Occlusion/ dental crown & bridge courses

INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.comwww.indiandentalacademy.com

CONTENTSCONTENTS
 INTRODUCTIONINTRODUCTION
 GENERAL CONSIDERATIONS IN OCCLUSAL THERAPYGENERAL CONSIDERATIONS IN OCCLUSAL THERAPY
 BRUXISMBRUXISM
 DEEP OVERBITEDEEP OVERBITE
 ANTERIOR OVERJET PROBLEMSANTERIOR OVERJET PROBLEMS
 ANTERIOR OPEN BITEANTERIOR OPEN BITE
 END TO END OCCLUSIONEND TO END OCCLUSION
 SPLAYED ANTERIOR TEETHSPLAYED ANTERIOR TEETH
 CROSS BITECROSS BITE
 CROWDED, IRREGULAR AND INTERLOCKED ANTERIOR TEETHCROWDED, IRREGULAR AND INTERLOCKED ANTERIOR TEETH
 CONCLUSIONCONCLUSION
 REFERENCESREFERENCES

OCCLUSION : The static relationship between the incising or masticatingOCCLUSION : The static relationship between the incising or masticating
surfaces of the maxillary or mandibular teeth or tooth analogues.surfaces of the maxillary or mandibular teeth or tooth analogues.
IDEAL OCCLUSION : A pre-conceived theoretical concept of occlusal,IDEAL OCCLUSION : A pre-conceived theoretical concept of occlusal,
structural & functional relationships that include idealized principles &structural & functional relationships that include idealized principles &
characteristics that an occlusion should have.characteristics that an occlusion should have.
Ideal occlusion should be ideal for the rest of the articulatory system, theIdeal occlusion should be ideal for the rest of the articulatory system, the
muscles and the TMJ’s.muscles and the TMJ’s.
PHYSIOLOGIC OCCLUSION : An occlusion that deviates in one or morePHYSIOLOGIC OCCLUSION : An occlusion that deviates in one or more
ways from the ideal yet it is well adapted to that particular environmentways from the ideal yet it is well adapted to that particular environment
with no pathologic manifestation or dysfunction.with no pathologic manifestation or dysfunction.
THERAPEUTIC OCCLUSION : An occlusion that has been modified byTHERAPEUTIC OCCLUSION : An occlusion that has been modified by
appropriate therapeutic modalities in order to change a non physiologicalappropriate therapeutic modalities in order to change a non physiological
occlusion to one that is at least physiologic if not idealocclusion to one that is at least physiologic if not ideal

Need for occlusal therapyNeed for occlusal therapy ::
Occlusal therapy : Any treatment that alters a person’s occlusal conditionOcclusal therapy : Any treatment that alters a person’s occlusal condition
Occlusion TMD Occlusal therapyOcclusion TMD Occlusal therapy
Indications for alteration of occlusal conditions :Indications for alteration of occlusal conditions :
 Improve functional and esthetic relationship between maxillary and mandibularImprove functional and esthetic relationship between maxillary and mandibular
teeth.teeth.
 Eliminate a temporomandibular disorder.Eliminate a temporomandibular disorder.
Types of occlusal therapy :Types of occlusal therapy :
 ReversibleReversible
eg : Use of an occlusal appliance.eg : Use of an occlusal appliance.
 IrreversibleIrreversible
eg : Selective grinding, fixed prosthetic procedures, orthodontic therapyeg : Selective grinding, fixed prosthetic procedures, orthodontic therapy

 Treatment goalTreatment goal - establish an orthopaedically stable position of the entire- establish an orthopaedically stable position of the entire
articulatory system.articulatory system.
Specific treatment goals :Specific treatment goals :
 Condyles are resting in their most superoanterior position against theCondyles are resting in their most superoanterior position against the
posterior slopes of the articular eminence.posterior slopes of the articular eminence.
 Articular discs are properly interposed.Articular discs are properly interposed.
 When the mandible is brought into closure in the MS position, theWhen the mandible is brought into closure in the MS position, the
posterior teeth contact evenly and simultaneously. All contacts occurposterior teeth contact evenly and simultaneously. All contacts occur
between centric cusp tips and flat surfaces, directing occlusal forces alongbetween centric cusp tips and flat surfaces, directing occlusal forces along
the long axes of the teeth.the long axes of the teeth.
 When the mandible moves eccentrically anterior teeth contact andWhen the mandible moves eccentrically anterior teeth contact and
disocclude the posterior teeth.disocclude the posterior teeth.
 In the upright head position, posterior tooth contacts are more prominentIn the upright head position, posterior tooth contacts are more prominent
than anterior tooth contacts.than anterior tooth contacts.

Treatment planning for occlusal therapy :Treatment planning for occlusal therapy :
Two general considerations :Two general considerations :
 The simplest treatment that will accomplish the treatment goals should beThe simplest treatment that will accomplish the treatment goals should be
carried out.carried out.
 Treatment should be started once the clinician has visualized the endTreatment should be started once the clinician has visualized the end
results.results.
Occlusal therapy - determined by the severity of malocclusion.Occlusal therapy - determined by the severity of malocclusion.
Treatment choicesTreatment choices ::
Selective grinding (occlusal adjustment) , fixed prostheses, removableSelective grinding (occlusal adjustment) , fixed prostheses, removable
prostheses, orthodontics and even surgical correction.prostheses, orthodontics and even surgical correction.
The best choice is to perform the least amount to dental alterations that willThe best choice is to perform the least amount to dental alterations that will
fulfill the treatment goalsfulfill the treatment goals

Factors influence the selection of treatment :Factors influence the selection of treatment :
 SymptomsSymptoms
 Condition of the dentitionCondition of the dentition
 Systemic healthSystemic health
 EstheticsEsthetics
 FinanceFinance

BRUXISMBRUXISM
Nonfunctional grinding of the lower teeth against the upper teethNonfunctional grinding of the lower teeth against the upper teeth
Types :Types :
NocturnalNocturnal
DiurnalDiurnal
Etiology :Etiology :
Occlusal interferencesOcclusal interferences
Emotional stressesEmotional stresses
Muscle spasmMuscle spasm
Spilt teethSpilt teeth
Fractured fillingsFractured fillings
Ramfjord - some kind of occlusal interferences will be found in every patientRamfjord - some kind of occlusal interferences will be found in every patient
with bruxismwith bruxism

Williamson - eccentric posterior tooth contact clearly related muscle hyperactivity toWilliamson - eccentric posterior tooth contact clearly related muscle hyperactivity to
occlusal interferences.occlusal interferences.
Consequences :Consequences :
 severe abrasive wear of occlusal surfacessevere abrasive wear of occlusal surfaces
 hypermobility of teethhypermobility of teeth
 adaptive changes in the temporomandibular joints, flattening of the condyles andadaptive changes in the temporomandibular joints, flattening of the condyles and
gradual loss of convexity of the articular eminencegradual loss of convexity of the articular eminence
 Hypertrophy of masseter muscleHypertrophy of masseter muscle
Restriction of the anterior guidance will produce excessive abrasive wear on theRestriction of the anterior guidance will produce excessive abrasive wear on the
restricting surfaces.restricting surfaces.
Pressure against the restrictive inclines causes - severe wearPressure against the restrictive inclines causes - severe wear
- hypermobility of interfering teethhypermobility of interfering teeth
- teeth forced out of alignment- teeth forced out of alignment
Rugh et al - habitual nocturnal bruxism continued even after occlusal interferencesRugh et al - habitual nocturnal bruxism continued even after occlusal interferences
were removed.were removed.

