This document discusses Class III malocclusion, including:
- Defining Class III malocclusion as when the lower dental arch occludes mesially to the upper arch.
- Describing the different types of Class III (skeletal, pseudo, dental) and factors that influence its development.
- Providing details on diagnostic criteria through extraoral and intraoral examination as well as cast and cephalometric analysis.
- Discussing differential diagnosis and factors that affect treatment planning for Class III malocclusion.
This document discusses the non-surgical management of skeletal class III malocclusions. It begins by defining class III malocclusions and describing their etiology, symptoms, and classification. It then discusses the functional and cephalometric analysis, timing of treatment, and different non-surgical treatment approaches for different types of class III malocclusions. Key points include that class III malocclusions can be caused by maxillary deficiency, mandibular excess, or both; involve an anterior crossbite relationship between the teeth; and are best treated early before abnormal muscle function worsens the skeletal discrepancy. Treatment approaches may involve dental decompensation and orthodontic appliances to correct the dental relationship.
Non surgical management of class 3 skeletal mal occlusion / fixed orthodonti...Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
This document discusses the non-surgical management of skeletal class III malocclusions. It begins by defining class III malocclusions and describing their etiology, symptoms, and classification. It then discusses the functional and cephalometric analysis, timing of treatment, and different non-surgical treatment approaches for different types of class III malocclusions. Key points include that class III malocclusions can be caused by maxillary deficiency, mandibular excess, or both; involve an anterior crossbite relationship between the teeth; and are best treated early before abnormal muscle function worsens the skeletal discrepancy. Treatment approaches may involve dental decompensation and orthodontic appliances to correct the dental relationship.
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
This document provides an overview of Class III malocclusions, including etiology, classification, treatment approaches, and future innovative techniques. Key points include:
- Class III malocclusions are characterized by mandibular prognathism and/or maxillary deficiency. Etiology may include hereditary or environmental factors.
- Treatment depends on the severity and can include orthodontics to alter tooth positions, myofunctional appliances to modify growth, or orthognathic surgery to correct skeletal discrepancies.
- Future innovative techniques being explored include using distraction osteogenesis to advance the maxilla or dental implants to provide anchorage for maxillary protraction without loss of dental anchorage.
- The
Non surgical management of Class 3 malooclusion /certified fixed orthodontic ...Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
This document provides an overview of Class 3 malocclusion, including its typical dental, skeletal, and soft tissue presentations. It discusses the classification of Class 3 as mild, moderate, or severe based on the degree of skeletal vs. dental discrepancy. Treatment options include growth modification with devices like facemasks, dental camouflage techniques like extractions, and orthognathic surgery to correct severe skeletal discrepancies.
This document discusses the classification, etiology, clinical features, and assessment of Class II malocclusions. It describes two main types of Class II malocclusions - Division 1 where the upper anteriors are proclined, and Division 2 where the upper anteriors are retroclined. Class II Division 1 is often due to a skeletal Class II pattern or habits that procline the upper incisors. Class II Division 2 can be associated with a mild skeletal Class II or reduced lower facial height. A thorough assessment of skeletal patterns, soft tissues, dental factors, growth potential, and likelihood of stability is needed to determine the appropriate treatment approach.
This document discusses the non-surgical management of skeletal class III malocclusions. It begins by defining class III malocclusions and describing their etiology, symptoms, and classification. It then discusses the functional and cephalometric analysis, timing of treatment, and different non-surgical treatment approaches for different types of class III malocclusions. Key points include that class III malocclusions can be caused by maxillary deficiency, mandibular excess, or both; involve an anterior crossbite relationship between the teeth; and are best treated early before abnormal muscle function worsens the skeletal discrepancy. Treatment approaches may involve dental decompensation and orthodontic appliances to correct the dental relationship.
Non surgical management of class 3 skeletal mal occlusion / fixed orthodonti...Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
This document discusses the non-surgical management of skeletal class III malocclusions. It begins by defining class III malocclusions and describing their etiology, symptoms, and classification. It then discusses the functional and cephalometric analysis, timing of treatment, and different non-surgical treatment approaches for different types of class III malocclusions. Key points include that class III malocclusions can be caused by maxillary deficiency, mandibular excess, or both; involve an anterior crossbite relationship between the teeth; and are best treated early before abnormal muscle function worsens the skeletal discrepancy. Treatment approaches may involve dental decompensation and orthodontic appliances to correct the dental relationship.
