫ Force magnitude cannot be easily determined since the amount offriction is relatively unknown and unpredictable.

⚫ Clinician has to depend on patients cooperation in wearingheadgear or elastics to achieve desired tooth movement.

1.Sliding / friction mechanics

.

5

⚫ Control of the force system that is applied to the teeth is one of themain problems in the field of biomechanics. Straight arch wiresseldom produce forces and moments that are of appropriatedirection and magnitude .For this reason, orthodontic loops havebeen extensively used, either in order to decrease the forcemagnitude or to produce a force system compatible with thedesired tooth movement.

⚫ A major use of loops is the retraction of canines, where a momentto force ratio is essential for the bodily movement. The design of ofthe loop influences the force levels and the moment to forceratio(M/F) in such a way that is difficult to change the one withoutadversely affecting the other.

⚫ Loop:

Loop is a orthodontic spring of various shapes & configurations.

⚫ This approach is friction-free; when activated, the arch wire loops distort from their original configuration; as the tooth (or teeth) moves, the loop gradually returns to its undistorted position, delivering the energy stored at the time of activation.

⚫ Brackets are not sliding along the arch wire during the process. Groups of teeth can therefore be moved with more accurately defined force systems for more precise anchorage control to achieve treatment goals more readily than methods in which friction plays a role.

2.Loop mechanics

⚫ By giving a loop ,that will increase the length of the wire , there bydecreasing the force value and increasing the flexibility.

⚫ To lower the load/deflection rate by addition of more wire.

⚫ Preactivation bends can be placed in loops to obtain higher moment,& to achieve frictionless tooth movement.

⚫ To avoid the inconsistency of the force system delivered by a straightwire. The major reason for putting in a loop is to control the forcesystem to the teeth on either side of the loop.

⚫ To increase the range of activation, to deflect the wire further withoutpermanent deformation.

Why a loop ?

1. It must provide appropriate levels of force and moment-to-force (M/F)

ratios to achieve the tooth displacement desired.

2. It must be able to undergo a reasonable range of activation/deactivation

in which the appliance delivers relatively constant forces and moments.

3. It must be small enough to fit comfortably in the space available for

intraoral treatment.

4. A loop should be “fail safe”- this means that, although a reasonable

range of action is desired from each activation, tooth movement should

stop after a prescribed range of movement even if the patient does not

return for a scheduled appointment.

5. It should be simple.

Ideal properties of a loop:

⚫ Translation of a free body occurs when a net applied force has a

line of action that passes through the body's center of mass. A

constrained body translates when the force's line of action passes

through its center of resistance, a fixed point determined by the

geometry of the body and its constraints.

⚫ It is often desired to move malposed teeth via translation to avoid

localized areas of high stress and strain that can produce

traumatic resorption of tooth roots and investing structures.

Tipping and root movement produce localized high stress areas.

Omega loop.It is fabricated by using .0215X.028 arch

wire

Can be used as a stop and tieback.

Fabrication.

Use a pencil to mark the center of the

wire.

Use tweed loop forming player.

Bend up the distal leg by 20 deg.

.

6

From the cant by slanting towards the ,using the

Beak player 1-1.5mm away from the beak end.

Bend it up the distal leg by 90 deg.

Plier is positioned at the top of the loop.

Bend up the distal leg by 90 deg.

To bend up the distal leg ,hold the plier

Positioned more backward.

Until wire become horizontal,bend the distal leg

Mesial;60 deg,distal ; 90 deg.omega loop must

Be bended at the degree of more powerful slant

Of cant towaards the center.

⚫ The vertical loop has two vertical components and

may be activated in any plane perpendicular to these

components.

⚫ It may be contoured as an open or closed loop.

The Vertical Loop;

⚫ A closed loop will always have a greater range of

activation than an open loop of the same design,

because of the additional wire and because of the

'Bauschinger effect' which states that the range of

activation of loop is always greatest in the direction of

the last bend.

⚫ To activate a open loop the legs of the loop are pulled

apart unbending the loop.

⚫ To activate a closed loop, the legs are brought

together, in the direction of the last bend of the loop.

The Vertical Loop;

Pre- activated vertical loop

⚫ Loop design suggested by Dr. Harry Bull .

⚫ The single open vertical loop is most efficent when used to open

space. In such cases, the arch wire is fixed to the brackets, the

loop is activated by compressing the legs, and as the loop returns

to its original position, the teeth move apart.

⚫ It can be used somewhat less effectively to close space, where a

short range of activity will accomplish the movement. Then it is

activated by opening the legs,.

Vertical loop

⚫ The single open vertical loop may also be used for added labio-

lingual deflection when rotation of a tooth is desired. By contouring

a vertical loop adjacent to the displaced contact of the rotated tooth,

immediate bracket engagement is possible.

⚫ The increased resiliency permits deflection of the loop and allows a

greater duration of activity that will tend to rotate the tooth toward its

desired position.

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7

Preactivated out-of-plane vertical loop

(a) geometry before installation,

(b) geometry after installation

Dimensions

⚫ The height of a vertical loop is limited by anatomical restrictions. It must

not impinge on the gingival or alveolar tissues. For practical, clinical

consideration, it is rarely possible to use vertical loops longer than 6 or

8mm, thought occasionally 10 mm. loops can be used. Standardizing

loop heights will tend to standardize predicted force potential and allow

the operator predicatable responses on activation.

⚫ The double vertical loop is contoured on either side of a

tooth and has two effective uses. One is to move a labially

or lingually displaced tooth into line through the labiolingual

spring quality inherent in the horizontal section between the

two loops. The other is to rotate a tooth.

⚫ When tied into the bracket of a rotated tooth, the loop on

one side of the tooth will be displaced labially, causing a

reciprocal rotational activity on the brackets.

The Double vertical Loop:

⚫ The double vertical loop has also been used to move a tooth

bodily in a mesial or distal direction. This is accomplished by fixing

or stopping the connecting horizontal section to the brackets, so

that the archwire cannot slide, and then opening one loop and

compressing the other. The contraction and expansion of the

loops will tend to move the tooth bodily in a mesial or distal

direction.

The Double vertical Loop:

TWIN HELICAL LOOP.

⚫ The presecne of two helices provides additional wire, permitting

greater force reduction and longer range of activity.

⚫ It is used to shorten arch length where great range of activity is

desired.

Modifications of the Vertical Loop.

TWIN HELICAL LOOP.

⚫ The design of this loop permits the legs to touch each other, using

minimal space in the interbarcket span.

⚫ The presecne of two helices provides additional wire, permitting

greater force reduction and longer range of activity.

⚫ Because of the position of the helices, this loop is activated by

extension, or drawing the legs apart. This, in turn, follows the

principle of activation the loop in the direction of the contour, in

that extension of the legs continues to wind the two helices.

.

8

T-loop.

⚫ The segmented arch technique, as developed by Burstone,

utilizes T-loop space closure springs for anterior retraction,

symmetric space closure or posterior protraction

⚫ One of the underlying principles of a segmented approach is

to treat the anterior and posterior units as if they were each

one large tooth. Each segment should be prepared for space

closure with the placement of large rectangular wires in the

bracket slots. The left and right buccal segments are

connected with a transpalatal arch or lingual arch, creating a

single large posterior unit.

⚫ The configuration for the basic T-loop spring uses .017x .025"

TMA wire.

General Concepts for Segmented T-Loop Use :

⚫ Understanding an appliance design requires

recognition of the passive form of a spring and

its activation. There are no forces or moments

acting on the spring in this state. The activation

of the spring requires the application of, forces

and moments to engage the spring in the

brackets or tubes. The spring exerts a force

system on the teeth in its active form.

⚫ An essential concept in understanding the use of T-loops for space closure is the neutral position. The neutral position is found by applying the activation moments to the spring without any horizontal forces. In other words, the anterior and posterior extensions of the spring are "twisted" to bring each level to its respective attachment on the occlusal plane. In this position the spring has zero horizontal force

⚫ The horizontal force is produced by pulling the

"T" open from this position. The activation of

the spring is always considered with respect to

the neutral position, and this can be evaluated

only by the application of the activation

moments. When the proper preactivation

bends are placed, the spring is designed such

that the spring forms a "T" in the neutral

position.

⚫ Differential anchorage is obtained by the application of

unequal alpha and beta moments. The higher moment

is applied to the anchorage teeth.

⚫ The differential moments are obtained by applying the

concept of the off-center V-bend. An off-center V-bend

in a wire results in unequal moments. The closer the V-

bend to a tooth or set of teeth, the higher the applied

moment

⚫ The segmented T-loop approximates a "V" shape.

Centering the T-loop equally between the anteror and

posterior tubes produces equal and opposite moments.

Positioning the loop slightly off center relative to the

anterior and posterior tubes generates unequal

moments. The spring is positioned closer to the

anchorage teeth. Clinically, the spring usually needs to

be 1 to 2mm closer to one side than to the other to

obtain a moment differential.

.

9

⚫ Subtle changes in the position of the V-bend can resultin significant changes in the moment magnitudes,especially with small interbracket distances.

⚫ One advantage of the segmented T-loop is the use of alarger interbracket distance, reducing the relative effectof minor errors in spring position.

⚫ For instance, a 1 mm error is a smaller proportion of a20 mm inter-bracket distance than a 10 mminterbracket distance

⚫ The T-loop can be activated of up to 6 mm. At

full 6 mm activation, tooth movement occurs in

three phases—tipping, translation, and root

movement.

⚫ For a symmetric, centered spring, the initial

force system applies a M/F ratio of about 6/1 to

the teeth. This results in tipping movement of

the anterior and posterior teeth into the space.

⚫ With about 2 mm of deactivation or space closure

(spring activation = 4 mm), the M/F ratio increases

toward 10/1, resulting in bodily tooth movement or

translation

⚫ With one to two more millimeters of space closure

(spring activation = 2-3 mm), the M/F ratio increases to

12/1 and higher. The high M/F ratio results in root

movement. In typical clinical application, the spring

does not need reactivation until all three phases of

tooth movement have been expressed

The three important criteria in the use of T-loop are:

⚫ T-loop design.

⚫ T-loop pre activation or gabling

⚫ T-loop position

T-loop pre-actication:

This design uses 0.017 x 0.025" TMA wire.

An essential concept in understanding use of T- loop for space

closure is the neutral position. The neutral position is found by

applying the activation moments to the spring without any

horizontal forces. The horizontal force is applied by pulling the T

open from its position

Checking neutral position. Equal

and opposite moments are

applied to spring, no horizontal

forces are applied so that

horizontal arms become parallel,

position of vertical arms are

checked

Trial activation. Horizontal arms are

kept parallel by applying force and

moment. Trial activation adds to

stability of spring shape

.

10

Before the “T” spring in inserted in to the mouth the spring needs

to be prepared as followes:

⚫ Curvature is bent in the occlusal part of the spring . this is the part

of the spring that may deform during activation and therefore,

needs to be over bent and followed by a trial activation. Remove

the excess curvature.

Open the ears in the gingival part of the T-spring and

add some angle on the occlusal part vertical arms so the

neutral position is correct.

Recheck the T-spring on the template which is the guide

for the required angulations.

Group B anchorage is the simplest

form of space closure. The

requirements for space closure

include equal translation of the

anterior and posterior segments into

the extraction space. Equal and

opposite moments and forces are

indicated. A T-loop spring centered

between the anterior (canine) and

posterior (molar) attachments

produces this force system.

T-loop position:

Symmetric Space Closure

-Group B Anchorage

The center position of the spring can be found by

⚫ To determine the amount of distal activation, the

following formula is used to establish spring length.

Distance = ( Inter bracket Distance – Activation ) / 2

⚫ Distance =the length of the anterior and posterior arms.

⚫ Inter bracket Distance = inter-tube distance from the

mesial of the molar tube to the canine auxillary tube.

⚫ Activation= 6mm in this spring


-Group B Anchorage

⚫ With the use of a vertical tube at the canine, a 90°

gingival bend at the calculated distance eases

placement and monitoring throughout space closure. If

the canine bracket does not have a vertical tube,

crimpable "cross-tubes" may be attached to the

anterior segment. To insert the T-loop place the spring

in the auxiliary molar tube. Then the 90° bend is

inserted into the canine tube. The distal end is pulled

back until the distal arm is the desired length, which

results in the desired activation (usually 6 mm


-Group B Anchorage

⚫ At 6 mm activation, the spring delivers an M/F

ratio of about 6/1 with a horizontal force of

approximately 320- 340 g. The horizontal force

dissipates at a rate of about 60 g/mm. The

tooth movement is expected to follow the

phases -tipping, translation, and root

movement.

Symmetric Space Closure-Group B Anchorage

.

11

⚫ Space closure should be monitored periodically. To

check the remaining activation, the spring is removed

from the canine tube and the remaining activation at

the neutral position is measured. The activation equals

the distance the gingival bend must be pulled mesially

to be inserted into the canine tube. The passive spring

form should also be evaluated since distortions in the

spring shape will alter the force system

⚫ The progress of the space closure is assessed by observing

the amount of remaining space, the the axial inclinations of

the anterior and posterior segments, and the occlusal

relations.

⚫ During the tipping phase the anterior and posterior occlusal

planes angles towards one another due to the segments'

tipped axial inclinations. This angulation corrects during the

root movement. When the occlusal planes regain

parallelism, spring reactivation is indicated.

⚫ The amount of reactivation of the spring should be based on

the space closure requirements at that time

⚫ The biomechanical paradigm forthis space closure problem is toincrease the posterior M/F ratio(beta M/F ratio) relative to theanterior M/F ratio (alpha M/F ratio)

⚫ Utilizing the V-bend principle, theT-loop is positioned closer to theposterior attachment or the molartube. It is not necessary to be veryfar off center to obtain anadequate moment differential, withmost cases requiring only 1-2 mmoff centering.

Maximum Posterior Anchorage

-Group A Space Closure

⚫ Activate the spring 4 mm for Group A space closure.

This reduces the horizontal force without adversely

affecting the moment difference. The moment

difference remains as the space closes and the spring

deactivates. The spring must be reactivated when 2mm

or less of activation remains.



⚫ Because the beta moment is greater than the alpha moment,

a vertical intrusive force acts on the anterior segment. This

intrusive force may exaggerate the tipping tendency and the

steepening of the anterior occlusal plane. Likewise, the

increased beta moment may steepen the posterior occlusal

plane. Maintaining an adequate horizontal force helps reduce

these effects. The posterior occlusal plane can also be

controlled with the use of a high-pull head gear



⚫ It is likely that a root correction stage will be required

following Group- A space closure. The nature of the

root correction needed will depend on the specific

needs of the case. En-masse anterior and posterior

root correction, anterior root correction, or separate

canine root correction are common possibilities



.

12

⚫ At an activation of 3mm, a horizontal force of 118g is

generated. The alpha M/F is 5.8 while the beta M/F is

10.2. At this activation, the anterior segment is undergoing

controlled tipping while the posterior anchorage unit

undergoes translation or root movement. As the spring

deactivates 1mm further during space closure, the beta

M/F ratio increases to 13.8. The spring should be

reactivated at the time.



⚫ Controlled tipping of the anterior teeth through the

range of activation is produced by a relatively

constant M/F of 5-6. Because alpha M < beta M,

vertical forces are produced, an intrusive force

anteriorly and an extrusive one posteriorly



⚫ Posterior protraction is the

most difficult space closure

procedure. The biomechanical

principle reverses the

approach to group A space

closure.

⚫ The alpha moment is

increased relative to the beta

moment. The difficulty results

from this extrusive force, thus

deepening the overbite.

Maximum Anterior Anchorage

-Group C Space Closure:

⚫ In group C space closure with a segmental T-loop, the

spring is positioned closer to the anterior segment. It is

important that the anterior wire segment achieve full

bracket engagement; otherwise, the play with in brackets

reduce the effectiveness of the moment differential. One

or two millimeters closer to the anterior teeth is typically

all that is necessary.

Maximum Anterior Anchorage

-Group C Space Closure:

⚫ Space closure can be expected to proceed with mesial

tipping of the buccal segment. To reduce the horizontal

force, an activation of 4mm is recommended. The

spring should be reactivated approximately every

2mm.