Treating bruxism problemTreating bruxism problem ::
 Habitual elevator muscle hypercontraction severe overload on teeth,Habitual elevator muscle hypercontraction severe overload on teeth,
supporting structures and temporomandibular joints.supporting structures and temporomandibular joints.
 Destructive effects reduced by distributing load to maximum no. of equal-Destructive effects reduced by distributing load to maximum no. of equal-
intensity tooth contacts during intercuspation.intensity tooth contacts during intercuspation.
 Harmonizing those contacts with centrically related condyles reduces theHarmonizing those contacts with centrically related condyles reduces the
overload on both the teeth and joint structures.overload on both the teeth and joint structures.
 Reduction of muscle contraction in eccentric jaw movements causesReduction of muscle contraction in eccentric jaw movements causes
reduction in size of hypertrophic elevator muscles.reduction in size of hypertrophic elevator muscles.
Goals :Goals :
 Elimination of centric relation interferences with extreme preciseness.Elimination of centric relation interferences with extreme preciseness.
 Manipulating the mandible into the terminal hinge position.Manipulating the mandible into the terminal hinge position.

 Treatment -Treatment -
 Directly : By equilibration, occlusal restorations or orthodonticsDirectly : By equilibration, occlusal restorations or orthodontics
 Indirectly : By occlusal splints.Indirectly : By occlusal splints.
 Selective grinding without mutilation of enamel - method of choice.Selective grinding without mutilation of enamel - method of choice.
 Occlusion equilibrated before restoration.Occlusion equilibrated before restoration.
 Equilibration should result in multiple equal-intensity stops in centric relationEquilibration should result in multiple equal-intensity stops in centric relation
with immediate disclusion by the anterior guidance in all excursions.with immediate disclusion by the anterior guidance in all excursions.
Use of appliances –Use of appliances –
Occlusal splintOcclusal splint
 Cover teeth in one arch - proprioceptive response in these teethCover teeth in one arch - proprioceptive response in these teeth
 Also prevents the minute rebound effect in these teethAlso prevents the minute rebound effect in these teeth
 Reduces wear that occurs during nocturnal bruxing.Reduces wear that occurs during nocturnal bruxing.
 Acrylic night guards - adjunct to occlusal correctionAcrylic night guards - adjunct to occlusal correction
- help stabilize hypermobile teeth and reduce bruxism- help stabilize hypermobile teeth and reduce bruxism

Soft vinyl mouth guard –Soft vinyl mouth guard –
 Chronic sinusitis patientsChronic sinusitis patients
 worn at night to cushion the teeth from the effects ofworn at night to cushion the teeth from the effects of
transitory occlusal interferences.transitory occlusal interferences.
 Caution should be urged to perfect the occlusion duringCaution should be urged to perfect the occlusion during
a time when the sinuses are normal.a time when the sinuses are normal.
 History regarding sinus headaches, postnasal drips, andHistory regarding sinus headaches, postnasal drips, and
nasal stuffiness.nasal stuffiness.
 Radiographic examinationRadiographic examination
Bruxism in childrenBruxism in children
 During mixed-dentitionDuring mixed-dentition
 Bruxism if severe, occlusal adjustment doneBruxism if severe, occlusal adjustment done
 Polish and round all sharp edges - eliminate grossPolish and round all sharp edges - eliminate gross
interferences.interferences.
 Orthodontic appliances (bite plane) to disengageOrthodontic appliances (bite plane) to disengage
offending toothoffending tooth

DEEP BITE
Increased vertical overlap of maxillary incisors over mandibular incisors when
the mandible is brought into centric occlusion
CLASSIFICATION :
1. Skeletal
2. Dental
PROBLEMS WITH DEEP BITE :
Where there are no stable contacts, the lower anterior teeth erupt into the
gingival tissues or into the palate.

 According to Stuart consequences of deep biteAccording to Stuart consequences of deep bite
 Painful anterior teethPainful anterior teeth
 Speech difficultiesSpeech difficulties
 Spread anteriorsSpread anteriors
 TMJ involvementTMJ involvement
 Difficulty in eatingDifficulty in eating
 Worn lower anteriorsWorn lower anteriors
Correction of deep biteCorrection of deep bite ::
 Reshaping upper lingual contoursReshaping upper lingual contours
 Shortening lower anterior teethShortening lower anterior teeth
 Simple exercise to reposition lower anterior teethSimple exercise to reposition lower anterior teeth

Three steps -Three steps -
 Reduce lower anterior teethReduce lower anterior teeth
 Definite centric stop for each lower anterior tooth intoDefinite centric stop for each lower anterior tooth into
upper lingual surface.upper lingual surface.
 Forward pressure on lower anterior teeth using indexForward pressure on lower anterior teeth using index
fingerfinger
 Removable orthodontic appliance – questionable pt. co-Removable orthodontic appliance – questionable pt. co-
operationoperation
Deep bite associated with anterior slide :Deep bite associated with anterior slide :
 Deep overbite problem + posterior interferences thatDeep overbite problem + posterior interferences that
deflect the mandible forward cause extreme wear ondeflect the mandible forward cause extreme wear on
upper anterior lingual surfaces.upper anterior lingual surfaces.
 Bruxism effect of lower anteriors carves out the lingualBruxism effect of lower anteriors carves out the lingual
contours and forms a concavity that extends up above thecontours and forms a concavity that extends up above the
level of gingival margin.level of gingival margin.

Treatment -Treatment -
 Equilibrate to permit the mandible to close without deflection.Equilibrate to permit the mandible to close without deflection.
 Shorten the lower incisors to position the incisal edges in an optimumShorten the lower incisors to position the incisal edges in an optimum
relation to previsualized centric stops on the upper incisorsrelation to previsualized centric stops on the upper incisors
 Restore the upper lingual contours to establish stable centric stops.Restore the upper lingual contours to establish stable centric stops.
 Harmonize the protrusive and lateral excursion after the centric contactsHarmonize the protrusive and lateral excursion after the centric contacts
have been determined.have been determined.