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
This document provides an overview of Class III malocclusions, including etiology, classification, treatment approaches, and future innovative techniques. Key points include:
- Class III malocclusions are characterized by mandibular prognathism and/or maxillary deficiency. Etiology may include hereditary or environmental factors.
- Treatment depends on the severity and can include orthodontics to alter tooth positions, myofunctional appliances to modify growth, or orthognathic surgery to correct skeletal discrepancies.
- Future innovative techniques being explored include using distraction osteogenesis to advance the maxilla or dental implants to provide anchorage for maxillary protraction without loss of dental anchorage.
- The
Non surgical management of Class 3 malooclusion /certified fixed orthodontic ...Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
This document provides an overview of Class 3 malocclusion, including its typical dental, skeletal, and soft tissue presentations. It discusses the classification of Class 3 as mild, moderate, or severe based on the degree of skeletal vs. dental discrepancy. Treatment options include growth modification with devices like facemasks, dental camouflage techniques like extractions, and orthognathic surgery to correct severe skeletal discrepancies.
This document discusses the classification, etiology, clinical features, and assessment of Class II malocclusions. It describes two main types of Class II malocclusions - Division 1 where the upper anteriors are proclined, and Division 2 where the upper anteriors are retroclined. Class II Division 1 is often due to a skeletal Class II pattern or habits that procline the upper incisors. Class II Division 2 can be associated with a mild skeletal Class II or reduced lower facial height. A thorough assessment of skeletal patterns, soft tissues, dental factors, growth potential, and likelihood of stability is needed to determine the appropriate treatment approach.
This document discusses the management of open-bite malocclusion in orthodontics. It describes open-bite classification, etiology, diagnosis and various treatment approaches. Management is based on the cause and involves either orthodontic correction using appliances like habit breakers, myofunctional appliances and fixed braces, or surgical correction like osteotomies, or a combination. Timing of treatment depends on the growth stage and severity. Early intervention aims to redirect growth, while later treatment focuses on orthodontics or orthognathic surgery.
The document discusses Kloehn's early advocacy for using orthopaedic forces to change tooth positions and influence alveolar growth, noting that intercepting the forward growth of the maxilla and alveolus in class II patients allows the mandible to reach a normal relationship. It describes how Kloehn's facebow works to restrain maxillary growth by applying cervical traction via an inner and outer bow connected to maxillary first molar bands. Potential side effects are also outlined if the appliance is not worn correctly or breaks.
Class II malocclusion is characterized by a distal relationship between the maxillary and mandibular teeth. It has a prevalence that varies across populations. Clinical features include a distal step in the deciduous molars, overjet, and a retruded mandible. Cephalometric findings show a prognathic maxilla, retrognathic mandible, or combination of the two. Early intervention utilizes cervical headgear to restrain maxillary growth and distalize the upper dentition, achieving Class I molar and overjet correction.
- Class 2 malocclusion is characterized by maxillary excess relative to the mandible.
- Early intervention during mixed dentition can guide maxillary growth using cervical headgear with a facebow. This restrains maxillary growth and distalizes the upper dentition.
- A Kloehn facebow consists of an inner and outer bow connected to maxillary first molar bands. It is effective but requires patient compliance as it is worn for 12-18 months.
Class II malocclusion is characterized by a maxillary excess or mandibular deficiency. Early intervention during mixed dentition with a Kloehn facebow can help guide maxillary growth. By applying distal forces to the maxillary molars, the facebow can restrain maxillary protrusion and distalize the upper dentition to achieve a Class I relationship. Long-term outcomes show maintenance of the correction and reduced need for future extractions.
This document discusses class II malocclusion and early intervention for growing maxillary excess. It defines class II malocclusion and outlines its prevalence, clinical features, and cephalometric findings. It emphasizes the importance of maintaining a healthy primary dentition to allow proper eruption of permanent molars. For growing maxillary excess, it recommends using a Kloehn cervical facebow headgear during the mixed dentition stage to restrain maxillary growth and distalize the upper dentition into a class I relationship.
This document discusses class II malocclusion features and early intervention. Key points include: class II is characterized by a prognathic maxilla, retrognathic mandible, or combination; early features include a distal molar relationship and narrow maxilla; cervical headgear can be used in mixed dentition to guide maxillary growth and distalize molars for correction. The Kloehn facebow is described for application of orthopedic forces to restrain maxillary growth.