⚫ The major side effects to monitor are loss of anterior

anchorage control. For mandibular molar protraction,

class ll elastics from the mandibular first molar to the

maxillary canine further increases the force on the lower

buccal segment.

⚫ Class lll elastics aid in protracting upper buccal segments,

although protraction headgear may be used to the upper

buccal segments, although compliance may be

questionable

.

13

Many times, because of anterior crowding or a midline

discrepancy, space must be made available through

separate canine retraction. The same treatment

decisions with regard to retraction and anchorage

requirement must be made as are made for enmasse

retraction. The choice of mechanics is determined by

the type of movement desired and anchorage

requirements

Canine retraction:

⚫ Because the force applied is buccal to the centre of

resistance of the canine, a moment is produced on that

canine during separate canine retraction, which will

cause the canine to rotate distal-in while it retracts.

⚫ There are two ways to counteract this moment.

1. Simultaneously applying a force from the lingual

2. Placing anti-rotation bend in to the retraction spring

⚫ Differential anchorage is obtained by the application of

unequal alpha and beta moments.

⚫ The higher moment is applied to the anchorage teeth.

⚫ The differential moments are obtained by applying in

concept of off-center V-bend.

⚫ An off center v - bend in a wire results in unequal

moments. The closer the v - bend to a tooth, higher the

moment applied

⚫ The segmented T-loop approximates a ‘V’- shape.

Centering the T-loop equal between the anterior and

posterior tubes generates equal and opposite moments.

positioning the T- loop slightly off center relative to the

posterior and anterior tubes produces unequal moments.

The spring is positioned closer to anchorage teeth, clinically

the spring usually needs to be 1 to 2mm closer to one side

than to the other side to obtain a differential moment.

A, Spring in passive form after insertion into molar auxiliary tube.

B, Spring in neutral position, activation is horizontal distance spring

must be pulled for insertion into canine vertical tube.

C. Spring activated and inserted into canine tube.

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14

Anti Rotation Bends:

⚫ According to Marcotte, it is 60°

⚫ According to Burstone. it is 120°

⚫ According to Proffit, it is 20

⚫ The canine is retracted with the spring on its labial surface, there is distal in, mesial out rotation tendency. There are two ways to control this first order rotation.

⚫ Lingual Klastics - Bonding a lingual button on the lingual surface permits the patient to attach an elastic to the canine as it retracts. Elastic can be changed daily by the patient. The distal force from the retraction spring must therefore be halved.

⚫ Antiorotation bends placed in the retraction spring. This method is not patient dependent and is the preferred method for canine retraction.

⚫ The antirotation bends are placed with two pliers. These first order bends are placed as torsion in both vertical legs of the T-loop

Side effects of T-Loop : M-loop (beta-titanium CNA Mashroom)

⚫ Utilized for a variety of applications, through it's advanced special

memory alloy material and improved loop shape, the CNA Beta III

Mushroom Loop significantly increases the efficiency of space

closure, anterior intrusion, retraction and elastic engagement. This

arch wire can be manipulated in the anterior or posterior

segments independently to create the desired movements.

The rounded gingival portion of the loop, unlike traditional T-Loop

and similar arch wires, is more anatomically shaped resulting in a

more tissue friendly appliance and therefore significantly more

comfortable for patients

83

⚫ To eliminate the side effects of the deep bite deepening and

anchor loss, an intrusion arch can be used as a piggy back arch

wire. This wire allows simultaneous intrusion of incisors during

cuspid retraction. Once the cuspids are retracted, anteriors can

be retraction can be accomplished with CNA M-loop arch wires.

⚫ Care should be taken to make trial activation and correct any

distortions that may occur during initial loading and activation

can be up to 5mm.Reactivation is necessary approximately every

6-8weeks.

.

15

M-Loop space closing arch wires

⚫ The contoured mushroom loop evenly transmits forces from and to

the anterior and posterior segments, creating an even and

continuous force for movement throughout treatment.

⚫ Minimal adjustments are needed as the memory attributes of the

wire provide predictable space closure in horizontal, transverse

and vertical directions.

⚫ To increase or decrease incisor torque, create a bend on the

mesial side of the loop.

⚫ For critical anchorage control, bend the posterior leg of the loop

gingival, to promote distal tip back.

⚫ Loops can be spread and opened for retraction or auxiliary springs

or elastomerics can be utilized for retraction

⚫ The arch wire choice for 0.022 bracket

priscription is a preformed M-loop

0.017X0-025 CNA, available with

Std.interloop distances from 26 -46mm.

⚫ Pre –activtion canbe done by seperating

the legs of M-loops approximately 3mm .

Additional gable bend may be placed ,as

needed mesially ti increase anterior

moment(torque) and distal to M-loop to

increase anchorage moment.The wire is

ready to be activated appproximately

4mm (3mm preactivation+ 1mm

activation).

Reactivation is necessary every 6-8

weeks.

⚫ Finishing phase- 0.017X0.025 or

0.018X0.025 CAN wires.

K -Loop

⚫ The K-Loop for Molar Distalization.

⚫ Developed by Valrun Kalra

⚫ Made of .017" X .025" TMA wire.

Legs of appliance bent

down 200.

Wire marked at mesial of

molar tube distal of premolar

bracket.

Bend placed 1 mm distal to distal mark

and 1 mm mesial to mesial mark. Stop

should be well defined and about 1.5mm

long

Wire marked at mesial of molar tube

distal of premolar bracket

Moments and forces produced by K-loop

.

16

.

200 bends in the appliance legs produces moments that counteract the tipping moments created by the force of the appliance, and these moments are reinforced by the moment of activation as the loop squeezed into place. Thus the molar undergoes a translatory moment instead of tipping

92

200

K-SIR loop

⚫ Simultaneous Intrusion and Retraction of the Anterior teeth

⚫ Designed by VARUN KALRA,

⚫ Retraction of the six anterior teeth under the edgewise system is

usually carried out in two distinc tsteps: canine retraction followed

by incisor retraction. In the Begg and Tip-Edge techniques, on the

other hand, the canines and incisors are retracted enmass .

⚫ Separate canine retraction has the disadvantages of increased

treatment time and the creation of an unesthetic space distal to

the incisors. The rationale for separate retraction in the edgewise

technique is that molar anchorage is conserved. However,

Burstone1 and Nanda2 have demonstrated molar anchorage

control, using non-frictional loop mechanics for en masse

retraction of the anterior teeth,that compares favorably with that of

conventional edgewise sliding mechanicsd en masse.

An appliance for simultaneous intrusion and retraction of the six

anterior teeth should ideally control:

⚫ Magnitude of forces and moments

⚫ Moment-to-force ratio

⚫ Constancy of forces and moments

⚫ Friction

⚫ From a practical standpoint, the appliance should:

⚫ Be easy to fabricate and adjust

⚫ Be comfortable for the patient

⚫ Require a minimal amount of patient cooperation

⚫ Be cost-effective

Appliance Design

⚫ The K-SIR (Kalra Simultaneous Intrusion and Retraction) archwire

is a modification of the segmented loop mechanics of Burstone1

and Nanda.2 It is a continuous .019" X .025" TMA archwire with

closed 7mm X 2mm U-loops at the extraction sites

•To obtain bodily movement and prevent tipping of the teeth into the

extraction spaces, a 90° V-bend is placed in the arch wire at the level of

each U-loop Centered .

•90° V-bend creates two equal and opposite moments (red) that counter

tipping moments (green) produced by activation forces. This V-bend, when

centered between the first molar and canine during space closure, creates

two equal and opposite moments to counter the moments caused by the

activation forces of the closing loops .

.

17

⚫ A 60° V-bend located posterior to the center of the interbracket

distance produces an increased clockwise moment on the first

molar , which augments molar anchorage as well as the intrusion

of the anterior teeth

⚫ To prevent the buccal segments from rolling mesio-lingually due

to the force produced by the loop activation, a 20° antirotation

bend is placed in the arch wire just distal to each U-loop .

Activation

⚫ A trial activation of the archwire is performed outside the mouth

(A). This trial activation releases the stress built up from bending

the wire and thus reduces the severity of the V-bends (B).

However, the shape of the archwire should be maintained in

subsequent activations of the loops

⚫ After the trial activation, the neutral position of the each

loop is determined with the legs extended horizontally .

In neutral position, the U-loop will be about 3.5mm

wide

⚫ In neutral position, the U-loop will be about 3.5mm wide. The

archwire is

inserted into the auxiliary tubes of the first molars and engaged in

the six anterior brackets (Fig.A).

⚫ It is activated about 3mm, so that the mesial and distal legs of the

loops are barely apart (Fig. B).

⚫ The second premolars are bypassed to increase the interbracket

distance between the two ends of attachment. This allows the

clinician to utilize the mechanics of the off-center V bend.

⚫ When the loops are first activated, the tipping moments generated

by the retraction force will be greater than the opposing moments

produced by the V-bends in the arch wire. This will initially cause

controlled tipping of the teeth into the extraction sites.

⚫ As the loops deactivate and the force decreases, the moment-to-force

ratio will increase to cause first bodily and then root movement of

the teeth. The arch wire should therefore not be reactivated at

short intervals, but only every six to eight weeks until all space has

been closed.

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18

⚫ Off-center V-bends will generate an extrusive force on the molars,

which is usually undesirable. One of the keys to preventing

unwanted side effects of an appliance is to keep the reactive

forces at a minimum while exerting an optimum level of force on

the teeth to be moved.

⚫ The K-SIR arch wire exerts about 125g of intrusive force on the

anterior segment and a similar amount of extrusive force

distributed between the two buccal segments --generally the first

permanent molars and the second premolars, connected by

segments of TMA wire (Fig. 7A). The force of 125g is effective for

intrusion of the anterior teeth, while the reactive extrusive force on

the buccal segments is countered by the forces of occlusion and

mastication.

⚫ Extrusion of the buccal segments is not usually noted, either

clinically or cephalometrically

Control of Reactive Forces

⚫ Another way to reduce the effects of the reactive force

is to add teeth to the anchorage unit. Including the

second molar will, of course, also increase anchorage

in the anteroposterior direction.

⚫ If even more anchorage is needed to resist both

anterior movement and the extrusive force on the

buccal segments, a high-pull headgear can be added

to the molars.

JCO-Online - VOLUME 35 : NUMBER 9 : PAGES (535-540) 1998

Indications.

⚫ The main indication for the K-SIR archwire is for the

retraction of anterior teeth in a first-premolar extraction

patient who has a deep overbite and excessive overjet,

and who requires both intrusion of the anterior teeth

and maximum molar anchorage.

⚫ However, the archwire can be modified to close

extraction spaces in moderate and minimum

anchorage situations with varying degrees of overbite.

Advantages.

⚫ Its simplicity of design, with a minimal amount of wire in

the loop configuration. It is, therefore, easy to fabricate,

comfortable for the patient, and less likely to cause

tissue impingement. The .019"X .025" TMA provides

sufficient strength to resist distortion, as well as enough

stiffness to generate the required moments.

⚫ At the same time, the design of the arch wire and the

material properties of TMA combine to produce

relatively low forces, a low load-deflection rate, and a

range of activation that allows the appliance to

continue closing space over an eight-week period.

⚫ Due to the frictionless mechanics used for space closure in this

system and the presence of the offcenter V-bend, which acts like

an anchor bend, molar anchorage control is excellent, even

withoutheadgear. The clinician is thus less dependent on patient

cooperation for a successful result in a maximum anchorage

situation.

⚫ Because the intrusion of the six anterior teeth occurs at the same

time as their retraction, and because the canines and incisors are

retracted as a unit, the K-SIR archwire shortens treatment time

compared to conventional edgewise mechanics. In addition, the

en masse retraction of the six anterior teeth prevents the

appearance of an unsightly space distal to the incisors, which

occurs if the canines are retracted separately

Opus Loop:

⚫ Developed by Raymond E. Siatkowski in 1997.

⚫ To achieve net translation, orthodontists have had to add residual moments tothe closing loop arch wire with angulation bends (gable bends) anterior &posterior to the loop.

⚫ Adding these residual moments has several disadvantages:

a) the teeth must cycle through controlled tipping to translation to root movement to achieve net translation.

b) the corect residual loops are difficult to achieve

c) the resulting ever changing PDL stress distribution may not yield the most rapid, least traumatic method of space closure.

⚫ He designed a new spring which delivers a non varying target M/F ratio within the range of 8.0-9.1 mm inherently, without adding residual moments by twist or bends anywhere in the arch wire or loop before insertion

Am J Orthod Dentofac Orthop 1997;112:393-402.)

.

19

Design;

⚫ The loop can be fabricated from .016X.022 or .018x.025 SS or

.017x.025 inch TMA wire.

⚫ The design of the loop calls for an off centre positioning with the

loop 1.5 mm from the canine bracket.


Activation.

It can be activated by tightening it distally behind the molar tube

and can be adjusted .To produce maximal ,moderate and

minimal incisor retraction, but like all closing mechanisms with

long range of action, must be monitored carefully.


Continues arch wire closing loop


⚫ Opus loop, which is capable of delivering a non-varying

target M/F within the range of 8.0 to 9.1 mm inherently,

without adding residual moments via twist or bends

(commonly gable bends) anywhere in the arch wire or loop

before insertion. The resulting precise force systems delivered

with nonvarying M/F can move groups of teeth more

accurately to achieve predetermined antero-posterior

treatment goals for esthetics and/or stability.

.

20

Gjessing’s canine retraction spring

⚫ Designed by Paul Gjessnig, Denmark

Spring design

⚫ The resultant spring design, made from

0.016 by 0.022 inch stainless steel wire

.The predominant active element is the

ovoid double helix loop extending 10

mm apically. It is included in order to

reduce the load/deflection of the

spring and is placed gingivally so that

activation will cause a tipping of the

short horizontal arm (attached to the

canine) in a direction that will increase

the couple acting on the tooth.

AJO-DO, Volume 1985 May (353 - 362): - Gjessing

⚫ Height is limited by practical considerations,

so that a double loop is necessary to

incorporate sufficient wire.

⚫ The gently rounded form avoids the effect

of sharp bends onload/deflection and,

through the use of the greatest amount of

wire in the vertical direction, reduction of

horizontal load/deflection is maximized. At

the same time, minimizing horizontal wire

increases rigidity in the vertical plane.

⚫ The smaller loop occlusally is incorporated to

lower levels of activation on insertion in the

brackets in the short arm (couple) and is

formed so that activation further closes the

loops.

⚫ The mesial and distal extensions of the looped

wire segment are angulated both in the

vertical and in the horizontal plane. When the

spring is in place, but prior to activation of the

driving force (neutral spring position, F = 0

gm), static antitip and antirotation couples will

be exerted to the canine

Activation

⚫ The distal driving force is generated by pulling the distal, horizontal leg

through the molar tube. A desirable force level of approximately 160 gm is

obtained when the two sections of the double helix are separated 1 mm.

During the activation the force is matched by an additional couple

(activation couple) arising from the double-helix loop which, in theory,

acts as four lever arms.

⚫ Incorporation of a segment of a circle ("sweep") in the distal leg of the

spring is an adjustment with the purpose of eliminating undesirable ß

moments acting at the second premolar bracket and tending to move the

root apex too far mesially.

⚫ Arch loops used doubly in pairs are

very efficient in moving teeth bodily

in a mesiodistal direction.

⚫ The loop toward which the

movement is to be made is usually a

closed, while that at the other end is

an open loop.

⚫ The arch wire on either side of the

loop is immobilized by the use of

stops.

⚫ The closed loop is opened during

activation and open loop is

compressed.

Double loop or arch loops:

.

21

Disadvantages PG spring

⚫ Difficult to control the position of the canine in all three planes as it

is retracted.

⚫ Enmass retraction using segmental retraction of canines does

not fail safe, because no stops to prevent excessive movement in

wrong direction.

⚫ Missed appointment and a distorted spring can cause potential

problem.

R-loop.

⚫ It can be fabricated by using 0.017 x 0.025” TMA wire

⚫ For a given tooth movement only one combination of force

and moment is correct R Loop can be used for 1st/2nd/3rd

order corrections.

⚫ All combinations of moments and forces are possible low

load deflection /large range of activation

⚫ No inconsistent force systems

⚫ Constancy of Force

⚫ Tooth movement produced by deactivation – friction not an

issue!