Deep bite problems with no deflective interferencesDeep bite problems with no deflective interferences
 Surface to surface contact in centric relationSurface to surface contact in centric relation
 Increasing V.D. - room for restoration, also involve restorationIncreasing V.D. - room for restoration, also involve restoration
of posterior teethof posterior teeth
 Upper teeth moved using an orthodontic appliance. OnceUpper teeth moved using an orthodontic appliance. Once
moved “kept” in that position by placement of a plasticmoved “kept” in that position by placement of a plastic
provisional splint as a retainer.provisional splint as a retainer.
 This keeps the teeth in position while the bone fills in andThis keeps the teeth in position while the bone fills in and
the periodontal ligament realigns.the periodontal ligament realigns.
 Introduces patient to new overjet , gives time to work outIntroduces patient to new overjet , gives time to work out
esthetics and function & allows patient adaptationesthetics and function & allows patient adaptation
 Upper anterior teeth – splinted or not ?Upper anterior teeth – splinted or not ?
 only when bone support diminished - stabilizationonly when bone support diminished - stabilization

Lingually inclined upper anterior teethLingually inclined upper anterior teeth
 Upper anterior teeth lingually inclined, no stop for lowerUpper anterior teeth lingually inclined, no stop for lower
teeth.teeth.
 Centric contact made against lower labial surfaceCentric contact made against lower labial surface
 Resolution –Resolution –
1.1. Shortening lower incisorsShortening lower incisors
2.2. Reshaping the lingual contours of upper incisorsReshaping the lingual contours of upper incisors
3.3. If upper incisors impinge on lower labial tissues -If upper incisors impinge on lower labial tissues -
shortened.shortened.
 Lower incisal edges moved forward into stable ‘ledge’ typeLower incisal edges moved forward into stable ‘ledge’ type
of centric stops on the upper surfaces orof centric stops on the upper surfaces or
 Upper lingual stops must be extended by restoration.Upper lingual stops must be extended by restoration.

Deep bite with no centric contacts:Deep bite with no centric contacts:
 No centric stops to prevent the lower anterior teeth from supraeruptingNo centric stops to prevent the lower anterior teeth from supraerupting
into the soft tissuesinto the soft tissues
Treatment -Treatment -
 Shortening the lower anterior teeth by grinding.Shortening the lower anterior teeth by grinding.
 Depressing the lower anterior teeth with an anterior bite plane leading toDepressing the lower anterior teeth with an anterior bite plane leading to
extrusion of the posterior teeth.extrusion of the posterior teeth.
Treatment modalities :Treatment modalities :
1.1. Orthodontic tooth movementOrthodontic tooth movement
2.2. Restorative reshapingRestorative reshaping
3.3. SplintingSplinting
4.4. Use of bite planeUse of bite plane
5.5. Establishment of contact on palatal barEstablishment of contact on palatal bar
of removable partial restorationof removable partial restoration

ANTERIOR OVERJET PROBLEMS
Causes:
Maxillary anterior protrusion or Mandibular anterior retrusion.
Consequences of improper anterior disclusion :
• Bruxing
• Inability to incise food completely
• Possible TMJ symptoms (especially clicking)
• Speech impairment
• Worn posterior occlusal surfaces
• Lateral stresses on posteriors causing bone loss
• Tongue habit
Excessive overjet produces -
• No stabilizing effect for lower anterior teeth in centric hence they
supraerupt.
• No posterior disclusion during protrusion
• Loss of esthetics

Treatment :Treatment :
 Stabilization of lower anterior teethStabilization of lower anterior teeth
 Providing the best possible anterior guidance for posterior disclusion inProviding the best possible anterior guidance for posterior disclusion in
protrusion.protrusion.
 Providing the best possible relationship for disclusion of the balancingProviding the best possible relationship for disclusion of the balancing
inclines.inclines.
 Improving alignment and shape of upper anteriors for better esthetics.Improving alignment and shape of upper anteriors for better esthetics.

Stabilization of lower anteriorsStabilization of lower anteriors ::
If anterior overjet problem not severe, lower teeth may contact in protrusiveIf anterior overjet problem not severe, lower teeth may contact in protrusive
and lateral function enough to stabilize them and prevent theirand lateral function enough to stabilize them and prevent their
supraeruption.supraeruption.
 The tongue position between the palate and lower anterior teeth duringThe tongue position between the palate and lower anterior teeth during
each swallow act as a substitute for the missing tooth contact and serve toeach swallow act as a substitute for the missing tooth contact and serve to
stabilize the teeth.stabilize the teeth.
 Other substitutesOther substitutes
 Lip bitingLip biting
 Sucking in lower lipSucking in lower lip
 If a habit pattern is the primary cause of the overjet problem, eliminationIf a habit pattern is the primary cause of the overjet problem, elimination
of the habitof the habit
Myofunctional therapy – but limited success reported.Myofunctional therapy – but limited success reported.
If habit cannot be broken, design the treatment to co-operate with the habit.If habit cannot be broken, design the treatment to co-operate with the habit.

Treatment options:
• Orthodontics – first choice.
• Restorative reshaping after orthodontic repositioning.
• Splinting in severe cases to prevent the lower anterior teeth from
supraerupting.
• Night guard biting planes may be used as a compromise treatment.
• Use of removable partial denture.
The lower anterior teeth contact the upper posterior palatal bar to provide
excellent stabilization.
Lower removable appliances may also stabilize teeth.

Providing protrusive disclusion of posterior teeth :Providing protrusive disclusion of posterior teeth :
 No vertical pattern of function hence protrude the mandible to allow theNo vertical pattern of function hence protrude the mandible to allow the
anterior teeth to function.anterior teeth to function.
 Unless the posterior teeth are discluded in function they are subjected toUnless the posterior teeth are discluded in function they are subjected to
excessive stress.excessive stress.
 Hypermobility of posterior teeth with varying degrees of periodontitis.Hypermobility of posterior teeth with varying degrees of periodontitis.
 Cuspids can be shaped to provide a protrusive guidanceCuspids can be shaped to provide a protrusive guidance
 Pontic may serve as a protrusive guidancePontic may serve as a protrusive guidance
 Stress diminishes as the distance form the condylar fulcrum increaseStress diminishes as the distance form the condylar fulcrum increase