This document discusses class II malocclusion and early intervention. It defines class II malocclusion and outlines its prevalence, clinical features, and cephalometric findings. It describes maintaining the primary dentition, using cervical headgear to guide maxillary growth in mixed dentition cases involving maxillary excess, and addressing habits. Headgear with a facebow can distalize the maxilla to achieve class I molar and canine relationships. Treatment is most effective in late mixed/early permanent dentition when compliance is possible.
management of anterior open bite
examination of open bite
treatment of open bite
etiology of open bite
II- Clinical examination
a- Extra-oral:
1- Dental open bite: patient with dental open bite often have normal facial proportion
2- Skeletal open bite: patient with skeletal open bite often show the following:
- Narrow and long face
- Slim nose with narrow nasal slits
- Incompetent lips, short upper lip and hyperactive lower lip
- Shallow labio-mental sulcus
- Excessive upper incisors show, and gummy smile
- Increase lower third of the face
- Receded chin point
- Increase inter-labial gap
- Steep mandibular plane
- Excessive anti-gonial notch
- Short ramus
b- Intra-oral examination:
1- Dental open bite: may be associated with:
= proclination of upper and lower incisors and open bite not more than 1mm ------ pseudo open bite
= localized open bite confined to one or two teeth ------ mechanical interference by nail biting or putting something between the teeth, lead to attrition at incisal edge
= well circumscribed open bite confined to the anterior region associate with history of thumb sucking -------- adaptive tongue thrust
= clinical crown of anterior teeth is short
2- Skeletal open bite:
May be associated with the following:
- Will circumscribed open bite extending to the 1st molars
- Ill-defined open bite extending to the last occluding molars
- Poor inter-cuspation
- Collapsed maxilla and buccal cross bite
- Anterior teeth may be extruded
- The posterior dentoalveolar segment is over-developed
III- Study cast
1- Anterior posterior relationship:
= anterior open bite rarely presented as a separate or isolated entity but may be associated with class I, II, III relationship
= the upper incisors are proclined, while the lower incisors often retroclined by the action of lower lip
= crowding is common finding in lower incisors, while the upper incisors may or may not show crowding
= as a general, dental open bite is frequently associated with Class I skeletal base and good intercuspation while skeletal open bite may be associated of skeletal anterior posterior dysplasia and poor intercuspation.
2- Vertical analysis:
= in dental open bite, the clinical crown of the anterior teeth is short, the anterior teeth lack vertical development due to mechanical interference or disturbance in eruption
= the vertical height of posterior teeth is normal
= in skeletal open bite: the anterior teeth may be extruded and there is excessive posterior dental alveolar development. The curve of spee is reversed
3- Transverse analysis:
Dental open bite has no discrepancy in lateral direction while skeletal open bite may be associated with collapsed maxilla and buccal cross bite
IV- Cephalometric analysis
1- Anterior posterior:
Dental open bite is most frequently associated with skeletal class I while skeletal open bite is most commonly associated with skeletal class II or class III skeletal pattern
2- Vertical cephalometric analysis:
The vertical facial measurem
Class III malocclusion is defined as the maxillary first molar occluding in the interdental space between the mandibular first and second molars. It can also be defined as the lower incisor edge occluding anterior to the upper incisors. Etiology includes heredity, age, functional factors like tongue posture, enlarged tonsils, premature loss of deciduous molars, lack of eruption of maxillary segments, and trauma during growth. A 25-year-old female patient presented with a prominent lower jaw, concave profile, Class III molar and canine relationship with 5mm reverse overjet, and mild crowding. Skeletal features include a retrognatic maxilla
1. Class 2 malocclusion is characterized by a distal positioning of the mandible or protrusion of the maxilla.
2. Early signs in the deciduous and mixed dentition include a distal step relationship of the second deciduous molars and transverse discrepancy between the maxillary and mandibular arches.
3. For cases involving maxillary excess, a Kloehn cervical facebow is used to restrain maxillary growth and distalize the upper dentition into a Class I relationship.