⚫ Dissociation of forces and moments possible

⚫ Ccontrol the appliance !!

Dimensions of R -loop

A B

A – mesial of molar tubeB – half of LL = distance between mesial of molar tube and distal of second premolar bracket

A B All bends are made with 442 ( ribbon arch ) plier

Right angle bend atmark B

A B

C

C – sufficient to clear the premolar bracket without interferenceapproximately 6-7 mm

.

22

A B

C

Horizontal bend at C A B

C D

D = L + bracket width (appr.5 mm)

L = distance between mesialof molar tube and distal of second premolar bracket

A B

C D

Vertical bend at D

A B

C D

E

E – equal to the distance between points B and C

A B

C D

E

Horizontal bend at mark E, bend the wire gingivally just short of the vertical segment A B

C D

E

Horizontal bend gingivallyJust short of the vertical leg

.

23

AB C

A = B = C

L

1

2

1

2

1

2

.

24

Dissociation of forces and moments

A B C

A B C

Dissociation of forces and moments

.

25

Vertical alignment with the use of rectangular loop. Force system acting on teethMp- in plane moment acting on posterior teeth.Fp- posterior horizontal forces.Vp- intrusive force acting on posteriorTeeth.VA - Vertical extrusive force acting on anterior teeth.MA- In plane momentum on ant. teeth.FA- anterior horizontal forces .

a-Activationb-horizontal distance between at which wires enter the brackets.

.

A Ricketts maxillary canine retractor extends from canine

edgewise bracket slot to 2nd molar tube encompassing 1st molar and

premolar brackets .

It is fabricated with 0.017 x 0.025 TMA wire. A gable bend of 450 in

canine position and an anti-rotation bend of 450 .

A retraction force of 1N is used for canine retraction. Because of the

force decay , the spring is activated once in every week.

Ricket’s canine retraction spring:

Advantages of Loop/Frictionless Mechanics

⚫ Precise control over the anterior and posterior

anchorage.

⚫ The tooth will move only to the limit to which the loop is

activated.

⚫ Differential tooth movement is possible.

⚫ Retraction loops or springs offer more controlled tooth

movement than friction.

14

9

◼ A good understanding of mechanics is required when using

retraction loops or springs, because minor errors in mechanics can

result in major errors in tooth movement.

◼In addition, more wire-bending skill and chairtime are required

than with sliding mechanics,

◼The retraction loops may be uncomfortable to some patients

especially those with less vestibular height.

◼ Like sliding mechanics, retraction loops produce an undesirable

mesial-out moment when individual teeth are retracted, due to the

force of the spring being placed facial to the center of resistance.

This moment can be minimized by using a lingual elastic— as is

usually done with sliding mechanics— or by placing an anti

rotational bend in the retraction loop

DISADVANTAGES OF( LOOP )FRICTIONLESS MECHANICS

.

26

151

References:• Biomechanics in orthodontics; Michael R. Marcotte.

• Biomechanics in Clinical Orthodontics; Ravindra Nanda.

• Modern Edgewise Mechanics and The segmented Arch Technique. Dr.Charles J. Burstone.

• Clinical Considerations in the Use of Retraction Mechanics. JCO 1991.

• The Rationale of the Segmented Arch. AMJ 1962; 48(11):805-821.

• Common sense mechanics: Part 2. Thomas F. Mulligan. JCO 1979.

• Optimizing anterior and canine retraction. Charles J. Burstone. AJO 1976.

• The K-Loop Molar Distalizing Appliance Valrun Kalra. JCO 1995.

• Simultaneous Intrusion and Retraction of the Anterior Teeth Varun Kalra.JCO 1998.

• Controlled Space Closure with a Statically Determinate Retraction System;Kwangchul Choy, Charles J. Burstone, AO 2002.

152

• A comparison between friction and frictionless mechanics with a newtypodont simulation system. AJODO. 2001;119(3):292-9.

• Biomechanical design and clinical evaluation of a new canine-retractionspring. Gjessing P. AJO 1985;87(5):353-62.

• T-loop position and anchorage control. Kuhlberg AJ, Burstone CJ. AJODO1997; 112(1):12-8.

• Continuous arch wire closing loop design, optimization, and verification.Part I. AJODO 1997; 112(4): 393-402.

.

1

1 2

Role of Nutrition in

orthodontics

Presented by: Dr. Naveen Sharma

3

Contents

• Introduction

• Definitions

• Classification of food

• Proteins. Carbohydrates. Lipids. Vitamins.

• Minerals

• Nutrition and dento facial growth

• Nutritional influence on the periodontium

• Guidelines for evaluation & assessment of nutritional status

• Balanced diet

• Conclusion

• Bibliography

4

Introduction

• Nowadays we live in a very diet conscious

society where more and more people are

adopting a healthy lifestyle through a healthy

diet.

• Evidence for which can be obtained from

knowing the fact that books written on nutrition

and diet are amongst the fastest moving books

off the shelves

5

Definition

• “The science of food, the nutrients and other

substances therein ,their action ,interaction and

balance in relation to health and diseases and the

processes by which the organism ingest, digest, absorbs,

transports ,utilizes and excretes food substances”

- Council of food and nutrition of the

American Medical Association

6

Historical Background

Schneider’s –

• Naturalistic era-(400 B.C-A.D 1750)

• Chemical analytic era(1750-1900)

• Biological era(1900-present)

.

2

7

Historical Background

• Molecular\ cellular era-(1955 –present)

• Guilford -1874 was among the first to advocate

that dietary deficiencies could be an underlying

cause of dentofacial irregularities

8

Definition

• Science of nourishing the body properly or analysis of the effects of food on living organisms.

• Relationship between man and his food and implies the psychological and social as well as the physiological and biochemical aspect

-Yudkin

9

Definitions

• Nutrition is a dynamic process in which the

food that is consumed is utilized for

nourishing the body.

• Diet : The term diet refers to the total oral

intake of substances that furnish nourishment

and/or calories to the body.

10

BASIC FUNCTION OF NUTRIENTS

• Supply energy .

• To promote growth.

• Repair of the body tissues .

• Regulate body processes.

11

Classification of nutrients

• Macronutrients; these are contribute the

main bulk of food.

Eg; proteins. fats and carbohydrates.

• Micronutrients; they are vitamins and

minerals and required in small amounts from

a fraction of a milligram to several grams.

12

Classification of food

✓CLASSIFICATION BY ORIGIN

✓CLASSIFICATION BY CHEMICAL COMPOSITION

✓CLASSIFICATION BY PREDOMINANT FUNCTION

✓CLASSIFICATION BY NUTRITIVE VALUE

.

3

13

Classification of foods

Classification by origin:

Food of animal origin;

Food of vegetable origin;

Classification by chemical composition

proteins

Fats

Carbohydrates

Vitamins

minerals

14

Classification by predominant

function

• Body building food eg; meat. poultry. fish.

eggs. pulses. groundnuts. etc.

• Energy giving food eg; cereals. sugurs.

roots. tubers. fat and oils.

• Protective foods eg; vegitables. fruits and

milk.

15

Classification by nutritive value

• Cereals

• Pulses (legumes)

• Vegetables

• Nuts and oilseeds

• Fruits

• Animal foods

• Fats and oils

• Sugars and jaggery

• Condiments and spices etc.

16

Carbohydrates

• Energy yielding nutrients, is the largest single

component ,aside from water ,of most diets.

• Composed of –

-carbon

-hydrogen

-oxygen

17

Carbohydrates

• Sources-

- rice - sweet potato

-wheat - honey

-bajra - jaggery

-pulses

-vegetables

• Recommended daily intake-440gms. 18

Carbohydrates

Classified as-

• Monosaccharides – eg; glucose ,fructose

,galactose.

• Disaccharides - eg; sucrose , lactose ,maltose

• Polysaccharides- eg; starch, glycogen

,cellulose

• Oligosacchrides-eg; maltotriose

.

4

19

Digestion of carbohydrates

• In mouth by salivary amylase polysaccharides are

converted into disaccharides,

• In stomach by acid further degradation of

molecule takes place,

• In small intestine by pancreatic amylase

completes the breakdown to monosaccharide,

• These monosaccharide then pass through the

small intestinal villi into bloodstream,

20

Carbohydrates

• SUCROSE GLUCOSE + FRUCTOSE

• MALTOSE GLUCOSE + GLUCOSE

• LACTOSE GLUCOSE + GALACTOSE

21

Carbohydrates

• Absorption and storage –

small intestines

stored as glycogen in liver and muscle

• Function –

main source of energy.

1 gm – 4 kcal of energy

22

Summary

• Glycogenesis- surplus glucose converted to

glycogen and stored in liver.

• Glycogenolysis-breakdown of glycogen in

liver to glucose.

• . Glycolysis-in muscle berakdown of glycogen

to pyruvic acid

• Gluconeogenesis or glyconeogenesis-glouse

and glycogen can be synthesised by the liver

from substances which are derived from non

carbhohydrates sources eg;aminoacid,seen

during prolonged starvation.

23

Carbohydrates

• Almost nothing is known of the effect of

carbohydrate deficient diet on the oral cavity.

• Deficiency dosage – less than 440gms per day

leads to underweight,weight

loss,lethargy,anaemia.

24

Carbohydrates

• There is a group of disease which represents a

primary genetically determined disturbance of

the mucopolysaccharide metabolism

.

5

25

Carbohydrates

• Hurler syndrome-

• Clinical features are.

• Head -appears large with prominent

forehead

-puffy eyelids

-nasal congestion with noisy breathing

-shortening and broadening of the mandible

26

Carbohydrates

- wide intergonial distance

- increased arch length from ramus to ramus

• dentition-small and misshaped teeth.

• Soft tissue –gingival hyperplasia.

27

Lipids

• These are the most concentrated energy yielding

group of nutrients.

• Basic structure –molecules of glycerol to which

one to three fatty acid molecules

28

Lipids

• Sources –

-fruits -egg yolk

-vegetables -butter

- milk - ghee

-meat -cereals

-fish

29

Lipids

• Classified as

- saturated

-unsaturated

• Physical properties –

insoluble in water.

less dense than water.

not affected by temperature.

30

Lipids

• Digestion-

stomach- with the help of lingual lipase secreted by the oral salivary gland and gastric lipase secreted from the stomach.

small intestine-emulsified by bile and further broken down by pancreatic lipase then absorbed through the small intestinal villi.

long chain fatty acids are converted into a chylomicron and dumped into the lymph system,which carries the chylomicron to the bloodstream

.

6

31

Lipids

• 30%-free fatty acid combine with bile salts

• 70%-resynthesised immediately to form triglycerides

• Normally the fats stored in adipose tissue.

32

Lipids

Function –

• Source of energy -1gm-9kcal.

• It insulate the body and protect various internal

organs.

• Carrier of the fat soluble vitamins.A,D,E and K

• Source of other essential fatty acids.

33

Lipids

• Disturbances in the lipid metabolism are

not very common but they do occur

-Gauchers disease

-Neimann Pick disease

34

Gauchers disease• Gauchers disease is an autosomal recessive defect

of lipid metabolism.

• Clinical feature

– Hepatosplenomegaly

– Osteolytic disease ensues along with pulmonary

disfuction

– Bone marrow shows diffuse changes numerous

large,fomey,slightly granular cells with small,round

pyknotic nuclei

• Treatment and prognosis;the disease resulting in

death usualy with in first year.

35

Niemann-Pick Disease

• AUTOSOMAL RECESSIVE TRAIT: characterized by

abnormal storage of phospholipids. resulting

from inherited deficiency of sphingomyelinase.

• Treatment and prognosis: symptomatic and

consists mainly of antibiotic for pulmonary

infection. Even organ transplantation also

recommended.

36

Proteins

• The term proteins mean –”to take first place”-

Mulder -1983

• Half the dry weight and 20% of the total weight

of an adult is protein.

.

7

37

Proteins

• Basic structure –

complex substances made up of many amino

acids.

there are 20 different naturally occurring amino

acid that have been identified as the building

blocks for body protein.

38

Proteins

Sources-

-wheat - peanut butter

-milk - peas

-egg white -cottage cheese

-legume -rice

-boiled ham -oatmeal

39

Proteins

• Classified according to functional point of

view

-amino acids -essential amino acids

-non essential amino acid

Classified according to quality of protein

– complete

- incomplete

-complementary

-supplementary 40

Proteins

• Digestion and absorption

-attached to another substance or surrounded by

fat or carbohydrate

Stomach – gastric proteases (pepsin)

Small Intestine – pancreatic enzymes

41

Proteins

• 30 %-absorbed directly

• 70%- chain of two or three AA

dipeptidases amino acids

• Amino acids – enters blood stream

42

Proteins

Functions –

• Essential for growth-hair,skin,nail

• Formation of essential body compounds

• Regulation of the water balance

• Act as buffers

• Protective role

• Transport of nutrients.

.

8

43

Proteins

• The inadequate consumption of protein and

energy as a result of primary dietary deficiency

conditioned deficiency may cause loss of body

mass and adipose tissue ,resulting in protein

energy malnutrition-

• Kwashiorkor

• Marasmus

44

Proteins

• Kwashiorkor –

Definition- protein deficiency with sufficient calorie intake.

Age-6 months and 3yrs -

Clinical Features -growth failure

wasting of muscles

- edema

-enlarged fatty liver

-serum protein low

- flag sign

45

Proteins

• Marasmus

• Definition –starvation in infants with a overall lack

of calorie.

• Age-infants under 1 yr of age

• Feature-wasting of all tissues

-no edema

-no hepatic enlargement

-monkey like face

46

Vitamins

• Defined as organic substances not made by the

body ,which is soluble in either fat or water and

ordinarily is needed in only minute quantities to

act in a variety of metabolic reactions.

47

VITAMINS

FAT SOLUBLE WATER SOLUBLE

48

Vitamins

Fat soluble Water soluble

• Intake is in excess Minimal storage of

of daily body needs dietary excess

• Not excreted Excreted in urine

• Deficiency symptoms Develop rapidly

slow to develop

• Not absolutely necessary Must be supplied in diet

.

9

49

Vitamins

Metabolism of vitamins

• They are released from food during the digestive process but are not digested,

• Water soluble vitamins are absorbed through the small intestine, excess is excreated by the kidney in the urine,

• Fat soluble vitamins are absorbed through the small intestine they are sent to the liver and fat depots and circulate through the blood.

50

Vitamins

• Vitamin A

• Acidic ,alcoholic, aldehyde form.

• Sources –spinach

- carrot, broccoli

-peas ,cabbage

- milk ,cheese

-butter, meat ,fish

-egg, beef

51

Vitamins

• Functions-

-Vision –role in dark adaptation and

vision in dim light

-Helps in bone remodeling.

DRI—approximately 800 mcg/day.

52

Vitamins

• Deficiency-night blindness

-keratinzation of cornea

-bitots spots

- xerosis conjunctiva

- xeropthalmia

- complete blindness

-loss of sense of taste

53

DEFICIENCY

Blindness from xerophthalmia

54

XERODERMA

FOLLICULAR KERATOSIS

.

10

55

ORAL MANIFESTATIONS

56

Vitamins

• Excess Vit A leads to ;

• Headache

• Vomiting

• Double vision

• Hair loss

• Bone abnormalities

• Liver damage

57

Vitamins

• Dentition-disturbances in differentiation and

growth of developing teeth

-calcification of teeth

-retardation of eruption

- disturbances in periodontal tissues.

-failure to form tooth enamel.

-xerostomia.

58

Vitamins

Vitamin D

Group of compounds called as cholicalceferol.

- Source –

- Endogenous synthesis-sunlight

- Exogenous synthesis-deep sea fish ,fish oil,

butter, milk.

59

Vitamins

• Function-

• Maintain normal plasma level of calcium and

phosphorus.

• It is necessary for all animals with a bony

skeleton ,since it facilitates absorption and

utilization calcium and phosphorus for bone

formation

60

Vitamins

DEFICIENCY OF VIT D

1.Rickets in growing child

Clinical features are,

-harrisons sulcus

-Rickets rosary

-pigeon chest

-Bow legs

-Knock knees

.

11

61

Deficiency of Vitamin D.

• Reduction in blood calcium and phosphorus, delayed closure of fontanels.