Improving position or shape of upper anteriors with excessive overjetImproving position or shape of upper anteriors with excessive overjet
Goals –Goals –
1.1. Stabilize the occlusionStabilize the occlusion
2.2. Provide better comfortProvide better comfort
Treatment options :Treatment options :
1.1. Simple reshaping with full coverage restorationSimple reshaping with full coverage restoration
2.2. Orthodontic alignmentOrthodontic alignment
Reshaping the anterior teeth with restorations :Reshaping the anterior teeth with restorations :
 Anterior guidance refined for minimal stress and optimumAnterior guidance refined for minimal stress and optimum
comfort.comfort.
 Modifications to achieve better esthetics and phoneticsModifications to achieve better esthetics and phonetics
 Special considerations :Special considerations :
 Malposed teeth should not be restoredMalposed teeth should not be restored
 Restored lingual contours should not overprotect theRestored lingual contours should not overprotect the
gingival tissuegingival tissue

Overjet problem with insufficient posterior anchorage :
When upper anterior teeth have flared labially because of lost posterior tooth
support, twofold problem –
• Loss of vertical stops by the posterior teeth.
• Lower anterior teeth close too far on a forwardly directed arc, lingual
movement of the upper anterior teeth is blocked.
• Insufficient posterior teeth unable to provide stable base for moving anterior
teeth

Four ways of accomplishing posterior anchorage
1. Extraoral anchorage – Headgear
2. Intraoral tissue-supported base – A tissue-supported base with
posterior teeth - increase vertical - unlock the lower anterior teeth
from upper lingual contact
3. Implant anchorage - Sufficient bone in posterior ridge areas -
osseointegrated implant on each side, the implants serve as
anchorage for moving the anterior teeth.
4. Anchorage from lower arch – If sufficient no. of lower posterior
teeth present, banded to provide stabilization & anchorage for
upper anterior teeth.
Surgical correction :
Orthognathic surgery

ANTERIOR OPEN BITE PROBLEMANTERIOR OPEN BITE PROBLEM
Anterior open bite is a condition where there is no vertical overlap between theAnterior open bite is a condition where there is no vertical overlap between the
upper &lower anteriorsupper &lower anteriors
Classification :Classification :
SkeletalSkeletal
DentalDental
Habits – thumb sucking , finger suckingHabits – thumb sucking , finger sucking
CrowdingCrowding
Airway obstructionAirway obstruction
- mouth breathers- mouth breathers
- allergies- allergies
- deviated nasal septum- deviated nasal septum
- enlarged adenoids or tonsils- enlarged adenoids or tonsils
Lip & tongue suckingLip & tongue sucking
Neurological problems (cerebral palsy)Neurological problems (cerebral palsy)

Minimal anterior opening :Minimal anterior opening :
1 mm separation – lip-sucking habit1 mm separation – lip-sucking habit
Develops as a protective device to avoid posterior interferenceDevelops as a protective device to avoid posterior interference
Correction – elimination of the habitCorrection – elimination of the habit
selective grinding to perfect posterior occlusionselective grinding to perfect posterior occlusion
Time required for repositioning of anterior teeth – 2 to 3 weeks – monthsTime required for repositioning of anterior teeth – 2 to 3 weeks – months
Moderate anterior open bite (1 to 5mm) :Moderate anterior open bite (1 to 5mm) :
1 to 5 separation – tongue thrusting , lip-biting (sometimes)1 to 5 separation – tongue thrusting , lip-biting (sometimes)
Tongue thrust may open the anterior teeth & also include posterior teethTongue thrust may open the anterior teeth & also include posterior teeth
sometimessometimes
Correction – elimination of the habitCorrection – elimination of the habit
minor tooth movementsminor tooth movements
restorative proceduresrestorative procedures
combinationcombination
In habits like pipe smoking or nail holding – separation duplicated inIn habits like pipe smoking or nail holding – separation duplicated in
restoration if patient plans to continue the habitrestoration if patient plans to continue the habit

Severe anterior open bite :Severe anterior open bite :
5mm or more separation – skeletal abnormality5mm or more separation – skeletal abnormality
open bite due to thumb suckingopen bite due to thumb sucking
perpetuated by tongue thrustingperpetuated by tongue thrusting
Problems with severe open bite -Problems with severe open bite -
 Supraeruption of lower teeth to close the spaceSupraeruption of lower teeth to close the space
 Poor anterior estheticsPoor anterior esthetics
 Anterior guidance cannot produce posterior disocclusionAnterior guidance cannot produce posterior disocclusion
in protrusionin protrusion
 Overstressed posterior teethOverstressed posterior teeth
 Increased elevator muscle activityIncreased elevator muscle activity
1.1. Orthodontic correction of anterior tooth relationOrthodontic correction of anterior tooth relation
2.2. Myofunctional therapy to eliminate tongue & lip habitsMyofunctional therapy to eliminate tongue & lip habits
3.3. Occlusal equilibration (Greater the reduction of posteriorOcclusal equilibration (Greater the reduction of posterior
tooth ht, the greater the reduction of the anterior opening.)tooth ht, the greater the reduction of the anterior opening.)
4.4. Splinting last resort to produce desired occlusal stabilitySplinting last resort to produce desired occlusal stability

Treating protrusive lateral tongue thrust –Treating protrusive lateral tongue thrust –
 Protrusive tongue thrust with lateral tongue thrust, prospects forProtrusive tongue thrust with lateral tongue thrust, prospects for
stable correction by closing the vertical are partially non existent.stable correction by closing the vertical are partially non existent.
 Only teeth in contact are the second or third molars.Only teeth in contact are the second or third molars.
 Shortening one or two opposing teeth on each side that haveShortening one or two opposing teeth on each side that have
contact usually closes the vertical dimension enough to bringcontact usually closes the vertical dimension enough to bring
most of the other teeth into contactmost of the other teeth into contact
 Lateral tongue habit broken to prevent recurrence.Lateral tongue habit broken to prevent recurrence.
 Lateral stresses on the contacting posterior teeth minimized byLateral stresses on the contacting posterior teeth minimized by
flattening of cusp inclines.flattening of cusp inclines.
 The more predictive approach to treatment, is to first determine ifThe more predictive approach to treatment, is to first determine if
the occlusion is stable by checking for signs of hypermobility orthe occlusion is stable by checking for signs of hypermobility or
change of tooth position.change of tooth position.

Progressive anterior separation :Progressive anterior separation :
 Adult patients who develop progressive anterior openAdult patients who develop progressive anterior open
bite should be observed very carefully for indications ofbite should be observed very carefully for indications of
rheumatoid arthritis. The fingers are most oftenrheumatoid arthritis. The fingers are most often
involved.involved.
 Restoration or repositioning the anterior teeth back toRestoration or repositioning the anterior teeth back to
contact contraindicated.contact contraindicated.
 Pt. made comfortable by maintenance of the bestPt. made comfortable by maintenance of the best
possible occlusal relationship on the teeth that contact.possible occlusal relationship on the teeth that contact.
 Selective grinding can be used to eliminate deflectiveSelective grinding can be used to eliminate deflective
contacts and to reshape any interfering inclines.contacts and to reshape any interfering inclines.