The document discusses class II malocclusion, including its prevalence, clinical and cephalometric features, and interceptive treatment during mixed dentition. Class II malocclusion is characterized by a distal relationship between the maxillary and mandibular teeth. During mixed dentition, the maxilla grows forward more than normal while the mandible grows less, worsening the malocclusion. Interceptive treatment aims to restrain maxillary growth using appliances like the Kloehn facebow to allow the mandible to catch up during its growth. Early treatment can help reduce the need for future extraction treatment.
The document discusses class II malocclusion, including its prevalence, clinical findings, and cephalometric characteristics. It also describes intercepting the developing class II malocclusion through early orthodontic intervention such as maintaining primary dentition, restoring caries, and using cervical headgear in mixed dentition cases involving maxillary excess to guide alveolar growth. Headgear application for 12-18 months can distalize maxillary molars, reduce maxillary protrusion, and allow normal mandibular growth.
This document discusses class II malocclusion, including its prevalence, clinical and cephalometric features during mixed and permanent dentition stages. Early intervention is important to intercept developing class II malocclusions. For cases involving maxillary excess, a Kloehn cervical headgear with facebow can be used starting in late mixed dentition to restrain maxillary growth and distalize the upper dentition. Headgear treatment for 12-18 months can improve the skeletal and dental profile in the sagittal, vertical and transverse planes.
The document discusses class II malocclusion and early intervention during the mixed dentition stage. It describes using a Kloehn cervical facebow to apply orthopaedic forces in cases where maxillary excess is the primary issue. The facebow is fitted to the maxillary first molars to restrain maxillary growth and distalize the upper dentition into a class I relationship. Proper age of treatment, components of the facebow, and effects on the craniofacial structures are outlined. Potential adverse effects and importance of long-term compliance are also noted.
1. The forward growing maxilla can be intercepted during mixed dentition using orthopaedic forces applied with a Kloehn facebow appliance.
2. The Kloehn facebow applies cervical traction to restrain maxillary growth and distalize the upper dentition into a Class I relationship.
3. When used for 12-14 hours per day, the Kloehn facebow is an effective but patient compliance-dependent way to intercept Class II malocclusions caused by maxillary excess.
1) The forward growing maxilla can be intercepted during mixed dentition using orthopaedic forces applied with a Kloehn facebow in the correct direction and amount.
2) The Kloehn facebow appliance is effective at redirecting maxillary growth but requires patient compliance to wear the headgear for 12-14 hours per day.
3) Long term effects of early headgear treatment show significant reduction in need for extraction treatment compared to controls and inhibition of maxillary growth, resulting in wider arches that are maintained long term.
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
This document discusses early intervention for class II malocclusions caused by maxillary excess. It describes using a Kloehn cervical facebow appliance during the mixed dentition stage to restrain maxillary growth and guide the mandible forward into a class I relationship. The facebow applies distalizing forces to the maxillary molars via headgear worn for 12-14 hours per day. This treatment modality was effective at correcting class II malocclusions but required good patient compliance.
Definition
Types of rotation
Etiology of rotation
Winging and counter winging rotation
Advantages of derotation
Biomechanics of rotation correction
Methods of correction rotation
Management of molar derotation
Retention of rotated tooth
Methods to prevent relapse
Active retention
Torque when, where, how?
Importance of torque
Biomechanics in torque
Torque expression in slot 0.018 and 0.022
Expression of torque
Mode of ligation and torque
Types of torque
- Passive
- Active
Factors affect torque
Torque with different appliances
Torque in base and face
Torque prescription in different techniques
Class II malocclusion and torque
Torque control in different treatment steps
Differential torque
Torque clearance
Intrusion and torque
Torque and intra-oral elastics
This document discusses the management of open-bite malocclusion in orthodontics. It describes open-bite classification, etiology, diagnosis and various treatment approaches. Management is based on the cause and involves either orthodontic correction using appliances like habit breakers, myofunctional appliances and fixed braces, or surgical correction like osteotomies, or a combination. Timing of treatment depends on the growth stage and severity. Early intervention aims to redirect growth, while later treatment focuses on orthodontics or orthognathic surgery.
The document discusses Kloehn's early advocacy for using orthopaedic forces to change tooth positions and influence alveolar growth, noting that intercepting the forward growth of the maxilla and alveolus in class II patients allows the mandible to reach a normal relationship. It describes how Kloehn's facebow works to restrain maxillary growth by applying cervical traction via an inner and outer bow connected to maxillary first molar bands. Potential side effects are also outlined if the appliance is not worn correctly or breaks.