Disproportionate growth occurs between face and skull. It may cause interference with bone growth.

• It causes retarded eruption of teeth early loss of decidious teeth due to caries.

• Jaw bones become thick.

• Teeth are ir-regularly arranged

62

• Maxilla become narrow and palate becomes high.

• Mandible becomes short.

• Infants with low vitamin D intakes showed delayed

eruption of teeth.

• Increased susceptibility of osseous tissue to muscular

traction as undesirable oral habits.

• Open bite, transverse hypodimensions and misshapen

palate are frequently observed in vitamin D deficiency.

63

Vitamins

2.Osteomalacia –in adults

-osteoid matrix which is laid down fails to

mineralize

Clinical future ;

-vague bony pain

-muscular weakness

-frequent fractures

64

Vitamins

• Excess of Vit D leads to ;

• Nausea,vomiting,and headache.

• Irreversible damage to kidney and cardiovascular

tissue.

• DRI-- approximately 5 to10 mcg/day.

65

Vitamins

• Vitamin E-

• Acts as an antioxidant and protects red blood

cell.

• Sources –vegetable oils, yellow

cornmeal, wheat

bread, egg ,butter .

• Role in human nutrition is poorly

understood.

66

Vitamins

Deficiency of vit E leads to ;

Heamolytic anemia

Excess intake of vit E leads to ;

Nausea

Diarrhea

Cramps and bleeding

Interfereance with anticoagulant drug

DRI—15 mg/day.

.

12

67

Vitamins

Vitamin K

• Basic structures consist of a group called as

quinones

• Sources-green vegetables

-fruits

• Function-it is necessary for the synthesis of

prothrombin.

68

Vitamins• Deficiency of vit K results ;

• Prolonged bleeding

• Increased clotting time

• Oral manifestations are,

• Increased gingival bleeding,

• Prothrombin level <35%--bleeding after tooth brushing,

• Prothrombin level <20%--spontaneous gingival hemorrhage,

• Exess intake of vit K ;

• Interfere with anticoagulants, which could results in hemorrhaging

• DRI—approximately 100 mcg/day

69

Vitamins

Vitamin C (Ascorbic Acid)

• Sources-citrus fruits –orange ,lemon ,grape ,certain vegetables.

• Vit C is Essential for;

• -formation of intracellular substance .

-formation of fibrus tissue matrices of bone.

-formation of tendon and cartilage.

-utilization of iron and calcium .

DRI—approximately 60 mg/day.

70

VITAMIN C

71

Vitamin C deficiency leads to;

In severe deficiency, the gums may become

retracted formation of periodontal pockets.

Loosening of teeth and loss of teeth.

• Vitamin C deficiency produces sub-clinical

scurvy which is related with damage in

development and eruption of the teeth and

formation of hypodimensional osseous bases.

• Exess leads to; Gi upset,diarrhea,and iron

toxicity.

72

Vitamins

.

13

73

Vitamins

74

Vitamins

• B complex-these consist of a group of essential

compounds which are biochemically unrelated

but occur together in some foods

• Sources-green leafy vegetables, cereals ,yeast

,liver, and milk.

75

Vitamin B complexThaimine(B1)

• Source; best source is pork, meat, poultry and egg.

• Function-carbohydrate metabolism.

• Deficiency- BERI BERI

• Dry beri beri-neuromuscular symptoms weakness,

paresthesia, sensory loss, polyneuritis.

• Wet beri beri-CV involvement

• DRI—approximately 1.1mg.

76

Vitamin B complex

Riboflavin(B2)

• Function-cellular respiration

DRI—depends on total calorie intake,energy needs,body size and growth rate. Around 1.1mg.

77

Vitamin B complex

• Vitamin B2 deficiency produces retardation of growth of dentofacial structures.

• A prenatal matarnal riboflavin (B2) deficiency produces anomalies of jaw and teeth; which shows shortness of mandible, and maxilla, cleft palate, severe anomalies of incisor teeth, dentofacial malformations resembled angler’s cl II malocclusion

• -ocular lesions

-cheilosis ,angular stomatitis

-glossitis.

-dermatitis. 78

Vitamins

• Niacin:B-3

• Function-metabolism of fat

• Deficiency-pellagra-dermatitis.

-diarrhoea.

-dementia.

• Exess- facial flushing.

• Liver damage.

• DRI– approxmately 14mg.

.

14

79

Vitamins

• Pyridoxine(B6)

• Function-exact function not known

-fat and protein metabolism

-transmission of neural impulse

• Source-any thing of animal origin

• Deficiency-dermatitis

-glossitis

-angular stomatitis80

Vitamin

• Excess intake of vit B6 –permanent

neurologic damage.

That includes numbness in extremities and

uncoordinated muscle movement.

• DRI—around 1.4mg/day.

81

Vitamins• Vit B-9 (folic acid)

• Function-helps in amino acid synthesis.

• Source-dark green leafy vegetables

• Deficiency-causes fetal neural tube defect and

macrocytic anemia

• DRI—approximately 400mcg/day

82

Vitamin

• Vit B-12 (cobalamine)

• Function-- converts folate into the form in which it can be used to produce red blood cell and nucleic acids for DNA synthesis.

• Deficiency—may cause pernicious anemia.

• DRI—approximately 2.4mcg/day.

83

Summary of deficiency states of vitamins

VITAMINS DEFICIENCY

A XEROPTHALMIA, DRY EYE.

B-1 BERIBERI

B-2 ARIBOFLAVINOSIS

B-3 PELLAGRA

B-6 MICROCYTIC ANEMIA

B-9 NEURAL TUBE DEFECT OF FETUS.

B-12 PERNICIOUS AND MEGALOBLASTIC

ANEMIA.

C SCURVY .

D RICKETS AND OSTEOMALACIA

E HEAMOLYTIC ANEMIA

K HEAMORRAGE –FAILURE TO BLOOD CLOT.

84

Oral deficency symptoms

Vit A-- xerostomia

oral leukoplakia

hyperkerotosis

softeing of skull bone due to <Ca deposition

Vit B-- red swollen lips

burning,smooth,red tongue

ulcerated burning gingiva

Vit C-- bleeding,swollen gums.loose teeth

slow healing.

.

15

85

Oral deficiency symptoms

• Vit D—failure of bone wounds to heal

• enamel hypocalcification

• loss of alveolar bone

• thinning of trabeculation

• Vit E—no known deficiency symptoms

• Vit K-failure of wounds to stop bleeding

86

Minerals

• Macro minerals which are present in relatively high

amount in body -calcium

-phosphorus

-potassium

-sodium

• Micro minerals those which are <0.005% of the body

weight -iron

• -copper

• -manganese

87

MineralsCalcium

• Inert inorganic element which is associated with bone and tooth formation.

• DRI—360mg for infants and 800mg children and adults

• Total calcium in the body is 100-170g

• 99% of which found in hard tissue.

• The level of the blood calcium controlled by parathyroid gland

• Sources-milk and milk products

green leafy vegetables

legumes

citrus fruits

88

Minerals

• Function –

1. Bone formation.

2. Tooth formation.

3. Essential for growth

4. Necessary for blood coagulation

5. Activation of several enzymes and release of certain

hormones

6. Role in the process of impulse transmission at

neuromuscular junction.

89

Factors which influence plasma

Calcium level

• Parathyroid hormone: Increase plasma Ca+ levels and

at the same time <the plasma phosphate level,

• high level of bone matrix stimulates the activity of

osteoclasts this causes demineralization of the matrix.

Ca+ and phosphate are removed

• Regulation of PTH secretion :decrease in Ca+ level

in plasma stimulates PTH secretion and increase in

ionic Ca+ level in plasma inhibits PTH secretion

90

Factors which influence plasma

Calcium level

• Calcitonin :hormone secreted by parafollicular cells of thyroid gland, incerase in Ca+ level stimulate release of calcitonin which in turn decreases the Ca+ in plasma.

• Plasma protein: decrease in these protein will be accompanied by decrease in total Ca+ level.

• Phosphate: Ca+ and PO4+ ions in plasma have reciprocal relationship, increase in serum PO4+ causes a fall in Ca+ ions.

.

16

91

Minerals

Abnormalities of Ca Metabolism –

• Osteoporosis-middle aged women

decreased density of bone

shortening stature

bone fractures

• Osteomalacia –decrease in the mineral content

lack of Vit D.

92

Minerals

93

Minerals

Phosphorus

• 1% of the total body weight.

• Major constituents of bone and teeth

• Regulates the release of energy in the form

of ATP.

94

Clinical Implications

95

Nutrition deficiencies –and

dentofacial growthNutrition and Skeletal Maturation

• Studies have shown

• “prolonged nutritive failure in growing child result in retardation of bone growth centers in the hand and wrist radiographs”.

• Calcium, Vit D and phosphorus are essential for the formation of bone and teeth.

96


dentofacial growth

• Malformations and prenatal deficiencies-

Dietary intake of the expectant mother is directly

related to the condition of the infant at birth.

• Warkany –showed riboflavin-cleft palate,

shortening of mandible

.

17

97


dentofacial growth• Evans ,nelson-showed acute folic acid deficiency-cleft palate.

• During hyperplastic phase Nutritional deficiencies leads permanent damage to the tissue

• During hypertrophyic phase bcz of Nutritional deficiencies growth may stop temporarily

Effect of Nutrition on teeth-

Local effect : chemical or physical action on the external surface of the tooth

Systemic effect :important during the tooth development.

Important during matrix formation and calcification

Influenced by maternal, infant and childhood diet.

98


dentofacial growth

• Role of fluorides-

• Anticariogenic factor.

• Long continued exposure to excessive amounts

may result –dental fluorosis

-skeletal fluorosis

99


dentofacial growth

• Increased density of various bones .

• Increased calcification of ligaments, tendons and

vague pain in small joints of the hands and feet

• In the most severest form –stiffening of the

spine virtually making the patient immobile.

100


dentofacial growth

• Nutrition and malocclusion-

• results from various nutrient deficiencies-

abnormal bone growth

-loss of teeth.

-severe caries.

-periodontal breakdown.

101


dentofacial growth• Vitamins in relation to growth and dentition-

• VitA-disturbances in differentiation and positional growth of the developing teeth.

defective calcification.

Retardation of eruption.

disturbances of periodontal tissues.

102


dentofacial growth• Vit B-

-loss of apatite

-disturbed digestion.

-Retardation of growth

• Vit C

-disturbed calcification of teeth.

-retarded eruption.

-thickened jawbones.

-narrow maxilla.

-short mandible.

-High vault palate.

.

18

103

Role of nutrition on the

periodontium

• Physical nature of the food-

-soft food vs. fibrous food.

Vitamin deficiency

Vit A leads to keratinizing metaplasia of the epithelium, > susceptability to infection and disturbances in bone growth.

Vit B deficiency leads to gingivitis, glossitis and glossodynia,

angular chelitis and inflamation of oral mucosa

Vit C leads to scurvy

- interferes with bone formation and remodeling of the periodontal bone

• Vit D leads to osteoporosis of alveolar bone and cemental resorption.

104

Role of Nutrition in Root Resorption

• Common iatrogenic problem associated with

orthodontic treatment

• Marshall et.al-greater degree of

resorption in deficient diets.

• Beck –calcium deficiency were more susceptible.

105

Effects of consistency of food

• Throughout its various stages of growth mouth is

affected by complex system of forces generated by

masticatory and respiratory activities.

• Diet that does not supply food of a sufficient hard

consistency does not supply adequate stimulus for

proper mastication resulting in a narrow maxillary arch .

• Similar observations have been made in humans –arch

collapse syndrome.

106


1. Low level of eruption –posteriors

2. Maxillary arch are narrower.

3. Mandible are shorter and condyles are thinner.

4. Less tonicity of temporalis and masseter.

5. Reduced linear dimension of skull.

107


• In humans-

• Some authors have proposed-weakening

of the temporomandibular articulation

• Resulting in malocclusion.

108

Nutritional consideration in

orthodontic tooth movement

• Tooth movement involves biologic responses to

orthodontic forces,

• Which may influenced by ascorbic acid.

• Lack of Vit C interferes with collagen synthesis

thus affecting both periodontal ligament and the

formation of osteoid.

• Also affects the stability of orthodontic

correction (ie)it affects retention.

.

19

109

Nutritional considerations in surgical

patient

• The mouth is the portal for entry of food into

the body thus maxillofacial surgery of these

structures may result in impaired food intake

both prior to and after surgery.

• We must ensure adequate nutritional support in

such patient.

• Patient require both an energy source and a

protein source.

110


patient

• Nutritional considerations in surgical patient Carbohydrates energy source for vital organs like brain.

• Protein is also important for imparting strength to the fracture repair. If it is absent then the wound healing is delayed.

• Vitamin A helps in epithelialization,collagen synthesis and cross linking & fibroblast differentiation,

111


patient

• Vit D and calcium helps in healing of hard

tissues.

• Vit E acts as an antioxidant and thus reduces the

damage from the free oxygen radical.

• Vit K helps in activation of various clotting

factors and thus essential for blood clot

formation during healing.

112

What is balanced diet??

What does it contain

113

“A balanced diet refers to intake of

appropriate types and adequate

amounts of foods and drinks to supply

nutrition and energy for the

maintainence of

bodycells,tissues,organs and to

support normal growth and function”.

114

Conclusion

• The proper nutritional status of the patient is of utmost

importance in orthodontic treatment, since success

depends on the response of bone to stimulation for the

accomplishment of desired result.

• Only when we begin to understand these vital nutrients

and the role played by each one in the normal

development of orofacial region and the body as a

whole can we realize its relevance in clinical application.

This will facilitate a comprehensive approach to

orthodontic treatment as a whole.

.

20

115

Bibliography• Contemporary orthodontics-Proffit

• Current Principles and Techniques –Graber Vanarsdall

• Nutrition and oral health-Pollack

• Introductory nutrition-Helen Andrews

• Principles of nutrition-Wilson,Fisher

• Clinical dietetics and nutrition-F.P.Antia

• Basic pathology-Robbins

• Pathology for dental students-Harsh Mohan

• DCNA :25 (1) 1981

• Cheraskin,E., and Riungsdorf, W.M,: Biology of the orthodontic patient . 1; plasma ascorbic acid levels. Angle Orthod., 39:325,1969.

• Litton, S.F., Orthodontic tooth movement during an ascorbic acid deficiency. Am. J. orthod., 65:290,1974

• Jones, N B.: dietary needs of the oral surgery patient with comparision of dietary supplements. J Oral Surg., 28:892, 1970

• McCanlies, J M., Alexander. C.M., robdent., J. H., et al.: effect of vitamin C on the mobility and stability of guinea pig incisors under the influence of orthodontic force. Angle Orthod., 31:257:1961

.

1

ORAL HABITS


CONTENTS

-Introduction-Definitions-Muscle Physiology of Stomatognathic system-Development of Habit-Classifications of Habits-Various factors to be considered before approaching towards anyparticular habit-Habit as a cause of malocclusion-Various Factors which determine the outcome of habit practice-Various deleterious oral Habits

a. Thumb/ digit suckingb. Tongue thrust/infantile swallow habitc. Mouth breathingd. Bruxisme. Lip habitsf. Finger nail biting habitsg. Self-injurious habits/masochistic habits

Although oral habits are being dealt by dentist especially byPedodontist and orthodontist Since long time, but till Todaythis Particular abnormal/normal entity is not fully known.Time-to-Time various hypothesis & explanations have beengiven by various authors but none of it specifically delineatethe habitsThose which are normal for a particular age group and others,which are deleterious to stomatognathic system. The mainreason for this difficulty is that a habit may be a part of normaldevelopment, a symptom associated with deep-rootedPsychological disturbance or a habit may be a result ofabnormal facial growth.

Though this is difficult to delineate it, but at the same time it isimportant to have differentiation of abnormal from normalbecause If normal development get disturbed unknowinglyand at the same time If abnormal growth or undererlyingpsychological cause let continue without interfering at propertime/age it will lead to long lasting effect on stomatognathicsystem its growth & development and psychologicaldevelopment of child.

Habit ?

When Considering habit as such, it should be kept in mind

that whether these performances are just habits or necessity

of an individual to perform e.g. mouth breathing can be

considered as a habit only if there is no underlying cause

e.g. nasal blockage which make it necessary for a individual

to breath through mouth.