Abnormal tongue sizeAbnormal tongue size
 No amount of occlusal reconstruction or myofunctional therapy helpfulNo amount of occlusal reconstruction or myofunctional therapy helpful
 Correction of irregularities in cusp height, marginal ridges can beCorrection of irregularities in cusp height, marginal ridges can be
accomplished without upsetting the balance between the tongue and teethaccomplished without upsetting the balance between the tongue and teeth
if the overall plane of occlusion is maintainedif the overall plane of occlusion is maintained
 Provisional restorations should be used to verify comfort and functionProvisional restorations should be used to verify comfort and function
before the restorations are finalized.before the restorations are finalized.
Orthodontic correctionOrthodontic correction
 Intraoral orthodontics in patients without severe skeletal malrelationship.Intraoral orthodontics in patients without severe skeletal malrelationship.
 Severe skeletal malrelation - Extraoral orthopedic appliances.Severe skeletal malrelation - Extraoral orthopedic appliances.
 Shortening a 2Shortening a 2ndnd
molar by 1mm produces about 3mm of anterior closuremolar by 1mm produces about 3mm of anterior closure
 The vertical dimension should be closed as much as possible by reductionThe vertical dimension should be closed as much as possible by reduction
of the height of the posterior teeth.of the height of the posterior teeth.
 Severe shortening will require restoration of the occlusion.Severe shortening will require restoration of the occlusion.
 Surgical correction become more logical choice of treatment.Surgical correction become more logical choice of treatment.

TREATING END TO END OCCLUSIONTREATING END TO END OCCLUSION
Three types – anteriorThree types – anterior
- posterior- posterior
- combinationcombination
Definition : incisal edges of lower anterior teeth aligned with incisal edge ofDefinition : incisal edges of lower anterior teeth aligned with incisal edge of
upper teeth .upper teeth .
OROR
Lower buccal cusps aligned with upper buccal cusps whenLower buccal cusps aligned with upper buccal cusps when
mandible is in centric relation at the correct occlusal vertical dimension.mandible is in centric relation at the correct occlusal vertical dimension.
Analysis : skeletal end to end relationshipAnalysis : skeletal end to end relationship
severe wear problemssevere wear problems

 If complete end to end stable / comfortable / intact PDLIf complete end to end stable / comfortable / intact PDL
 If occlusal interference noted – selective grinding.If occlusal interference noted – selective grinding.
 In posterior cusp tip to cusp tip – centric relation interference relieved.In posterior cusp tip to cusp tip – centric relation interference relieved.
 Goal – provide stability in centric relation & relief in excursions.Goal – provide stability in centric relation & relief in excursions.
 Cusp tip to flat surface relation stable - teeth in good balance with tongue &Cusp tip to flat surface relation stable - teeth in good balance with tongue &
cheek & direction of force favourable.cheek & direction of force favourable.
 If posterior tooth must be restored decision regarding contour to be made.If posterior tooth must be restored decision regarding contour to be made.
 In functioning anterior guidance – flat occlusal morphology can be used.In functioning anterior guidance – flat occlusal morphology can be used.
 Stable centric stops can be provided in several ways :Stable centric stops can be provided in several ways :
= lower cusp tip to upper flat surface.= lower cusp tip to upper flat surface.
= flat occlusal contours.= flat occlusal contours.
= warped posterior contours.= warped posterior contours.

UNILATERAL END TO END RELATIONSHIPUNILATERAL END TO END RELATIONSHIP
 One side - end to end relationship ; other side - cusp fossa relation causingOne side - end to end relationship ; other side - cusp fossa relation causing
harm to the side that occludes correctly.harm to the side that occludes correctly.
 Three practical solutionsThree practical solutions
= orthodontics= orthodontics
= flattening of the balancing inclines on the intercuspated side= flattening of the balancing inclines on the intercuspated side
= centralization of the lower cusps.= centralization of the lower cusps.
RESTORING END TO END ANTERIOR TEETH :RESTORING END TO END ANTERIOR TEETH :
 Moving the upper incisal edges forward & lower incisal edges inwards -Moving the upper incisal edges forward & lower incisal edges inwards -
extends the protrusive contact by few mm.extends the protrusive contact by few mm.
 2 – 3 mm added anterior guidance sufficient to disclude posteriors2 – 3 mm added anterior guidance sufficient to disclude posteriors
 Guidance made nearly flatGuidance made nearly flat
 Extending anterior guidance contact ,not steepening.Extending anterior guidance contact ,not steepening.
 Restorative recontouring of teeth causes special problems ifRestorative recontouring of teeth causes special problems if
stresses moved off the direction of the long axis.stresses moved off the direction of the long axis.
 Long standing end to end bite.Long standing end to end bite.

End to end relationship with extreme wearEnd to end relationship with extreme wear
 CAUTION: 1 ½ mm increase should provide the needed spaceCAUTION: 1 ½ mm increase should provide the needed space
SPECIAL CONSIDERATIONSSPECIAL CONSIDERATIONS ::
 Stability : - harmony with the neutral zoneStability : - harmony with the neutral zone
- non interference with the envelope of function- non interference with the envelope of function
 FunctionFunction
 Skeletofacial profile.Skeletofacial profile.

SPLAYED ANTERIOR TEETHSPLAYED ANTERIOR TEETH
Definition : Teeth that incline outwardly from strong tongueDefinition : Teeth that incline outwardly from strong tongue
pressure.pressure.
 The labial inclination results in spaces between the teeth,The labial inclination results in spaces between the teeth,
with or without loss of pdl support.with or without loss of pdl support.
Splayed lower anterior teethSplayed lower anterior teeth
 Close open spaces by moving lower anterior teeth into aClose open spaces by moving lower anterior teeth into a
more lingually positioned arch form but the relationship ismore lingually positioned arch form but the relationship is
unstable.unstable.
 Three potential reasons for the instability :Three potential reasons for the instability :
1.1. Nonconformity with the neutral zone.Nonconformity with the neutral zone.
2.2. Loss of holding contacts against the upper teeth.Loss of holding contacts against the upper teeth.
3.3. Loss of anterior guidance for disclusion of the posteriorLoss of anterior guidance for disclusion of the posterior
teeth.teeth.