Class II malocclusion is characterized by a distal relationship between the maxillary and mandibular teeth. It has a prevalence that varies across populations. Clinical features include a distal step in the deciduous molars, overjet, and a retruded mandible. Cephalometric findings show a prognathic maxilla, retrognathic mandible, or combination of the two. Early intervention utilizes cervical headgear to restrain maxillary growth and distalize the upper dentition, achieving Class I molar and overjet correction.
- Class 2 malocclusion is characterized by maxillary excess relative to the mandible.
- Early intervention during mixed dentition can guide maxillary growth using cervical headgear with a facebow. This restrains maxillary growth and distalizes the upper dentition.
- A Kloehn facebow consists of an inner and outer bow connected to maxillary first molar bands. It is effective but requires patient compliance as it is worn for 12-18 months.
Class II malocclusion is characterized by a maxillary excess or mandibular deficiency. Early intervention during mixed dentition with a Kloehn facebow can help guide maxillary growth. By applying distal forces to the maxillary molars, the facebow can restrain maxillary protrusion and distalize the upper dentition to achieve a Class I relationship. Long-term outcomes show maintenance of the correction and reduced need for future extractions.
This document discusses class II malocclusion and early intervention for growing maxillary excess. It defines class II malocclusion and outlines its prevalence, clinical features, and cephalometric findings. It emphasizes the importance of maintaining a healthy primary dentition to allow proper eruption of permanent molars. For growing maxillary excess, it recommends using a Kloehn cervical facebow headgear during the mixed dentition stage to restrain maxillary growth and distalize the upper dentition into a class I relationship.
This document discusses class II malocclusion features and early intervention. Key points include: class II is characterized by a prognathic maxilla, retrognathic mandible, or combination; early features include a distal molar relationship and narrow maxilla; cervical headgear can be used in mixed dentition to guide maxillary growth and distalize molars for correction. The Kloehn facebow is described for application of orthopedic forces to restrain maxillary growth.
This document discusses class II malocclusion and early intervention. It defines class II malocclusion and outlines its prevalence, clinical features, and cephalometric findings. It describes maintaining the primary dentition, using cervical headgear to guide maxillary growth in mixed dentition cases involving maxillary excess, and addressing habits. Headgear with a facebow can distalize the maxilla to achieve class I molar and canine relationships. Treatment is most effective in late mixed/early permanent dentition when compliance is possible.
management of anterior open bite
examination of open bite
treatment of open bite
etiology of open bite
II- Clinical examination
a- Extra-oral:
1- Dental open bite: patient with dental open bite often have normal facial proportion
2- Skeletal open bite: patient with skeletal open bite often show the following:
- Narrow and long face
- Slim nose with narrow nasal slits
- Incompetent lips, short upper lip and hyperactive lower lip
- Shallow labio-mental sulcus
- Excessive upper incisors show, and gummy smile
- Increase lower third of the face
- Receded chin point
- Increase inter-labial gap
- Steep mandibular plane
- Excessive anti-gonial notch
- Short ramus
b- Intra-oral examination:
1- Dental open bite: may be associated with:
= proclination of upper and lower incisors and open bite not more than 1mm ------ pseudo open bite
= localized open bite confined to one or two teeth ------ mechanical interference by nail biting or putting something between the teeth, lead to attrition at incisal edge
= well circumscribed open bite confined to the anterior region associate with history of thumb sucking -------- adaptive tongue thrust
= clinical crown of anterior teeth is short
2- Skeletal open bite:
May be associated with the following:
- Will circumscribed open bite extending to the 1st molars
- Ill-defined open bite extending to the last occluding molars
- Poor inter-cuspation
- Collapsed maxilla and buccal cross bite
- Anterior teeth may be extruded
- The posterior dentoalveolar segment is over-developed
III- Study cast
1- Anterior posterior relationship:
= anterior open bite rarely presented as a separate or isolated entity but may be associated with class I, II, III relationship
= the upper incisors are proclined, while the lower incisors often retroclined by the action of lower lip
= crowding is common finding in lower incisors, while the upper incisors may or may not show crowding
= as a general, dental open bite is frequently associated with Class I skeletal base and good intercuspation while skeletal open bite may be associated of skeletal anterior posterior dysplasia and poor intercuspation.