Another important characteristic associated with all

habits is that these performances are learned pattern of

abnormal muscle function; in other words, habits are

nothing but altered muscular function/force balance.

This important association necessitate the

understanding of normal physiologic function of

stomatognathic system which will be dealt later.

DEFINITIONS

Dorland (1957) – Dorland defined habit in general “as a fixed or

constant practice established by frequent repetition.”

Buttesworth(1961)- defined habit as a frequent or constant

practice or acquired tendency which has been fixed by frequent

repetition

Both these general definition of any habit highlight one

common fact that it takes time for habit to get established by

frequent repetitions. this time duration and frequent repetitions

ultimately establish habit at unconscious/ subunconsious level

which is the ultimate depth of psychological association with

habits. These general definitions of habit hold true for oral habits

also.

Mathewson (1982) particularly highlighted the muscular

involvement In oral habit. According to him, oral habit can be

defined as learned pattern of muscular contractions.

Development of habit

Development of habit should not be confused with one normal

developmental Phenomenon Instinct. Newborn infant develops

some Instincts composed of elementary reflexes. An instinct is

one where the pattern and order are inherited while in habit,

pattern and order are acquired. If these acquired pattern and

order are repeated over a long Period of time, it becomes habit.

At beginning infant/child makes an effort by frequent learning and

practice, later on muscles start responding rapidly. It has been

established by psychologist through various studies that

unconscious mental pattern of child develops from five sources

named instinct, Insufficient or incorrect outlet to energy, pain or

discomfort, abnormal physical size of parts, imitation of or

imposition of others.

.

2

Muscle physiology of stomatognathic system

Before going into details of oral habits , it is important

to know the basic muscle physiology of this complex and

integrated system. It is necessary and important because as already

mentioned all habit express their deleterious effects through

muscles functions, Interestingly which is under the control of an

individual, but not easy for an individual to directly change this set

pattern within a short period of time because all these events are

associated at unconscious level. These muscle forces, which at a

time went wrong and produced untoward effects will be managed

and channelized properly to bring back the stomatognathic system

to normal healthy and efficient level from where it was taken away.

Basic muscle characteristics

There are various Physiologic characteristics of muscle which

explain their role as a guard to direct various Growth processes to right

direction

Among all them, the following properties are important in relation to

our field

Muscle elasticity – muscle in its non active form i.e. not undergoing

contraction is no way exception to rule of elasticity and this property

express itself as a rubber band effect which is evident within structural

limitation and individual characteristic of muscle.

Contractility- quality of contractility i.e. ability of tissue to decrease

its longitudinal dimension is unique characteristic of muscle.

Muscle tone- skeletal muscle always maintain a level of partial

contraction i.e. no muscle is in a full relaxation state. This special

property is important in maintenance of precise counter balancing force

in orofacial region which is ultimately responsible for stability of

whatever an orthodontists particularly; and any other specialty which

plays with stomatognathic system; achieve by its best efforts.

Myostatic or stretch reflex - This is caused by pull on muscle’s

attachment to its supporting tissue e.g. when a dentists pulls patients

lips, he encounters increasing resistance of lip muscle and associated

altered movement of tongue. This property comes in play when

functional examination of tongue is done.

These properties are not the only properties of muscles. There are

various other unique properties e.g. All or none law, resting length

law etc. But these mentioned four properties will be helpful in

understanding of two important muscular mechanism which keep

equilibrium among various forces.

Buccinator mechanism

This mechanism explain one interesting finding that if bones

always yield to pressure / forces and muscles are always in a

definite amount of contraction by virtue of muscle tone, than why

bone of orofacial region doesn’t yield to these muscular forces.This

fact can be explained by counter-balancing forces of Buccinator

mechanism

Two parts of this counter balancing system are forces from outside

the dentition/outside alveolar process and those from inside the oral

cavity.

Dentition is literally wrapped around externally from forces of

orbicularis oris muscle, fibers of this muscle intermingles postero-

laterally with buccinators muscle, which in turn joins internally at

pterygomandibular raphe with fibers of superior constrictor of

pharynx which ultimately joins mid- cranial base prominence named

Pharyngeal tubercle.

These forces are counter balanced by forces of large muscular

organ tongue. Rest mild balancing forces which precisely balance

this system are those from periodontal ligaments through a

phenomenon called active stabilisation.

Triangular force concept

This muscular force balance comes into picture

especially in case of swallowing. This hypothesis explains that it is

wrong to blame tongue thrust as a cause for anterior open bite

malocclusion. It discards the term tongue thrust because tongue

doesn’t thrust forward during swallowing because during

swallowing greater extent of physical stress of orofacial

musculature is posterior and lateral direction with the minimal

amount of anterior stress.

From all this brief discussion of muscle physiology and their

integrated role and action, it looks important and vital that the

ultimate goal for correction of deleterious effects produced by

habits should be focused to achieve normal muscular function/

force balance. Though it takes time, but it is possible to convert

back musculature to their proper structure & function.

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3

Classification of habits

-Obsessive habits (deep rooted)

- Intention habits e.g. digit sucking, nail biting

- Masochistic/self injurious habits e.g. gingival stripping habit

-Non-obsessive (easy learned and easy to drop)

-Unintentional e.g. chin propping

-Functional habits

e.g. mouth breathing

Bruxism

Tongue threshing etc

Various Authors have classified habits e.g.

James (1923) - useful habits

- harmful habits

Kingsley (1958) - Functional oral habits

- Muscular habits

- Combined

Morris and Bohana (1969)

-Pressure/non Pressure habits

-Biting habits

Klein (1971) -empty habits

-meaningful habits

Finn (1987)

-Compulsive habit

-Non-compulsive habit

-Primary habit

-Secondary habit

Though some authors have classified habits as beneficial habits

and harmful habits, but if looked in strict sense, it is not valid

classification e.g. breathing, mastication is classified in

Beneficial habit group as it was the thought that these habits

help in beneficial way in growth and development of orofacial

system. Although it is true about their beneficial contibution in

normal development, but these are not habit but are normal

physiologic function

Deleterious oral habits

These habits are sometime called pernicious oral habits. But

this is misnomer as word pernicious mean fatal which may risk life

as in medical field one common example is pernicious anemia.

Though oral habits may cause marked damage to structure and

function of stomatognathic system, but in strict sense it cannot be

considered as pernicious.

Factors to be considered while dealing with oral habits

One should not jump into instant diagnosis of any mild deviation

of normality as habit. Various factors should be considered

before making any relevant diagnosis and subsequent treatment

plan if needed.

1. Can the habit be considered normal for any particular age

group or stage of development. Thumb sucking may be

considered normal up to age of 3-4 years

2. Why the child has acquired habit.

3. What are the psychologic Implications of allowing the child to

continue the habit or forceful interruption of habit. If a habit is

being forcefully interrupted e.g. thumb sucking , child may

substitute tongue thrusting habit for thumb sucking.

4.Is that habit is harmful or potentially harmful to mouth or related

oral structure. it is important for any habit that it should be

analyzed whether it will or may lead to malocclusion and

associated problem. e.g. being a orthodontist it is imp that

tongue thrusting habit should be intervented only if it had

produced malocclusion or has potential to do so. If tongue

thrusting is related to only speech difficulties than only speech

therapy is indicated.

.

4

5. If habit is harmful, will the damage to mouth and dentition will

disappear spontaneously when habit is discontinued or the

deleterious effects will persists. It is known that if thumb sucking

habit is discontinued in its initial phase i.e. in primary dentition

there will be no untoward effect on permanent dentition. reverse of

this sequence is also true ie sometimes correction of malocclusion

will lead to elimination of habit.e.g. in case of simple tongue thrust

habit, elimination of anterior open bite will eventually eliminate

habit.

6. When is it reasonable to desire that habit be broken. This

highlights very important dimension in management of habit,

time .It is wrong for trying to eliminate each and every habit

when it is diagnosed first because as already mentioned some habit

are part of normal development of child. Thumb sucking especially

in first year of life is absolutely normal and essential physiologic

activity. Similarly infantile swallow up to the age of 1 ½ years i.e.

up to the time of eruption or deciduous molars is essentially

normal physiologic activity.

7. What appropriate means to be used to discourage habit

Other basic factors which should be consider when planing

treatment for any habit are

a) Rationale- since problem is of controlling a biologic process

hence rational for therapy should be basically physiologic and

not mechanical. Attempt should be always to alter the neuro-

muscular reflex which will aid in muscular relearning. If any

mechanical device is under consideration for any particular

case, it should have sound rationalse

b) Primacy of malocclusion-it should be determined whether

malocclusion is of primary or secondary concern. If

malocclusion is of primary nature that it has given origin to

habit, then malocclusion should be treated primarily & habit

will get corrected itself.

c) Type of pre- existing malocclusion and facial morphology.

Various habits may require different approach especially

regarding mechanotherapy, but one common approach to all

habits is the psychological counseling and developing good

rapport with the child because it is ultimately child who has to

give up habit.

Digit sucking

Digit sucking may involve either thumb or finger but most of

the times thumb is involved in this habit. In few cases where

chin is prominent eg in class III skeletal pattern it is easier for

child to place finger rather than thumb.

Digit sucking may be defined as placement of

digit(thumb/finger) into various depth into mouth.

Possible etiologic factors

As with all habits, no single factor can explain the cause for digit

sucking habit. Various theories have been proposed. But before

going to causative factors it s interesting to note that time of

initiation of digit sucking habit is related to some underlying

predisposing factor e.g. if a child starts digit sucking habit in first

few weeks of life it is typically related to feeding problem. Few

children develop digit sucking at time of eruption of primary teeth

as teething device particularity during painful eruption of primary

molars ; still later few children develop this habit to relieve

emotional and psychological stress.

.

5

All digit sucking habits should be studied further for their

psychological implications.. Habits may be related to hunger,

satisfying sucking instinct, Insecurity, or even as a desire to

attract attention. For successful habit elimination therapy,

possible underlying cause should be identified.

Theories of various causative factors in thumb sucking habit

1. Classic Freudian theory (sigmund Freud, 1905 ) according to

this theory, especially during first year of life oral cavity is the

primary sensory site which derives pleasure from sucking. Hence

it is considered normal for child to perform this habit.

2 Oral derive theory ( sears and wise 1982) according to this

theory oral derive is established by prolonged breast feeding.

Hence according to this theory digit sucking habit is not due to

frustration of weaving but is due to prolong nursing which

established very strong oral devices for sucking

3. Learning theory (Davidson 1967) this theory advocates that

non-nutritive sucking habit stems from an adaptive response. Infants

associate sucking with such pleasurable feeling as hunger and later

on these events are recalled by sucking the suitable object available

mainly digit.

4.Rooting and placing reflex theory(by Johnson and larson1993)

it combines the psychoanalytic theory of sigmund Freud and

learning theory. This theory states that all children posses an

inherent biologic derive for sucking. Rooting and placing reflex---

whenever anything is placed in mouth it initiates sucking reflex.

This reflex is common in infants of all mammals

Eventhough various theories have been put forward to explain digit-

sucking habit, no single particular cause may be labeled as causative

factor.

Grades of digit sucking

Subtelny (1973) has graded thumb sucking into 4 types

Type A:- whole digit is placed inside the mouth with pad of

thumb pressing against hard Palate and at same time maxillary

and mandibular anterior contact is present.

this type is most common type of thumb sucking habit patterns

Type B:-Thumb is placed into the oral cavity without touching

the vault of palate while at same time maxillary and mandibular

anterior contact is present.

Type C:-thumb is placed into mouth just beyond the first joint

and contacts the hard palate and only the maxillary incisors,

there is no contact with mandibular incisors.

Type D:- This is the least common type of all pattern of thumb

sucking habit. Very little portion if thumb is placed into mouth.

Factors influencing the effect of thumb/digit sucking on

dentition.

There are various factors which will modify the effect

Of habit performance on dentition.

These factors are

1 Pattern of habit performance

2 Various parameters of habit i.e. frequency, duration and

intensity.

Pattern of habit performance

The most common pattern is placement of thumb inside the oral

cavity in such a manner that thumb- print area rest against rugae

of hard palate. Index finger may curle over the bridge of nose

or rolled into first with other fingers. In this pattern, thumb is

resting against the both upper and lower incisors which lead to

proclination of upper incisors and retroclination of lower

incisors.

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6

Various parameters of habit that dictate the severity of

malocclusion.

Intensity- It implies that how vigorously habit is performed.

Thumb/ digit may be kept Passively in mouth or may be sucked

with enthusiasm

Frequency- It denotes how often habit is practiced i.e. only for

few minutes or child is never without digit in mouth.

Duration-It indicates the total time period of habit being

practice e.g. it maybe years or only months

Deformities/Malocclusion that develop because of habit

practice will depend on interaction of all these factors.

Maxillary incisors experience labial and apical forces

whereas mandilbular incisors are pressed lingually & apically

Because digit is placed in palate area which displaces the tongue

inferiorly and Laterally between posterior teeth, it disturb the

balance of buccinators mechanism forces and shift balance to

overall increased buccued forces to maxillary dention (because of

lower tongue position)

Typical malocclusion that develops is

- Labial flaring of maxillary incisors which lead to spacing

between these teeth.

- Lingually collapsed mandibular incisors with crowding

- these factors lead to increased over jet & decreased overbite

- Less frequent but quite possible is bilateral posterior cross bite

due to collapsed maxillary denture under the influence of buccal

forces

- Deep palatal vault because of direct pressure from thumb and

also exaggerated appearance of this deep vault due to narrow

maxillary arch.

- There is no evidence that digit sucking may induce any change

in molar relationship as believed earlier that prolonged digit

sucking may precipitate class II molar Relationship.

- Melsen et al has reported that prolonged sucking may

predispose to abnormal swallowing habit.

- Apart from malocclusion in few cases , prolong sucking may

cause skeletal change. E.g mandibular postural retraction may

develop if weight of hand or arm continuously force mandible to

assume retracted position in order to comfortably performs habit.

- Open bite developed due to thumb sucking habit may predispose

to simple tongue thrust habit because this open bite has to be

sealed by tongue

- Because of altered forces balance in and around maxillary

complex, it becomes almost impossible for nasal floor to drop

vertically to its expected normal position during growth This lead

to narrow nasal floor and high palatal vault.

-Upper lip becomes hypotonic and lower lip hyperactive

since orbicularis oris muscle has to elevate lower lip

between malposed incisors during swallow. This abnormal

muscle adaptation stabilizes the deformation produced by

sucking habit, in other words it prevent spontaneous

correction of malocclusion even after stoppage of habit

Development of habit may be divided into three distinct

phases of Phase I, Phase II, Phase III

Phase I- Normal and sub clinically significant sucking

This phase extends from birth to 3 year of age. Almost all

children develop transient thumb sucking & considered

normal for this age. But it should be checked whether child

show tendency for ‘Thumb specific” type of vigorous sucking.

If so, a definite prophylactic approach should be undertaken

e.g use of specific nuk- sucker nipple.

Phase 11 – clinically significant sucking

This Phase extends from age of 3 years to 6-7 years . Presence

of sucking During this Phase should be attended more

seriously because

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7

-It’s a indication of possible clinically significant underlying cause e.g.

most commonly anxiety and emotional disturbance.

-It is the best time to solve dental problems related to thumb sucking.

Definite programme for habit correction should be considered.

PhaseIII - Intractable sucking

This phase denotes definite and significant deleterious effects of habit.

Usually malocclusion associated with phase of habit is not self-correcting.

DIAGNOSIS

1) History-

As during dental appointment a child may seldom indulge in habits

so proper history should be taken

-Enquire the feeding pattern and parental care

-Questions regarding the frequency, intensity and duration of habit.

-Presence of other related habits e.g. tongue thrust etc should be

evaluated.

2) Clinical findings-Various clinical finding say suggest or

substantiate the presence of habit e.g.

-Clean pulp of thumb and short nail

-Dento-alveolar pattern i.e. typical flaring of maxillary

incisors and collapsed crowded lower anterior

-Excessive /vigorous thumb sucking may cause irritated and

reddened palatal rugae area

Various other clinical features (manifestations) as described

earlier may support the diagnosis of digit sucking habit.