Conforming with neutral zone -Conforming with neutral zone -
 Absence of hypermobility or migration, teeth inAbsence of hypermobility or migration, teeth in
conformity with neutral zoneconformity with neutral zone
 Spaces closed either by restoration or lateral movementSpaces closed either by restoration or lateral movement
within the arch form.within the arch form.
 Lateral tooth movement improves spacing, restorativeLateral tooth movement improves spacing, restorative
procedures for reshaping teeth or adding pontics if theprocedures for reshaping teeth or adding pontics if the
space requires.space requires.
 Spacing requirements worked out on mounted casts withSpacing requirements worked out on mounted casts with
full wax up before any orthodontic proceduresfull wax up before any orthodontic procedures
 Unacceptable arch formUnacceptable arch form esthetic or functional reasons -esthetic or functional reasons -
neutral zoneneutral zone
 Arch form altered - excessive pressure from the tongueArch form altered - excessive pressure from the tongue
or perioral musculature reduced, or stabilizationor perioral musculature reduced, or stabilization
increased.increased.
 Splaying of lower anterior teeth occasionally -Splaying of lower anterior teeth occasionally -
mandibular prognathism.mandibular prognathism.
 Upper incisors interfere with CR ,mandible forced into aUpper incisors interfere with CR ,mandible forced into a
protrusive displacement that loads the lower incisors inprotrusive displacement that loads the lower incisors in
a labial direction.a labial direction.

 Elastic ligature in combination with a lingual archElastic ligature in combination with a lingual arch
bar.bar.
 Useful when posterior teeth have been lost.Useful when posterior teeth have been lost.
 The arch bar is adapted to the existing curvature ofThe arch bar is adapted to the existing curvature of
the arch, and a loop is made at each end of the bar.the arch, and a loop is made at each end of the bar.
 The elastic ligature is then wrapped around eachThe elastic ligature is then wrapped around each
tooth securing it to the bar with a continuous strandtooth securing it to the bar with a continuous strand
of elastic.of elastic.
 The pressure from the ligature helps pull the teethThe pressure from the ligature helps pull the teeth
together also pulls them against the bar.together also pulls them against the bar.
 After correct alignment, teeth held in place withAfter correct alignment, teeth held in place with
ligature wire or some form of retention until theligature wire or some form of retention until the
supporting structures reorganizesupporting structures reorganize

Maintaining holding contacts & anterior guidanceMaintaining holding contacts & anterior guidance
 If lower incisal edges are moved or recontoured, each reciprocalIf lower incisal edges are moved or recontoured, each reciprocal
holding contact must be reoriented to the new position.holding contact must be reoriented to the new position.
 Proper contour prevent eruption and provide axially alignedProper contour prevent eruption and provide axially aligned
loading.loading.
 No restriction of function & loss of the disclusive effect on theNo restriction of function & loss of the disclusive effect on the
posterior occlusion.posterior occlusion.
Splayed upper anterior teethSplayed upper anterior teeth
 Splayed upper anterior teeth - changes in the neutral zone –Splayed upper anterior teeth - changes in the neutral zone –
reverse lip pressure.reverse lip pressure.
 When lower anterior teeth are upright but upper teeth splayed,When lower anterior teeth are upright but upper teeth splayed,
the lower lip substantially lingual to the upper anterior teeththe lower lip substantially lingual to the upper anterior teeth
during swallowing. This lip posture forces the lower anteriorduring swallowing. This lip posture forces the lower anterior
teeth lingually and upper anterior teeth labially.teeth lingually and upper anterior teeth labially.
 Lower teeth – stable - tongue-pressure resistance against lowerLower teeth – stable - tongue-pressure resistance against lower
lip.lip.
 Lower lip outward force against upper anterior teeth + forwardLower lip outward force against upper anterior teeth + forward
tongue pressure, overpowers the upper lip.tongue pressure, overpowers the upper lip.
 The more the upper teeth splay, the less resistance applied byThe more the upper teeth splay, the less resistance applied by
the upper lip against the angled labial surfaces.the upper lip against the angled labial surfaces.

TreatmentTreatment
 Aim – reposition the teeth back into a more upright position.Aim – reposition the teeth back into a more upright position.
 Lower incisors supraerupt when upper anterior teeth splay, shorten them toLower incisors supraerupt when upper anterior teeth splay, shorten them to
make room for proper upper tooth alignment.make room for proper upper tooth alignment.
 Alter the shape of the upper lingual surfaces to provide stable holdingAlter the shape of the upper lingual surfaces to provide stable holding
contacts.contacts.
 Vertical stability – orthodontic or restorative therapyVertical stability – orthodontic or restorative therapy
 Splinting or a bite planeSplinting or a bite plane
Other causes –Other causes –
 Severe bone loss in the anterior segments in the absence of posterior toothSevere bone loss in the anterior segments in the absence of posterior tooth
support.support.
 Enlarged tongueEnlarged tongue
 Prognosis improved when normalized lip seal facilitated by better toothPrognosis improved when normalized lip seal facilitated by better tooth
alignment.alignment.
Splaying as a result of enlarged tongueSplaying as a result of enlarged tongue
 Nighttime use of a retainerNighttime use of a retainer
 Not used if tongue too largeNot used if tongue too large
 Surgical techniques for decreasing tongue sizeSurgical techniques for decreasing tongue size

MANAGEMENT OF CROSS BITEMANAGEMENT OF CROSS BITE
 Acc. to Graber : “ Condition where one or more teeth may be abnormallyAcc. to Graber : “ Condition where one or more teeth may be abnormally
malposed bucally or lingually or labially with reference to the opposingmalposed bucally or lingually or labially with reference to the opposing
tooth or teeth”.tooth or teeth”.
 CLASSIFICATION :CLASSIFICATION :
A. anterior crossbiteA. anterior crossbite
1) single tooth1) single tooth
2) segmental2) segmental
B. posterior crossbiteB. posterior crossbite
1) unilateral1) unilateral
2) bilateral2) bilateral
C. Based on natureC. Based on nature
1) skeletal1) skeletal
2) dental2) dental
3) functional3) functionalwww.indiandentalacademy.comwww.indiandentalacademy.com

ANTERIOR CROSS BITEANTERIOR CROSS BITE
 CAUSES :CAUSES :
 Mandibular prognathism – true basal jaw dysplasiaMandibular prognathism – true basal jaw dysplasia
 Maxillary retrognathismMaxillary retrognathism
 TREATMENT :TREATMENT :
 Extraoral orthopedic traction in early treatment .Extraoral orthopedic traction in early treatment .
 Success in 3 – 4 months ( 2 – 6 yrs) ( Grabber )Success in 3 – 4 months ( 2 – 6 yrs) ( Grabber )
 Ant . Cross bite worsens with growth spurtsAnt . Cross bite worsens with growth spurts
 Early cross bite analysis – computerised cephalometric growth predictorsEarly cross bite analysis – computerised cephalometric growth predictors
 Ricketts – parameters of comparison regarding growth direction and degree.Ricketts – parameters of comparison regarding growth direction and degree.
 Simple cross bite in young children – tongue bladeSimple cross bite in young children – tongue blade