2- Vertical analysis:
= in dental open bite, the clinical crown of the anterior teeth is short, the anterior teeth lack vertical development due to mechanical interference or disturbance in eruption
= the vertical height of posterior teeth is normal
= in skeletal open bite: the anterior teeth may be extruded and there is excessive posterior dental alveolar development. The curve of spee is reversed
3- Transverse analysis:
Dental open bite has no discrepancy in lateral direction while skeletal open bite may be associated with collapsed maxilla and buccal cross bite
IV- Cephalometric analysis
1- Anterior posterior:
Dental open bite is most frequently associated with skeletal class I while skeletal open bite is most commonly associated with skeletal class II or class III skeletal pattern
2- Vertical cephalometric analysis:
The vertical facial measurem
Class III malocclusion is defined as the maxillary first molar occluding in the interdental space between the mandibular first and second molars. It can also be defined as the lower incisor edge occluding anterior to the upper incisors. Etiology includes heredity, age, functional factors like tongue posture, enlarged tonsils, premature loss of deciduous molars, lack of eruption of maxillary segments, and trauma during growth. A 25-year-old female patient presented with a prominent lower jaw, concave profile, Class III molar and canine relationship with 5mm reverse overjet, and mild crowding. Skeletal features include a retrognatic maxilla
1. Class 2 malocclusion is characterized by a distal positioning of the mandible or protrusion of the maxilla.
2. Early signs in the deciduous and mixed dentition include a distal step relationship of the second deciduous molars and transverse discrepancy between the maxillary and mandibular arches.
3. For cases involving maxillary excess, a Kloehn cervical facebow is used to restrain maxillary growth and distalize the upper dentition into a Class I relationship.
The document discusses class II malocclusion, including its prevalence, clinical and cephalometric features, and interceptive treatment during mixed dentition. Class II malocclusion is characterized by a distal relationship between the maxillary and mandibular teeth. During mixed dentition, the maxilla grows forward more than normal while the mandible grows less, worsening the malocclusion. Interceptive treatment aims to restrain maxillary growth using appliances like the Kloehn facebow to allow the mandible to catch up during its growth. Early treatment can help reduce the need for future extraction treatment.
The document discusses class II malocclusion, including its prevalence, clinical findings, and cephalometric characteristics. It also describes intercepting the developing class II malocclusion through early orthodontic intervention such as maintaining primary dentition, restoring caries, and using cervical headgear in mixed dentition cases involving maxillary excess to guide alveolar growth. Headgear application for 12-18 months can distalize maxillary molars, reduce maxillary protrusion, and allow normal mandibular growth.
This document discusses class II malocclusion, including its prevalence, clinical and cephalometric features during mixed and permanent dentition stages. Early intervention is important to intercept developing class II malocclusions. For cases involving maxillary excess, a Kloehn cervical headgear with facebow can be used starting in late mixed dentition to restrain maxillary growth and distalize the upper dentition. Headgear treatment for 12-18 months can improve the skeletal and dental profile in the sagittal, vertical and transverse planes.
The document discusses class II malocclusion and early intervention during the mixed dentition stage. It describes using a Kloehn cervical facebow to apply orthopaedic forces in cases where maxillary excess is the primary issue. The facebow is fitted to the maxillary first molars to restrain maxillary growth and distalize the upper dentition into a class I relationship. Proper age of treatment, components of the facebow, and effects on the craniofacial structures are outlined. Potential adverse effects and importance of long-term compliance are also noted.
1. The forward growing maxilla can be intercepted during mixed dentition using orthopaedic forces applied with a Kloehn facebow appliance.
2. The Kloehn facebow applies cervical traction to restrain maxillary growth and distalize the upper dentition into a Class I relationship.
3. When used for 12-14 hours per day, the Kloehn facebow is an effective but patient compliance-dependent way to intercept Class II malocclusions caused by maxillary excess.
1) The forward growing maxilla can be intercepted during mixed dentition using orthopaedic forces applied with a Kloehn facebow in the correct direction and amount.
2) The Kloehn facebow appliance is effective at redirecting maxillary growth but requires patient compliance to wear the headgear for 12-14 hours per day.
3) Long term effects of early headgear treatment show significant reduction in need for extraction treatment compared to controls and inhibition of maxillary growth, resulting in wider arches that are maintained long term.