Management

Factors to be considered

The single most important factor to be considered in

management is age of child, up to age of 3-4 years this habit is

considered normal

It’ true that if digit-sucking habit has potential to cause

malocclusion it should be treated; but there are certain type of

malocclusion which should be taken into consideration e.g.

straight profile with firm class I occlusion may withstand effects

of thumb sucking better than class II skeletal pattern.

Occasionally it is been reported that thumb sucking habit may

be beneficial in class III malocclusion and facial pattern.

Various steps in management

Control of habit –usually begin in phase I1 problem. Habit

should be discussed with child in very friendly atmospheres.

To show the importance of correcting such habits, which will

develop child’s interest and demand to correct habit; study

models and photographs of patients who had similar problems

of habit can be shown. Both pre treatment and post treatment

records should be shown. During this phase, only child is

given importance and habit is not discussed in presence of

parents. To parents it should be made clear that this habit

should not be a part of family discussion.

During this time, various reminding methods may be used to

help child. E.g.: Time –charts are very useful.

One interesting concept is developed by Dunlop called

Dunlop’s Beta-hypothesis. He believed that if any child in

asked to concentrate on the .Performance of act(i,e habit) at the

time he practice , it will slowly force the child to stop that

particular act.

Child is asked to sit in front of mirror and deliberately perform

thumbs sucking habit and observing himself as he indulges in

habit.

Phase III

It is better to have psychologist consultation because most of

children in this phase of habit practice have underlying

psychological problems. Counseling, behavior modification etc

Procedure should be undertaken even in this phase, but it may need

appliance therapy.

Choice of appliance

Any appliance no matter how ideal it is , should never be placed in

child’s mouth or used as reminding device against the child’s will

because ultimately its child’s co-operation rather than appliance

itself which is going to make outcome successful. Ideal appliance,

which will be used for this purpose-

a) Should offer no restraint to normal muscular function and growth

b) Should not involve parents

c) Should not attach shame with its use

.

8

Removable appliances

Various removable appliances may be used e.g. palatal crib,

palatal rake , palatal / lingual arch with spurs, Hawley’s retainer

with spurs.

Lingual arch with a spurs is best in achieving breakage of

reflex activities of thumb sucking. A clear and immediate

discomfort / pain will keep on reminding neuromuscular system

reflex even without any involvement of child as when child is

sleeping.

Fixed mechanotherapy

Even though fixed appliances do not involve Child’s direct

involvement and cooperation, it should not be placed against

child’s will. The only indication of these appliances is when child

wanted to cooperate but have frequently broken or lost the

appliance. All these appliances prevent placement of thumb into

mouth with comfort..Deciduous or permanent molar are banded and

lingual arch is soldered to these bands with interlacing wires in

area of anterior hard palate.

Quad halix- frequently these patient have constricted maxillary

arch which need expansion, a quad halix is given which serves

both purposes i.e habit brekage & maxillary expansion. Anterior

two halix of this appliances prevent comfortable placements of

thumb at rugae area.

This over line approach should be gradually applied . one should

never jump directly to mechanotherapy. If this attempted without

gaining chind’s cooperation and trust; it is going to fail. Always

Child’s effort and cooperation should be praised and reinforced.

TONGUE THRUSTING

Tongue thrusting and infantile swallow habits are related

so closely to each other that it is very difficult to differentiate

and describe them individually. infantile swallow is a complex

muscular function aberration in which tongue thrusting is one

component.

Development of normal / mature swallow is unique and

advantageous muscular developmental aspect which guide the

correct movements of one particular muscular organ of body,

tongue which is being distinguished from all other muscles by

the fact that it is the only muscle which is joined to bone only at

one end, the other end( tip of tongue) is free.

Definitions of Tongue thrust

Brauer (1965) : A tongue thrust is said to be present if tongue is

observed thrusting inbetween, and teeth did not close in centric

occlusion during deglutition.

Tulley (1969) : He states tongue thrust as the forward movement

of tongue tip between the teeth to meet the lower lip during

deglutition and in phonation, so that tongue becomes interdental.

Barber (1975) : Tongue thrust is an oral habit with persistence of

an infantile swallow pattern during childhood and adolescence and

thereby produces an open bite and protrusion of anterior teeth .

Schneider (1982) : Tongue thrust is a forward placement of tongue

between the anterior teeth and against the lower lip during

swallowing.

Classification of Tongue thrust

-Etiologic classification – since tongue thrust may be associated

with many factors, it is helpful to classify tongue thrust depending

on underlying cause.

.Physiologic : It comprises tongue thrust associated with

physiologically normal infantile swallow of infancy.

.Habitual : Habitual tongue thrust is the continuation of tongue

thrust even after the correction of underlying causative

malocclusion. Eg If simple tongue thrust continue after correction

of anterior open bite.

.Functional : When tongue thrust mechanism is adaptive behaviour

developed to achieve some function eg to achieve a normal oral

seal in case of anterior open bite.

.Anatomic : Eg a person with enlarge tongue (macroglossia).

.

9

Clinical classification

James s. Brauer & Holt classified tongue thrust habit

depending on deformity it cause

Type 1 : non deforming tongue thrust

Type 2 : deforming anterior tongue thrust

Type 3 : deforming lateral tongue thrust

Type 4 : deforming anterior + lateral tongue thrust

Etiology of tongue thrust :

Fletcher has identified various factors which may lead to

tongue thrust.

I. Learned behaviour (ie a type of habit)

-Prolonged thumb sucking habit

-Prolong period of soreness of gums and teeth keeping

teeth apart during swallowing hence changing the

swallowing pattern.

-Improper bottle feeding

-During mixed dentition, tongue held in open spaces

which lead to habitual mobile activity of tongue.

-Prolonged period of tonsillar enlargement and soreness

which changes the position of tongue for patient comfort.

II Maturation

-Late maturation from infantile swallow to mature swallow.

-Tongue thrust is a part of normal childhood behavioural

pattern which gradually modifies as lingual spaces and

suspensory system changes.

-III. Mechanical restriction

-Constricted dental arches force the tongue to assume

lowered and forward position

-Macroglossia forces the tongue forward to properly

manipulate the bolus

Enlarged tonsills and adanoids

IV Neurologic disturbances

-Hyposensitivity of palate precipitate crude pattern of food

manipulation and swallowing.

-Disruption in tactile sensory control and coordination

-Motor disability and loss of precision in oral function

V Psychogenic factors

-Substitution of tongue thrust for forcibly discontinued

thumb sucking.

-Exaggerated motor function of tongue

VI Genetic factors

-Inherited variation in orofacial forms

-Inherited orbicularis oris hypertrophy resulting from

specific anatomical variation and neuromuscular interplay.

-Genetic mouth behaviour predetermined pattern .

General implication of tongue thrust habit in various forms of

malocclusion.

Though it is not yet established cause and effect relationship

between tongue thrust and malocclusion, it is seen that tongue thrust

and / or particular posture / position of tongue may be associated with

particular type of malocclusion.

Class I malocclusion: Most common type of malocclusion seen in class

I cases with tongue thrust habit is anterior open bite. Occasionally

bimaxillary protrusion is partly attributed to tongue abnormality being

large or posture forward causing forward positioning of both arches.

Class II malocclusion: Class II div 1 malocclusion is particularly

associated with abnormal orofacial musculature tongue being one of

them. Because of reduced space due to backwardly placed mandible,

tongue assume a higher posture.

Class III malocclusion: Since lower jaw is protruded, more space is

available for tongue in floor of mouth which leads to lower posture of

tongues. Unbalanced buccal forces lead to constricted maxillary arch

and deep palatal vault.

Various forms of tongue habits

Simple tongue thrust :

It is defined as tongue thrust with teeth together swallow.

It is usually associated with history of thumb / digit sucking habit

eventhough this predisposing habit no longer be practiced.

Prolonged thumb sucking habit lead to development of anterior open

bite which necessitate tongue to form anterior oral seal. So this

simple tongue thrusting habit is almost always adaptive response to

open bite malocclusion rather than being cause of it .

Malocclusion associated with simple tongue thrust is well

circumscribed anterior open bite.

.

10

Complex Tongue Thrust

Defined as tongue thrust with teeth apart swallow.

Complex tongue thrust is likely to be associated with chronic

nasorespiratory distress, tongilitis etc.

When tonsils are enlarged and inflammed, root of tongue in

its normal posture and position encroach enlarged faucial pillars

causing pain and discomfort. To avoid this discomfort, mandible

reflexly drops down separating teeth and providing room for tongue

to thrust forward during swallow for more comfort. Hence pain and

lessened space in throat precipitate new forward posture of tongue

and new swallowing reflex.

In case of chronic mouth breathing, large free way space is

present because of dropping down of mandible and protruding

tongue to provide adequate airway. Since maintenance of airway is

more demanding and vital than normal swallow, so later is

conditioned for the necessity of mouth breathing. Jaws are thrust

held apart during swallow so that tongue may remain in protracted

position.

Malocclusion associated with complete tongue thrust has two

distinguished features

.Poor occlusal fit. There is no firm intercuspation when

study models are oriented together. This finding is unique

for malocclusion associated with complex tongue thrust.

Reason for this is that since teeth are not held in centric

occlusion during swallowing, which over a prolonged period

of time lead to instability of this natural occlusal fit.

.Generalized anterior open bite

Unlike simple anterior tongue thrust, open bite produced by

complex tongue thrust is diffuse.

Occasionally there may not be a open bite with complex tongue

thrust if tongue is positioned evenly on top of all teeth during

swallow.

Abnormal tongue posture

Abnormal tongue posture is not a habit as such especially

endogenous type . But it is worth to mention it along with thrusting

habits because malocclusion associated with both of these is almost

similar ie open bite.

Abnormal tongue posture produces more obvious open bite than

tongue thrust because abnormal posture is maintained almost all the

time unlike thrust which occur only during swallow.

There are two forms of protracted abnormal tongue posture.

1. Endogenous

2. Acquired

Endogenous type abnormal posture

Usually during eruption of teeth, tongue adapt a posture confined

within dental arches. But some children because of unknown factors

keep tongue anteriorly between incisors. Though occasionally this

abnormal posture may produce marked open bite, but interestingly

most of times incisor relationship is stable inspite of abnormal posture.

Acquired abnormal tongue posture

This usually result from chronic pharyngitis, tonsillitis etc. but

may also present in cases with narrow maxilla. Posterior open bite

associated with abnormal tongue habit is actually most of times due to

abnormal tongue posture.

When maxilla is expanded with RME, this will lead to

correction of adaptive posture and posterior open bite.

Regarding prognosis, prognosis of acquired abnormal posture

is better than endogenous type because specific cause may be

eliminated in case of acquired one.

4 Retained infantile swallow

Infantile / visceral swallow is normal for infants upto age of

11/2 year beyond which this immature type of swallowing pattern

get change to mature swallow through transition period.

Retained infantile swallow is rare but if present, it has poor

prognosis. So it is very important to diagnose this rare entity

correctly, which require knowledge of infantile and mature swallow

pattern features. Various characteristic features differentiate mature

from immature swallow.

Infantile swallow

Infantile swallow is one of the good example that whatever might be

best suited at one time for a particular physiologic need / situation may

become problem after a specific time.

Infantile swallow pattern is unique and sophisticated in various

ways

-In neonates, stomatognathic musculature is most sophisticated

musculature in whole body.

-Discrete unilateral response of tongue towards the side of

stimulation is not found in any other muscle in body.

-Mouth is primary sensory input area of child especially during first

6 months.

-Suckling is a rhythmic activity which need great assistance of

tongue & orofacial musculature. As child see source of nutrition,

head is extended towards the source ( e.g during breast feeding),

infant closes lips around nipple like a sphinctor, jaws kept apart,

tongue comes in between gum pads followed by rhythmic

depression of cheek, bobbing of hyoid bone and fast backward and

forward movements of tongue.

.

11

Muscle most likely responsible for maximum share of suckling work

is Genioglossus. Characteristic features of infantile swallowing (by

Moyer)

-Jaws are apart with tongue between gum pads

-Mandible is stabilised primarily by contraction of facial

muscles and interposed tongue.

This is an important features because usually children with infantile

swallow have expressionless faces as muscles of facial expression are

performing heavy duty of stabilising mandible instead of performing

delicate facial expression

Swallow is guided and greatly controlled by sensory exchange

between lips and tongue.

Transition period

This period characterize the transition of infantile swallow to

mature swallow. This takes places gradually and starts with eruption of

deciduous teeth especially deciduous molars. In normally developing

and maturing child, mature swallow may be observed by age of 1 ½

years. Most characteristic feature during transition period is diminished

activity of buccinator muscle.

Moyer has stated following characteristics of mature

swallowing pattern.

-Teeth are together during swallowing.

-Mandible is stabilised by muscles of mastication rather than muscles

of facial expression.

-Tongue tip held against palate above and behind the upper incisors.

-Minimal contraction of lips

Other features of mature swallow are

-Mandibular posture is no longer prognothic

-Tongue no longer plunges forward and backward as needed in suckling

/ immature swallow.

Phases of mature swallow

Knowledge of various phases of mature swallow helps in

differentiating mature swallow from immature swallow and moreover

various activities of muscles during swallowing may be known which helps

in correlating various types of abnormalities associated with swallowing

problems.

There are four integrated phases of mature swallow

.Preparatory phase :

It begins with entry of food into mouth

-food is converted into bolus which lies on tongue-at this stage, oral cavity becomes sealed unit as tongue presses against

-soft palate posteriorly

-buccal teeth and soft tissue laterally

-lips and teeth anteriorly- Jaws stabilized by muscles of mastication.Oral phase

-Opening of posterior aspect of sealed oral cavity

-Soft palate seals off nasal cavity-Posterior part of tongue drops down and moves backward

-Various peristaltic types movement of tongue..

Pharyngeal phase

Food moves from oral cavity to pharynx and whole pharyngeal complex

reflexly move upward

Eosophageal phase :

Food passes through pharynx to eosophagus and is involuntry in control.

During this phase still going on, tongue and palate return to their original

position for next swallowing cycle.

Important questions after considering all these normal and immature

swallowing pattern is that “Is there any altered muscular force balance

occuring with infantile swallow which may lead to deliterious effect

on dentition”.

This question is still unexplained fully especially with regard to tongue.

Acc. to proffit, altered tongue activity is adaptives response rather than as

causative factor in malocclusion.

One logic to substantiate this hypothesis is that if tongue really cause

malocclusion (eg anterior open bite) then it must express its ill effects on

deciduous dentition because infantile to mature swallow transition occur

at age 1 ½ years.

Effect of altered tongue movement

Acc. to Garliner, tongue may act as impeding force or as a

moving force. Impeding force prevent any natural movement of

dental units (eg prevent eruption of teeth). But as moving force, it

actually moves the teeth.

Simple anterior swallow :

Simple anterior swallow is characterized by anterior position

of tongue during swallow. Tongue may be hitting against the upper

incisor or protruding in between upper and lower incisors.

While it hit against the incisors, it act as moving force and

cause labial flarring of these teeth. But when tongue protrude

between upper and lower incisors, it act as impeding force which

may (if present during eruption of incisors) prevent eruption of

incisors and hence anterior openbite .

complex swallowing problem.

In this type, the abnormality of musculature extend from

molar to moral. Malocclusion seen is open bite which is not limited

to anterior region.

Unilateral swallowing problem

Tongue moves at 45angle against the dentition in bicuspid

and molar areas and stress of this force may manifest as open bite

from lateral incisor to first molar.

Bilateral swallowing problem

Characterized by bilateral depression in molar areas but some

occlusion may be present in anterior region

With all these 4 swallowing problem, the effects produced on

dentition are not only because of tongue itself but because of

involvement of various other muscles eg :

.

12

-weakness of orbicularis oris muscle owing to fact that

protrusion of tongue in simple anterior swallow seals the oral

cavity preventing need of normal function of orbicularis oris.

This weakened muscle exaggerate the effect of tongue as

moving forces on incisors because there is no adequate counter

balancing force from labial side by orbicularis oris.

Weak masseter muscle

Normal masseter muscle activity depend on contact between

posterior teeth. Presence of tongue between posterior teeth Prevent

full expression of masseter muscle activity which on long term basis

cause disuse atrophy of massester.