PROBLEMS ASSOCIATED WITH ANTERIOR CROSS BITE :PROBLEMS ASSOCIATED WITH ANTERIOR CROSS BITE :
 No centric contact on anterior teethNo centric contact on anterior teeth
 No anterior guidanceNo anterior guidance

PSEUDOPROGNATHISM :PSEUDOPROGNATHISM :
 Results from tooth interferences that force the mandible forwardResults from tooth interferences that force the mandible forward
 If upper anterior teeth slant lingually to permit the lower anteriorIf upper anterior teeth slant lingually to permit the lower anterior
teeth to close in front of them – favourable prognosis.teeth to close in front of them – favourable prognosis.
 Open the bite during correction – removable lower appliance thatOpen the bite during correction – removable lower appliance that
provides steep inclines worn continouslyprovides steep inclines worn continously
 Cross over in matter of weeks.Cross over in matter of weeks.
 Removable appliance – retention, once upper ant. teeth in frontRemovable appliance – retention, once upper ant. teeth in front
of the lower ones.of the lower ones.
 If extensive restoration of all anterior teeth required – combinationIf extensive restoration of all anterior teeth required – combination
approach – shortening the anterior teeth (removable appliance notapproach – shortening the anterior teeth (removable appliance not
requiring any bite opening can be used) & as teethrequiring any bite opening can be used) & as teeth
in acceptable relation, preparation completed & provisional plasticin acceptable relation, preparation completed & provisional plastic
bridges made as retainers.bridges made as retainers.
 Two important considerations:Two important considerations:
 Sufficient alveolar bone labiallySufficient alveolar bone labially
 Liguoversion upper ant. teeth moved labial to lower teeth - stressesLiguoversion upper ant. teeth moved labial to lower teeth - stresses
reversed.reversed.

CONSERVATIVE APPROACH FOR RESOLVING ANTERIOR CROSS BITE PROBLEMSCONSERVATIVE APPROACH FOR RESOLVING ANTERIOR CROSS BITE PROBLEMS ::
 Selective shaping & occlusal equilibrationSelective shaping & occlusal equilibration
 Orthodontic repositioning of the teethOrthodontic repositioning of the teeth
 Restorative reshapingRestorative reshaping
 Combination of the aboveCombination of the above
 Combination of reshaping and restoring – preferred – anterior cross bites thatCombination of reshaping and restoring – preferred – anterior cross bites that
can contact end to end in centric relation.can contact end to end in centric relation.
 Increasing vertical dimension – lower incisors arc back more in line withIncreasing vertical dimension – lower incisors arc back more in line with
upper ant. Teeth.upper ant. Teeth.
 Increased vertical established with equal intensity centric contacts on all theIncreased vertical established with equal intensity centric contacts on all the
teeth.- favourable prognosis.teeth.- favourable prognosis.

OPENING THE BITE IS A LOGICAL CHOICE IF :OPENING THE BITE IS A LOGICAL CHOICE IF :
 An acceptable end to end relationship can be achieved at the incisors inAn acceptable end to end relationship can be achieved at the incisors in
harmony with centric relation.harmony with centric relation.
 The required increase in vertical dimension is acceptable.The required increase in vertical dimension is acceptable.
 The posterior segments require restoration for other reason.The posterior segments require restoration for other reason.
 IfIf conservative proceduresconservative procedures fall short of optimum esthetics –fall short of optimum esthetics –
 Live with the prognathism with fairly good assurance that the dentition canLive with the prognathism with fairly good assurance that the dentition can
be maintained.be maintained.
 Select a surgical correction.Select a surgical correction.

SURGICAL CORRECTION OF ANTERIOR CROSS BITE :SURGICAL CORRECTION OF ANTERIOR CROSS BITE :
 Resection through the ramus.Resection through the ramus.
 Horizontal resection of the maxillaHorizontal resection of the maxilla
 Sectional osteotomies.Sectional osteotomies.
 CAUTION :CAUTION :
 Lower arch aligned with the upper arch when the condyles are in centricLower arch aligned with the upper arch when the condyles are in centric
relation – successful surgical result.relation – successful surgical result.
 TEMPOROMANDIBULAR JOINT DISORDERS AND ANTERIOR CROSSTEMPOROMANDIBULAR JOINT DISORDERS AND ANTERIOR CROSS
BITE :BITE :
 Interferences to centric relation eliminated to prevent muscle spasm.Interferences to centric relation eliminated to prevent muscle spasm.
 Equilibration – labial surface of upper anteriors or lingual surface of lowerEquilibration – labial surface of upper anteriors or lingual surface of lower
anteriors.anteriors.
 Temporary bite raising appliance for posterior teeth to open up the bite.Temporary bite raising appliance for posterior teeth to open up the bite.

 POSTERIOR CROSS BITE :POSTERIOR CROSS BITE :
 Posterior cross bite can be stable , functional , comfortable and esthetic as thePosterior cross bite can be stable , functional , comfortable and esthetic as the
normal counterpart.normal counterpart.
 EVALUATING POSTERIOR CROSS BITE :EVALUATING POSTERIOR CROSS BITE :
 Direct result of basal bone malrelationsDirect result of basal bone malrelations
 Tooth to bone relationship in the same archTooth to bone relationship in the same arch
 Relationship of the teeth to the tongue and cheeks.Relationship of the teeth to the tongue and cheeks.
 Occlusal relationships ( direction / distribution of stresses, stabililty )Occlusal relationships ( direction / distribution of stresses, stabililty )
 RESTORING POSTERIOR CROSS BITE :RESTORING POSTERIOR CROSS BITE :
 Balancing inclined interferences – not restored.Balancing inclined interferences – not restored.
 If reversed – excess stress.If reversed – excess stress.
 Upper inclines that face the cheek &Upper inclines that face the cheek &
 Lower inclines that face the tongue should never contact in lateral excursion.Lower inclines that face the tongue should never contact in lateral excursion.
 When the posterior teeth cross bite restored lower lingual cusps – functionalWhen the posterior teeth cross bite restored lower lingual cusps – functional
cusps.cusps.
 In group function lower lingual cusps contact the lingual inclines of the upperIn group function lower lingual cusps contact the lingual inclines of the upper
buccal cusps in working excursions.buccal cusps in working excursions.www.indiandentalacademy.comwww.indiandentalacademy.com