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
This document discusses early intervention for class II malocclusions caused by maxillary excess. It describes using a Kloehn cervical facebow appliance during the mixed dentition stage to restrain maxillary growth and guide the mandible forward into a class I relationship. The facebow applies distalizing forces to the maxillary molars via headgear worn for 12-14 hours per day. This treatment modality was effective at correcting class II malocclusions but required good patient compliance.
Definition
Types of rotation
Etiology of rotation
Winging and counter winging rotation
Advantages of derotation
Biomechanics of rotation correction
Methods of correction rotation
Management of molar derotation
Retention of rotated tooth
Methods to prevent relapse
Active retention
Torque when, where, how?
Importance of torque
Biomechanics in torque
Torque expression in slot 0.018 and 0.022
Expression of torque
Mode of ligation and torque
Types of torque
- Passive
- Active
Factors affect torque
Torque with different appliances
Torque in base and face
Torque prescription in different techniques
Class II malocclusion and torque
Torque control in different treatment steps
Differential torque
Torque clearance
Intrusion and torque
Torque and intra-oral elastics
Extra-oral forces
And
Appliances
Prepared by:
Dr. Mohammed Alruby
Definition
Philosophy
History and development
Classification of extra-oral forces
Advantages of extra-oral forces
Disadvantages of extra-oral forces
Uses of extra-oral forces
Headgear
Appliance enhanced the action of headgear
Protraction appliances
Types of reversed headgear
Chin cup appliance
Orthopedic correction of class III
Orthopedic correction of open bite
Orthopedic correction of class II
Retention after orthopedic correction
Definition
It is a force derived from an extra-oral appliance that uses the forehead, the top of the head or the back of the neck as anchorage to apply forces to the dental or basal arch. It may be orthodontic force or orthopedic force to move the dentition, or restrict or redirect the growth respectively.
Philosophy:
The philosophy beyond the use of extra-oral force is based upon the old concept that, (the application of appreciable amount of force against the growing bone con modify or alter the direction of bone growth and consequently alter the shape and position of the bone
= the well-known best examples are the induced skull deformation in Colombia –India and feet deformation in Chinese girls
History and development:
Appliances resembling chin cups have been in use since the early 1800's. According to Graber, the early attempts with the chin cup were not successful because of incomplete knowledge of mandibular and facial growth, its use on non-growing patients, and an inadequate understanding of the forces generated by the chin cup.
1802: Cellier and Josef Fox in 1803, utilized chin caps in combination with bite blocks to correct the “underslung chin”
1866: Norman Kingsley introduced extra-oral head cap anchorage or force for maxillary distal movement
1880: Kingsley described an appliance that could influence the position of the dentition in upper jaw with the aid of extra-oral forces
1887: E.H.Angle recommended the use of occipital bandage in treatment of maxillary protrusion
1904: Jackson was first describing the facial mask
1892: headgear appliance was originally designed by Kingsley
1920: Angle and his followers were convinced that class II and class III elastics not only moved teeth but cause a significant skeletal changes: stimulate growth of one and restrain growth for the other so we not need to use any extra-oral force just wait until permanent dentition is completed
1923: Case recommend the use of extra-oral force against maxilla in treatment of class II and class I maxillary protrusion
1947: Kleohn, presented his treatment results with cervical neck strap, subsequent to this report, many other variation of the headgear appliance were presented
1960: Delaire facemask
Classification of extra-oral force appliances according to uses
The extra-oral pull is generally applied bilaterally, for three main purposes:
(1) as a restraining force
(2)
Effects of extra-oral appliances
And
Forces
Prepared by
Dr. Mohammed Alruby
Factors affect extra-oral force
Studies of maxillary protraction force
Results of extra-oral force
Effects of extra-oral appliances
The effects of extra-oral forces on dentofacial structure depend on the following factors:
- Direction of force
- Magnitude of force
- Duration of force
- Growth
- Patient cooperation
1- Direction of force:
Kloehn 1953, Gould 1975, Greenspan 1970, Merrifield and Cross 1970, and Worms et al 1973, all give an adequate description for the direction of force application and their effect on maxillary molar position, tipping, bodily, extrusion, intrusion movement
The direction of force should be adjusted according to the patient needs and objective of treatment as:
- When bodily movement is required, the force should pass through the center of resistance of molars (at the tri-furcation of roots) and the extra-oral tube should be placed gingivally as possible