This weakened massester muscle further reinforce the

infantile swallow because normal masseter muscle activity is not

there to support & stabilize mandible during mature swallow.

Hyperactivity of mentalis muscle because extensive movement of

lower lip occur during immature swallow.

Diagnosis :

History

History should include following

-Information regarding any other oral habits eg thumb sucking, mouth

breathing

-Information regarding any infection of upper respiratory system,

inflammed tonsils for long duration.

-Information regarding the swallowing pattern of sibling for possible

hereditary etiologic factors.

-Information regarding parameters of habit performance eg

intensity,duration and frequency.

Examination

It is very important to do proper functional analysis to

determine the specific type of habit and possible involved factors.

Perverted swallowing habit should be detected and corrected early to

facilitate normal development of dentition and palate.

Functional analysis of tongue

Tongue and lip functions are synchronized in their

activities. Thus it is possible to get idea about abnormal tongue

function from observed lip musculature. Eg : In infantile swallow

pattern with tongue thrust, lower lip also shows marked activity.

Ideally tongue should be examined without displacing

either tongue or lips because when lips and cheeks are retracted

with mouth mirror, normal tongue activity may be inhibited.

A) Posture of tongue

Tongue is examined for posture while mandible is at

physiologic rest position. One way is to trace this posture from

cephalogram taken with mandible at rest position. Clinically it is

evaluated by asking Patient to sit in upright position, & then tongue

and lip relationship examined gently. In this position, dorsum of

tongue should touch palate lightly and tip resting in lingual fossa or

at crevices of mandibular incisors.

Next tongue is observed during various swallow. During

normal mature swallow tip of tongue should touch curvature of palate

just behind the maxillary incisors.

As during swallowing it may be difficult to observe various

tongue movement and position directly, an indirect method is given

by Dr. Everitt Payne et al called Payne technique.

This technique measures where exactly tongue hit during

normal swallowing.

The revealing substances used in this technique is orabase. With 1%

sodium fluorescien solution in water soluble base. Procedure is as follow

-Tongue is dried at areas where revealing substance is to be placed.

-A thin layer of substance is coated over the dry portion of tongue and

patient is asked to swallow.

-Black light technique (i.e dark room facility) will show exactly where all

tongue moved during swallow because in dark room, sodium fluoresciene

will glow.

Swallow

Swallow is a complex integrated physiologic process which is

entirely a muscular activity. As various muscles are involved, specific and

definite stress patterns are observed in swallowing. Normal swallow

procede as follow

-Tongue tip placed just behind maxillary incisors.

-Midpoint of tongue is raised to top of oral cavity i.e against hard

palate.

-Tongue moves against hard palate in posterior direction tipping at

45so that posterior part of tongue will lie against the pharyngeal

wall.

-Simultaneous with tongue action, buccinator and masseter

-muscle extert lateral forces against dentition.

-Orbicularis oris generates posterior force against maxillary

anterior teeth.

Hence 3 major muscle groups are activated

.Tongue – tongue itself is very strong muscle which

counter-act the force of buccinator, masseter and

orbicularis oris muscles.

.Masseter and buccinator

These muscles get activated during each swallow. Failure

in activation of these muscles is caused by either placement

of tongue between posterior teeth or poor posterior

occlusion.

.Orbicularis oris muscle

Acts as stabilizing force. Hence act as natural anterior

retainer for maxillary incisors. These various stress pattern

and their significance is well understood by triangular

force effect.

.

13

Methods of swallow examination

-patient is ask to sit upright with unsupported back and head.

-Observe unnoticed various swallow.

-Then small amount of water is placed in mouth and patient is asked

to swallow.

Various events that occur in mature swallow (which act as guide to

differentiate mature from immature swallow) are

-Mandible raises to bring teeth together during swallow.

-Lips touch lightly without any obvious movements.

-Facial muscles do not show any obvious contractions.

-Hand is placed over temporalis muscle and patient is asked to

swallow. If Contraction of temporalis felt, it indicates that

stabilization and elevation of mandible during swallow is brought by

contraction of muscle of mastication.

-Lower lip is held gently with fingers or a tongue depressor is placed

over lower lip. Individuals with normal swallowing completes the

swallowing cycle with no movement of lip.

Those patient who have immature swallowing will feel that their

swallowing act is inhibited by finger held lip because strong

mentalis and lip contraction are needed for mandibular stabilization

in teeth apart swallow.

Functional features of various types of swallow

1. Normal infantile swallow :

This is seen in infants below the age of 1½ year beyond which a

normally growing child show mature swallow.

-Tongue lies between gum pads

-Mandible stabilized by muscles of facial expression, buccinator

being the most prominent.

-Reduced activity of buccinator is a feature of transition from

infantile to mature swallow.

-Most characteristic feature of cessation of infantile swallow is

appearance of contraction of mandibular elevators during swallow

to stabilize the mandible.

2. Mature swallow

-Contraction of mandibular elevators

-Very little / minimal lip and cheek contraciton)

Mild activity of lips may be seen with mature swallow during mixed

dentition period because spaces are present due to some missing teeth

as a part of transition of dentition. So lips show mild contraction to

secure the oral seal.

3. Simple tongue thrust swallow

-Typical contraction of lips, mentalis.

-Normal contraction of mandibular elevator as teeth are

together during this swallow.

-This type of tongue thrust is a adaptive response to existing

malocclusion ie anterior open bite.

-Inflammed tonsils in mild form that do not impart tooth apart

swallow may lead to simple tongue thrust swallow.

In prolonged cases of tonsiller enlargement or inflammation,

eventually complex tongue thrust will develop.

Complex tongue thrust swallow

-characterized by absence of contraction of masticatory muscles ie teeth

are not held together during complex tongue thrust swallow.

-Facial and mentalis muscles show obvious contraction.

Retained infantile swallow

Defined as predominant persistence of infantile swallowing reflex

after arrival of permanent teeth.

-True retained infantile swallow is rare.

-There is very strong contraction of lips and facial muscle even to the

extent that massive grimace is evident.

-Particular noticeable contraction is of buccinator muscle.

-Patient has inexpressive faces because muscles of facial expression are

involved in stabilization of mandible.

-Patient suffer with severe masticatory difficulty as most of the times

only one molar in each quadrent is in occlusion. Mastication usually

occur between tongue tip and palate because of inadequacy of occlusion.

Hence a typical history of soft diet is frequently found in patient with

retained infantile swallow. Gag threshold is also low.

Management of abnormal tongue thrust and swallowing habits.

At this point, particular type of muscle abnormality (habit) should be

identified because different type of habits need different line of

management and also with different prognosis.

Various factors to be considered before any treatment planing are

1. Age : Although transition from infantile to mature swallow should

occur at age of 1½ years, but treatment should not start before eruption

of permanent incisor unless untill obvious malocclusion occur in

deciduous dentition. This is because occasionally some children are late

maturers and therefore infantile swallow pattern may remain to some

extent in deciduous dentition period.

But if habit does persist during eruptive stages of permanent teeth

eg permanent incisors it should be taken seriously because as already

mentioned, tongue may act as impeding force and prevent eruption of

permanent teeth & causing anterior open bite.

.

14

2. Associated manifestation :

As with any other habit, treatment is not recommended unless it

has affected dentition or speech. But a watch should be kept on suspected

cases where habit has potential to produce malocclusion.

3. Malocclusion – sometimes malocclusion itself is a cause for habit, as

anterior open bite may lead to simple anterior tongue thrust habit. So in

those cases, correction of malocclusion itself will lead to spontaneous

correction of habits

4 Associated other habits

If patient has thumb sucking habit with tongue thrusting habit, thumb

sucking habit should be eliminated first.

5 .Associated problems of orofacial system :

If patient has problems which act as cause for tongue thrust, than those

causative factors should be removed first eg enlarged & inflammed tonsils

of chronic nature should be treated / removed first.

6 Speech defects

Tongue thrust (complex tongue thrust) may be associated with

speech defects eg ‘s ‘ lisp. In those case, orthodontic and speech therapy

should be considered together.

Treatment modalities

1 .Training for correct swallow and posture /position of tongue

.Myofunctional exercises

2 .Mechanotherapy for habit breakage

3 Surgical treatment

4 Speech therapy

Myofunctional exercises

1. For tongue

2. For masseter

Masseter count to ten exercise

3. For lips

4. For swallow

1 a)For tip of tongue

One elastic swallow

5/16 inch elastic is placed on tip of tongue. Patient is guided to

place this elastic with tongue tip at correct desired position i.e just

posterior to incissive papilla, then asked to clench back teeth, open

the lips and swallow.

It is important that exercise should be performed with lips

apart; reason being to break reflex action where tongue tries to

touch closed tips.

For tip of tongue

For mid portion of tongue

For posterior part of

tongue

1 b)Tongue hold exercise

Same 5/16 inch elastic is placed on tip of tongue but to hold this

elastic slightly posterior to incissive papilla for prescribed period of

time. Gradually holding time is increased from 5 minutes to 1 hour.

This is the only exercise in initial plan of therapy which is

performed with closed tips reason for this is.

-To stimulate nasal rather than oral breathing by forcing the lips to

close.

-To accustom patient to negative pressure which occur during

swallowing act

-This tongue hold exercise also places the entire tongue in mouth at

proper position.

Exercise for mid portion of tongue

Two elastic swallow

two 5/16 inch elastics, one on tip and other an mid point of tongue

are placed. patient is instructed to place tongue tip at predetermined

position (i.e just posterior to incissive papilla) and other mid elastic

on hard palate and than swallow. This corrects the abnormal

tongue position in infantile swallow where tongue tip is placed

lower and mid portion is collapsed

Hold pull exercise

Tip and mid point of tongue an placed at correct pre determined

position. With this position, mandible is opened gradually. Purpose

of this exercise is to keep front and mid portion of tongue at proper

position during swallowing.

Exercise for posterior part of tongue

There elastic swallow

Three 5/16 elastics are placed, one on tip, other on mid point of

tongue and 3rd on posterior part, but care should be taken not to keep

posterior elastic too backward otherwise patient may swallow it.

During normal swallow, posterior part of tongue is pressed against

the pharyngeal wall

This exercise is also performed with lips open to break tongue lip

reflex.

.

15

Exercise for masseter

Reason for prescribing masseter muscle exercise is that in

complex tongue thrust when teeth are apart during swallowing,

masseter muscle is not activated and on long term basis this muscle

undergoes disuse atrophy. Masseter muscle is much required

during normal swallow to elevate and stabilize mandible.

Masseter count to ten exercise

This is an isometric resistance exercise which strengthen masseter

muscle. Patient is asked to clench posterior teeth forcefully and

counting ten. Exercise should be performed frequently in morning

and evening.

Exercise for lips

As noted earlier, tip and tongue actions are synchronized so its

important that lips functions should also be proper for proper

swallowing.

Tug of war and button pull exercise

Both these exercises are to strengthen the lip musculature.

A string is tied to two buttons usually size of a quater and one button is

placed between lips of patient and other is held by parent in tug of war

Exercise or by the patient himself in case of button pull exercise

Mashmallow twist exercise

Excellent strengthning exercise for lower lip. Specially designed kits are

available with plastic discs weighing exactally same one another. String

is placed in patient’s mouth and patient lifts discs by extending lower lip.

Number of discs are increased gradually when patient lifts discs

comfortably until total become ten.

Exercise for swallow

Once patient has masterd muscle exercises for tongue, lips and masseter,

this integrated muscular activity is brought into normal mature

swallowing pattern.

Elastic for tongue exercises are replaced by liquid food and

patient is guided to perform mature swallow act. once patient becomes

comfortable with liquid food, solid food replaces liquid food.

Subconscious therapy

Once voluntary conscious swallowing pattern is learned by

child, then ultimate success lies in the conversion of this conscious

swallowing to subconscious/ unconscious swallowing behaviour.

Subconscious therapy is divided into three parts

•Time charts

•Subliminal therapy

•Auto- suggestion

Time charts

There charts remind patient to perform correct swallowing pattern at

specific times of day which will set a correct swallowing picture in

patient’s mind. The most important thing about these time charts is

that this recall must occur at exactly same time everyday

Day time

Sunday Morning Noon Night

To

Sunday

Subliminal therapy

child is asked to place a reminding sign within sight of place where

he/she eats. This reminding signs aids in subliminal recall, everytime

child eats.

Auto suggestion

Patient is asked to swallow correctly six time just before going for

sleep and than repeat six times “I will swallow correctly all night” .

.

Mechanotherapy for correction of Tongue Trusting habit.

Both fixed and removable appliances can be used to restrain

the various tongue movement. Fixed appliances should never be

used without child’s co-operation , otherwise child will take it as

punishment.

Purposes of appliances

-Tongue Thrust correcting appliances tend to force tongue downward

and backward. These appliances are more effective when they form a

sort of picket fence behind lower incisors, as with palatal spurs. spurs

are bent downward and their correct position is attained with normal

posterior occlusion during swallow.

-Appliances also re-educate tongue position so that dorsum of tongue

approximates palatal vault and tip of tongue contacts the palatal rugae

area.

This proper position of dorsum of tongue prevent lateral spreading

and consequent lateral pressure on dentition during swallow.

Removable appliances

Variety of modifications of Hawley’s appliance may be

used e.g. Tongue rake, tongue crib, Tongue spikes.

Most efficient is tongue spikes with sharp ends as it

brakes the reflex of tongue thrusting. Patient may feel

discomfort for initial few days but tongue adapts rapidly.

These removable appliance may be kept for 4-6 months .

Advantage of Howley’s appliance is that at same time

of habit correction, minor irregularities of teeth can be

corrected .

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Fixed habit breaking appliance

Tongue spike may be used as fixed appliance by soldering

lingual arch with spikes to molar bands.

If tongue crib is soldered similarly as tongue spike , it may

be unsuccessful because the tongue pressure transmitted through

crib to molars may actually move entire upper arch forward.

Fixed tongue spike require 4-6 month time period to

correct habit.

Oral screen

Oral screen is another effective means of habit correction

with added advantage that being a myofunctional appliance, the

various deleterious forces may be transmitted to desired direction

as beneficial forces. For tongue thrust habit correction, combine

oral and vestibular screens are formed.

Miscellaneous appliances

Depending on patient’s over all treatment plan, some otherappliances may also correct tongue thrust habit along with theirintended function e.g. Activator may prevent tongue thrusting inanterior and lateral direction.

Surgical options

Very rarely a surgical treatment may be needed for correction oftongue Posture and position as in case of Macroglossia whichneccesitate partial glossectomy.

In cases where chronically enlarged tonsils poseproblems for habit correction, tonsils should be removed.

Prognosis

Prognosis of simple anterior tongue thrust is excellent and mostof times get spontaneously corrected once underlying cause i.e.Anterior open bite is corrected.

Prognosis for complex tongue thrust is poor.

For retained infantile swallow, prognosis is very poor.

Mouth Breathing

Mouth breathing is always abnormal, whether it is a habit or

necessity due to blockage of normal upper respiratory passage.

New born infants are obligate nasal breather and slowly this

pattern shifts to facultative nasal breathing i.e. a child/person may

breath through mouth but primary breathing is through nasal route.

Then one question arises “why one should breath through nose and

not through mouth”.

There are various physiologic factors associated with nasal

breathing which protect respiratory system. Important one are

humidification and warming of air, filtration of various harmful

particles. As will be mentioned later, nasal breathing is essential for

normal growth and development of stomatognathic system.

From this discussion, it is clear that a person will always try to

breath through nose and not from mouth. Hence, if someone breath

through mouth because of some underlying factors e.g. nasal

obstruction, Anatomically abnormal lips etc., it can not be termed

habit as these factors force individual for mouth breathing. But if

he/she continue to breath through mouth even after elimination of

underlying cause, then it can be termed as habit.

so initiation of mouth breathing is not a habit but continuation

beyond a particular time i.e after removal of cause, it becomes

habit.

Definition

Sassouni (1971) defined mouth breathing as habitual respiration

through mouth instead of nose.

Merele (1980) suggested term oro–nasal breathing instead of

mouth breathing because according to him, breathing is never

100% through mouth whatever may be the cause for mouth

breathing.