 Lingual inclines of lower buccal cusps should notLingual inclines of lower buccal cusps should not
interfere in balancing excursions - shortened.interfere in balancing excursions - shortened.
 In patients with pronounced curve of spee lowerIn patients with pronounced curve of spee lower
buccal cusps flattened.buccal cusps flattened.
 If lower teeth are lingually tilted and upper teeth areIf lower teeth are lingually tilted and upper teeth are
vertical the buccal inclines of lower lingual cusps –vertical the buccal inclines of lower lingual cusps –
functional inclines for working excursions.functional inclines for working excursions.
 Upper lingual cusps – non functioning, nonUpper lingual cusps – non functioning, non
contacting cusps in cross bites.contacting cusps in cross bites.
FOSSA CONTOURS :FOSSA CONTOURS :
 Lower fossae contoured to receive upper buccalLower fossae contoured to receive upper buccal
cusps in stable CR.cusps in stable CR.
 Fossa walls – not steep to permit cusp to pass in &Fossa walls – not steep to permit cusp to pass in &
out without interferenceout without interference

EQUILIBRATING POSTERIOR CROSS BITE :EQUILIBRATING POSTERIOR CROSS BITE :
 Buccal inclines of the upper lingual cusps – ground out of contact inBuccal inclines of the upper lingual cusps – ground out of contact in
eccentric jaw position.eccentric jaw position.
 Upper buccal cusps shaped to improve the buccolingual position in theUpper buccal cusps shaped to improve the buccolingual position in the
lower fossae , selective grinding on the lower fossa walls and cusplower fossae , selective grinding on the lower fossa walls and cusp
inclines.inclines.
 Equilibration should provide non interfering closure in centric relationEquilibration should provide non interfering closure in centric relation

CROWDED ,IRREGULAR OR INTERLOCKING ANTERIOR BITECROWDED ,IRREGULAR OR INTERLOCKING ANTERIOR BITE
SkeletalSkeletal
Dental (crossbite, deep bite)Dental (crossbite, deep bite)
Irregular anterior bite destructive if –Irregular anterior bite destructive if –
UncleanableUncleanable
UnstableUnstable
Functional interferencesFunctional interferences
Periodontal problemsPeriodontal problems
Methods of correcting interlocking bites :Methods of correcting interlocking bites :
1.1. Sufficient room to accommodate anterior teeth if properly alignedSufficient room to accommodate anterior teeth if properly aligned
2.2. Insufficient room to align anterior teeth without changing posterior archInsufficient room to align anterior teeth without changing posterior arch
formform

Removable appliancesRemovable appliances
Minor tooth movementMinor tooth movement
Solving space problems :Solving space problems :
 Narrow the teethNarrow the teeth
 Reshaping adjacent teethReshaping adjacent teeth
 Reduce no. of teethReduce no. of teeth
 Changing shape of the archChanging shape of the arch
 Changing axial inclination of anterior teethChanging axial inclination of anterior teeth
Narrowing crowded teethNarrowing crowded teeth
 Separating discs ,abrasive stripsSeparating discs ,abrasive strips
Techniques to realign the teethTechniques to realign the teeth
Finger pressureFinger pressure
Ligatures & rubber bandsLigatures & rubber bands
Removable appliancesRemovable appliances
Bands & bracketsBands & brackets

CORRECTING ANT. IRREGULARITY WITH SELECTIVE EXTRATIONCORRECTING ANT. IRREGULARITY WITH SELECTIVE EXTRATION
Stable posterior occlusion – extn –single lower incisorStable posterior occlusion – extn –single lower incisor
No problem in esthetic, function or stabilityNo problem in esthetic, function or stability
Stripping or tooth reduction –insufficient spaceStripping or tooth reduction –insufficient space
Extracting all lower incisors :Extracting all lower incisors :
Indications –Indications –
1.1. Extensive restorative proceduresExtensive restorative procedures
2.2. Maintenance problemsMaintenance problems
3.3. Complication of treatment planComplication of treatment plan
Extracting upper anteriors :Extracting upper anteriors :
First bicuspids – preferred ,laterals may be extractedFirst bicuspids – preferred ,laterals may be extracted
Selective ext. with restorative reshaping – severely crowdedSelective ext. with restorative reshaping – severely crowded
anteriors if post. occlusion stableanteriors if post. occlusion stable

Combining restorative procedures with orthodonticsCombining restorative procedures with orthodontics
Narrowing or shortening – align teeth into available spaceNarrowing or shortening – align teeth into available space
Temporary acrylic restorations – in place of bandsTemporary acrylic restorations – in place of bands
Advantages –Advantages –
 AnchorageAnchorage
 Guide teeth into positionGuide teeth into position
 RetainersRetainers
Delayed lower anterior crowdingDelayed lower anterior crowding
Growth sprutsGrowth spruts
Posterior occlusal interferencePosterior occlusal interference
Inadequate centric contact for lower anteriorInadequate centric contact for lower anterior
Prevention :Prevention :
Lingual arch bar bonded to lower cuspidsLingual arch bar bonded to lower cuspids
Providing stable centric contactsProviding stable centric contactswww.indiandentalacademy.comwww.indiandentalacademy.com

REFERENCESREFERENCES
 Management of temporomandibular joint disorders & occlusion, 5Management of temporomandibular joint disorders & occlusion, 5thth
ed – Freyed – Frey
P OkesonP Okeson
 Evaluation, Diagnosis & Treatment of Occlusal problems, 2Evaluation, Diagnosis & Treatment of Occlusal problems, 2ndnd
ed – Dawsoned – Dawson
 Occlusion, 4Occlusion, 4thth
ed – Ash & Ramjforded – Ash & Ramjford
 Contemporary Orthodontics, 3Contemporary Orthodontics, 3rdrd
ed - Profitted - Profitt
 Text book of Gnathology – Stuart & StallardText book of Gnathology – Stuart & Stallard
 J Oral Rehab 2005,32(11);794-99J Oral Rehab 2005,32(11);794-99
 Acta Odont Scand 2005,6(2);99-109Acta Odont Scand 2005,6(2);99-109
 Quint Int 2004,35(10);811-14Quint Int 2004,35(10);811-14
 J Oral Rehab 2001,28,1085-90J Oral Rehab 2001,28,1085-90
 J Ortho 2001,28(1);19-24J Ortho 2001,28(1);19-24
 Euro J Ortho 2000,22(1);61-67Euro J Ortho 2000,22(1);61-67

 Acta Odont Scand 2002,60(3);180-85Acta Odont Scand 2002,60(3);180-85
 Angle Ortho 2004,74(6);765-68Angle Ortho 2004,74(6);765-68
 Angle Ortho 2004,74(6);754-58Angle Ortho 2004,74(6);754-58

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