Classification

Finn (1987) classified mouth breathing into

1. Anatomic

Anatomic mouth breather is one whose short upper lip does not

permit complete closure of lips along with lower lip without

effort

2. Obstructive

This group include those individuals who have partial / almost

complete obstruction to normal flow of air through nasal passage.

3. Habitual

this group include those who continue to breath through

mouth even after removal of nasal obstruction.

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Etiology

Apart from anatomically short upper hip, the other cause for

mouth breathing is nasal obstruction.

This airway obstruction may be due to

- enlarged turbinates

- Deviated nasal septum (DNS)

- Allergic rhinities, nasal polyps

- Obstructive sleep apnoea.

Although many times Adenoid faces characterized by long narrow

face and nasal passage are associated with mouth breathing, but it is

not very clear that whether this particular pattern is due to mouth

breathing or it develops to facilitate mouth breathing. It is noted that

in a parson with Adenoid faces, a moderate local factor may obstruct

nasal passage which may not do so in normal child.

The only direct effect of mouth breathing is mouth breathing

gingivitis and increased risk of caries especially in maxillary

Anterior Region. Then, “How does mouth breathing can lead

to malocclusion”.

The Answer lies in the fact that mouth breathing necessitates

altered facial musculature balance by lowering the position of

tongue and mandible in order to keep oral airway patent. If these

postural changes are maintained, anterior lower facial height

would increase and posterior teeth will supra-erupt.Unless vertical

growth of ramus is present, mandible will rotate downward and

backward opening the bite anteriorly and increasing overjet.

Increased stretch of cheek may exert pressure and cause

narrowing of maxillary arch.

DIAGNOSIS

History

History is very important because it may give clue of

underlying etiologic factor.

Parents should be asked whether child had / have frequent

occurrenc of tonsillitis, allergic rhinitis etc; or if child frequently adopt

lip apart posture.

Examination for moth breathing

Observe the patient unoticed when he/ she sit comfortably on

chair. Initially patient might have anxiety which may lead to mouth

breathing even in some normal children. Most obvious observation that

can be made is lip apart posture. In normal relex individual, lips are

touching lightly. But in mouth breather, lips will be definitely apart at

rest for passage of air. Lips will be dry, scaly because of continuos

drying and this may predispose to lip wetting habit. Same drying effect

predispose for mouth breathing gingivitis and increased risk of dental

caries.

Functional Examination

Ask the patient to take a deep breath. A mouth breatherwhen asked to close his / her lips and take deep breath, there willbe no appreciable charge in size and shape of external nares incontrast to normal nasal breather which show dilatation of naresduring lips closed deep breathing because nasal breathers normallydemonstrate good reflex control of alar muscle which control thesize and shape of external nares.

Various clinical tests may be performed to demonstrateabsence of nasal breathing and also to differentiate betweenblocked right or left nostril.

1 Water holding test

This is most commonly performed test in clinics. Patient is asked to hold water in mouth for a prescribed period of time. It is obvious that if child is mouth breather, it will be impossible for child to hold water in mouth.

2. Mirror test

A two sided mirror is placed in horizontal / oblique directionbetween nose and mouth. If child is nasal breather, there will befog on side of mirror facing towards nose.

3. Butterfly test – it is to differentiate nasal obstruction betweenright and lift nostril. A small butterfly shape piece of cotton isplaced on upper lip and observed. The side of nose which ispatent, will cause fluttering of cotton on respective side.

4. Inductive plethysmography (Rhinomanometry)

This is only reliable test to quantify the amount of air which isactually passing through nose and mouth. long face children mayhave less then 40% of nasal breathing.

5. Cephalometrics

Cephalometric may show the amount of nasopharyngeal space,size of adenoids etc especially if cephalograms are taken fromvarious angles.

Management

Treatment consideration

Age – self-correction of mouth breathing could be expected as

child mature unless there is an obvious and marked nasal

obstruction. This is due to the fact that there is an increase in nasal

passage as child grows especially if obstruction was due to

enlarged adenoids.

E.N.T Consultation

almost all the time cause of mouth breathing is nasal obstruction,

so any E.N.T pathology should be ruled out before any habit

correction attempt.

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Treatment

Elimination of cause – Any underlying cause must be

removed e.g nasal obstruction

Interception of habit

Even after removal of causative factor if habit persist,

following measures should be taken

Exercises

1. Physiologic exercises

2. lip exercises

physiologic exercises

Deep breathing exercises are done in morning and evening. Child is

instructed to raise arms sideways and take deep inhalation through

nose. After a short period of time, arms are dropped to sides and air

is exhaled through mouth.

lip exercises

These exercises are aimed to restore normal size, posture and

functional tone of lips.

But before these exercises are attempted, any malocclusion which

prevent proper functioning of lips (i.e preventing proper lip seal)

should be eliminated e.g Bimax. protrusion.

lips of chronic mouth breather are abnormal in following respects

- under development of upper lip i.e. short upper lip.

- Lower lip is flabby and hypotoned.

Voluntary muscle exercises and normal functioning will restore these

structures to their correct size and optimal size, tone and functioning

provided such exercises are performed routinely.

The various exercises are

.lip elongating exercises

. Wilson exercise

lip elongating / stretching exercise

Modeling compound of adequate amount & in

mouldable form is placed in Anterior Vestibule so that it

fills whole vestibule plus some of material extend between

incisors on which patient bites and make permanent

indentation which will later on help in stabilization of

device when in use.

Device is used by asking patient to place it in

mouth and then try to bring lips together. This exercise is

very helpful especially in case of short upper lip. A more

durable from of same device can be made from acrylic.

Wilson’s Exercise (by William E. Wilson)

This exercise is very helpful when under grown

and hypotoned lips are due to chronic mouth breathing.

This exercise develops orbicularis oris and associated

muscles establishing normal muscular tone around mouth

opening plus stimulating nasal passage by heavy rush of air

through one nostril at a time

Technique

Child is instructed to perform this technique as follow

- Stand in front of mirror

- close teeth and lips without forcefull action

- Contract the muscles at left corner of mouth causing left cornerto be pulled backward and upward.

- palmer surface of left hand fingers are placed on right cheek,and now press this cheek tissue forward and to left, at the same timeholding the right nostril closed with index figure of left hand. Tissuesat left corner of mouth must continue in contraction all through thismuscle pulling with left hand fingers.

- While tissues at left corner are still contracted and right cheekis under pressure by fingers, breath deeply 3 times through the leftnostril.

- Relax the muscle and remove left hand.

- Perform similar procedure on opposite sides.

- Perform this habit 3 times thrice a day.

Appliances for correction of mouth breathing

Oral / Vestibule screen

It is most effective way to re-establish nasal breathing by

preventing air entering into oral cavity.

vestibule screen made of acrylic with holes is very effective.

Holes should be blocked gradually as child start feeling comfortable

and ultimately all the holes are closed.

A modification of this conventional vestibular screen is given

by Holtz where a ring is placed in Anterior portion of screen at level

of inter-labial gap. Advantage of this modification is that it can be

used as lip exercise device.

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Maxillothorax Therapy (by Macaray 1960)

This therapy uses a activator made up of aluminum withwhich development of dental arches and dental base relationshipcan be corrected along with correction of mouth breathing.

This stable aluminum activator is incorporated at angle ofmouth with horizontal hooks to which expanding rubber bands areattached.

Child holds activator in mouth and at the same timecarries out exercises as follow

Child stands with his back against the wall, rises andlowers on his toes and at the same time performing lightly forcedbreathing with tightly closed lips.

As from the name itself it is indicative that this exercisehelps in throrax / chest expansion along with correction of mouthbreathing.

Lip habits

Normal hip anatomy and function are important for

speaking, eating and maintaining a balanced occlusion.

Lip habit may involve either of lips but predominantly lower

hip is involved.

Definition

Lip habit may be defined as those habits that involve

manipulation of lip/ lips and perioral structures.

Types of lip habits

Two types of lip habits

- wetting the lips with tongue

- pulling the lips into mouth between the teeth (Schneider

1982)

lip sucking habit has potential to produce malocclusion if

practiced with sufficient intensity and frequency. lip wetting is not

a problem for occlusion.

Lip Sucking

It is commonly associated with lower lip where lip is

pulled between teeth and clinically lips are characterized by

reddened, irritated areas below vermilion border.

An important but distinct variation of lip sucking habit is

Mentalis habit.

Mentalis muscle originates on labial surface of mandible in arch

of apices of mandibular incissors. Its fibre get extended inferiorly

crossing over the midline and intersecting and inserting into soft

tissue of chin. Function of mentalis muscle is to lift the lower lip.

When muscle is flexed, skin of chin appear puckered.

lip sucking and mentalis habits may be differentiated by

the fact that in case of lip sucking, entire lip including vermilion

border is pulled into mouth whereas in mentalis habit, vermilion

border of lower lip is often everted with lingual aspect elevated

into mouth and a sublabial contracture line develops between lip

and chin. Vermilion border of lower hip may be relocated further

out side mouth because of continuous drawing and wetting.

But regarding development of malocclusion, lip sucking and

mentalis habit have similar effect as in both cases lip in wedged

between upper and lower incisors and on long term bases, it will

cause proclination of upper incisors with development of spaces

& collapsed , crowded lower incisors.

Menatalis habit along with hyperactive inferior orbicularis

oris may cause gingivitis in mandibular anterior region due to

continuous Irritation.

This clinical finding is important because presence of

gingivitis in mandibular anterior region without involving

maxillary anterior region( which is characterstick site in case of

mouth breathing gingivitis ) may indicate hyperactive mentalis

muscle.

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Etiology

1. Malocclusion

Class II Div 1 malocclusion with large overjet and deep bite

predispose to lip sucking habit because child tend to produce

normal lip seal during swallowing by placing lower lip

posterior to maxillary incisors.(called lip trap )

2 Habits – Thumb sucking habit my predispose to lip

sucking habit by increasing overjet.

3 Emotional stress – This may increase the intensity and

duration of lip sucking habit.

Management

Associate factors which predispose to habit e.g class II Div

1 malocclusion or increased overjet due to previous thumb

sucking should be eliminated.

A self disciplinory approach where child reinforces

himself that he will not indulge in habit is very effective because

most of them are adolescent.

Lip Bumper

lip bumper acts as both reminding device and habit

interrupting appliance by making it difficult to draw the lip

between anterior teeth.

Bruxism

Bruxism is grinding of teeth especially at night. Strictly speaking

it can not be considered habit because almost all the times there is a

definite underlying etiologic factor e.g occlusal discrepancies.

But if habitual grinding continues even after removal of

causative factor, then it can be considered as habit.

Definitions

Ramfjord (1966) –Ramfjord defines bruxism as a habitual

grinding of teeth where individual is not chewing or

swallowing.

Vanderas (1995) defined bruxism as non functional movement

of mandible with or without an audible sound occurring during

day or night.

Manifestation

Signs and symptoms of bruxism depend on frequency,intensity, duration of habit and age of patient.

1. Occlusal Trauma

Bruxism may lead to teeth mobility which is more in morning dueto nocturnal bruxing activity.

2. Attrition

Typical wear facets are seen on occlusal table of posterior teeth. Ifbruxism habit is performed as lateral functioning, incisal wear isalso common especially tip of canines.

3 Muscle tenderness

Patient give history of muscle tenderness espcially in morning. On palpation, lateral pterygoid and masseter are common to show this tenderness.

4 T.M.J disorder

Prolong habit will lead to clicking, crepitates in TMJ and deviation of mandible on closure because habit is usually performed more on one particular side.

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Etiology

1. CNS – Etiology of bruxixomania could be from certain definite

cortical lesions e.g children with cerebral palsy and mental

retardation.

2. Occlusal discrepancies – Improper interdigitation of teeth is

most common cause for bruxism.

3. Psychological factors – Teeth grinding could be a

manifestation of inability to express emotions such as anxiety,

anger etc.

4. Genetics – Genetics may be factor because there is a reported

incidence bruxism in certain families.

5. Occupational factor – Competition sports may lead

to clenching which later on may turn as habit.

6. Systemic factors – deficiency of mg2+ has been

reported as one of the cause.

7. Gingival and periodontal factors – chronic gingival

and periodontal lesion e.g. chronic periodontal abscess

may impart teeth grinding habit as patient feel comfort.

Diagnosis

History is very important. patient is asked about

muscular tenderness in morning. Occasionally patient may not

be aware of habit if only nocturnal bruxism in present. In those

cases parents may provide information regarding habit.

ExaminationTypical wear facets on occlusal table are evident.

By using articulating paper, underlying occlusal disharmony

may be find out.

Treatment

Occlusal splints and occlusal adjustments are usually

sufficient to correct habit. But most important part is that nothing

should be considered without removing the occlusal interference by

occlusal adjustments. Removal of interference result in immediate

disappearance of habitual grinding if occlusal disharmony is the

sole cause.

Occlusal splints are indicated to deprogramme the existing

muscular pattern. Soft splints are advisable with flat occlusal

surfaces so that manidibular movements will be free in all

planes which breaks the reflex response of muscles

established during habit.

2. Restorative treatment – If attrition is very sever which

pose threat for pulpal integrity, adequate restorative treatment

should be provided as initial measure.

3. Psychotherapy / Relaxation training.

If patient perform habit mainly due to stresses, a psychological

counseling is needed so that patient may avoid provocative

behavior.

4 Biofeedback is one of the means. In this technique patient is

allowed to view EEG Monitor while the mandible is postured with

minimal muscular activity.

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3 Physiotherapy

If musculo-skeletal pain and stiffness are present, a brief

course of physiotherapy is advisable because indirectly it

also helps patient’s psychological relaxation.

4 Symptomatic treatment

Pain reliving drugs may be used. Other means for pain

relieve are TENS and Acupuncture methods.

Finger nail biting Habit.

This is one of the most common habit in adolescent and

Adults.

Age of occurrence

Nail biting is absent before age of 3, incidence rises

from 4-6 year of age and remain stable between 7 and 10

year and rises to peak during adolescence.

Persistent nail biting may be indicative of emotional

problem.

In teenage, nail biting habit may be substituted by pen /

pencil biting etc..

Rarely nail biting habit may cause malocclusion

because psychosocial pressure act as restraining

stimulus for habit performance. But if habit is practiced

with optimal frequency & intensity, minor rotation,

mild crowding may develop

3 Physiotherapy

If musculo-skeletal pain and stiffness are present, a

brief course of physiotherapy is advisable because

indirectly it also helps patient’s psychological

relaxation.

4 Symptomatic treatment

Pain reliving drugs may be used. Other means for pain

relieve are TENS and Acupuncture methods.

Diagnosis

• History and examination of finger nail will reveal the habit.

Management Psychologic counseling is sufficient in most of

cases. Avoid punitive methods e.g Scolding, nagging etc because as

habit is commonly due to emotional disturbance, these punitive

methods may exaggerate the emotional problems.

•If child is cooperative, various reminding methods may be used e.g

nail polish, application of mild bitter substances on fingers and

nails.

Self Injurious Habits

(Masochistic / Sadomasochistic habits)

These are self injurious habits where patient enjoys inflicting

damage to himself. It is very rare in normal children but can be seen in

mentally restarted children.

Definition

These habits may be defined as Repetitive acts that result in physical damage

to individual.

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Etiology

1. Organic – Various syndromes and syndrome like

diseases e.g Lesch – Nyhan disease and De Lange’s syndromes

may be causative factors which lead to repetitive biting of lip,

finger, cheek, knee etc.

2. Functional – This can be further divided into-----

Type A – These are injuries superimposed on pre-existing

Lesion e.g a child with skin lesion of fingers perform finger

nail biting habit so skin lesion doesn’t heal.

Type B – These include injuries secondary to another

established habit. E.g Rotation of thumb with thumb suking habit

may damage soft tissue of hard palate.

Type C – it include injuries of unknown or complex etiology.

Treatment : Always with these habits, treatment should be initiated

with psychotherapy because almost all these patient have strong

emotional or psychopathic features.

Palliative Treatment

It is the adjunctive therapy e.g bandages for

ulceration etc.

Mechanotherapy

Vestibular screen will prevent unconscious

damaging act e.g. cheek biting while sleeping. Mechano

therapy may also includes use of restraints and protective

padding.

BIOPROGRESSIVE THERAPY - mgumst

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