- When bodily displacement of maxilla is required, the force should pass through the center of maxillary resistance (zygomatic bone)
- When extrusion of molars is required, (in case of deep bite) the force should pass below the center of resistance (below the level of occlusal plane)- cervical headgear is the best choice
- When intrusion is required (open bite cases) the force should pass above the level of occlusal plane
- In occipital headgear, the vector of force may pass through the center of resistance of 1st molar and thus causes: -------------- distal translation of 1st molar
- If the vector of force passes above the center of resistance causing:
a- Distal root torque
b- Mesial crown tipping
c- Intrusion of maxillary 1st molar ---- that, ----- closing the bite and same can occurs in the vertical or high pull headgear
== the direction of force can be determined by adjusting the outer bow in relation to the occlusal plane or center of resistance
== the best method for recording the force direction is the lateral cephalometric radiograph with the appliance in place, then the outer bow is adjusted in relation to the occlusal plane and the center of resistance of tooth or jaw
= in Kloehn’s face bow, the direction of force is 25 – 30 degree below the occlusal plane so that, the vector of force is far away from the center of resistance of 1st molars, thus cervical headgear causes distal tipping and extrusion of 1st molars and open bite
The direction of force depends upon the following variables:
I- Vertical position of the outer bow relative to the center of resistance:
= force applied by oblique headgear passing through the center of resistance will cause translation of the tooth and make intrusion at the same time
= force applied by oblique headgear passing above the occlusal plane
but below the center of resistance will cause:
a- Distal crown tipping, mesial root torque
b- Extrusion of mesial marginal ri
Characteristic of light
History
Laser physics and properties
Component of laser
Classification of laser
Biological effect of laser
Laser effect on dental tissues
Laser safety in dental practice
General application of laser
Personal protective equipment
Types of laser intensity in orthodontics
Uses of laser in orthodontics
Effect of laser in orthodontics
Introduction
History
Classification of maxillary fractured Lefort
Special consideration for orthognathic surgery
- Patient selection:
Age of patient
Assessment of patient motivation and expectation
The nature and severity of skeletal dysplasia
Systemic evaluation
- Patient evaluation:
(1) General evaluation
(2) Esthetic evaluation
(3) Functional evaluation
(4) Radiographic evaluation
a- Ceph ---
PA
Lateral: ------ soft and hard
b- Panorama
c- CBCT
d- Periapical
Protocol for basic orthognathic record collection
Treatment planning
- Time of treatment
- Objective of orthodontic treatment
Pre-surgical
Post-surgical
- Sequence of treatment:
Pre-surgical phase
Orthodontic in theatre
Post-surgical treatment
Surgery without orthodontics
Stability and clinical success
complications
Medical glossary
Prepared by:
Dr. Mohammed Alruby
Medical glossary
Aberrancy: occurring or developing away from the normal situation
Acantholysis: loss of coherence between epithelial cells due to degeneration of desmosomes (intercellular bridge) this will lead to the formation of intra-epithelial clefts, vesicle and bullae
Acanthosis: epithelial hyperplasia, mainly of the stratum spinosum, leading to increase thickness of the stratum granulosum due to increased number of cell layers of prickle cells
Achondroplasia: an autosomally inherited disorder characterized by abnormality of conversion cartilage into bone predominantly affecting the epiphyses of long bones, leading to retarded growth at the epiphyses and resulting in dwarfism with short extremities but normal trunk
Acidogenic: referring to organisms capable of producing acid
Aciduric: referring to organisms capable of surviving and metabolizing under highly acidic conditions
Acquired: a term used to describe a condition, habit or other characteristic which is not present at birth, which developed in the individuals by reaction to some environmental factor (to acquire is to obtain)
Agenesis: failure of formation leading to absence of a part or organ
Aglossia: failure of formation leading to absence of the tongue
Agnathia: absence of the jaw, usually the lower jaw, usually accompanied by approximation of the ears
Amyloid: pertaining of starch, having the characteristic of starch. A protein compound of albumin and chondroitin sulphate which resembles starch in appearance and may be pathologically deposited in certain tissues
Anaplasia: atypical differentiation or lack of differentiation of epithelial cells occurring in the malignant disease. Anaplastic cells have large, hyperchromatic, irregularly shaped nuclei and frequently show a typical mitosis.
Aneuploidy: an abnormal number of chromosomes in a nucleus. This usually arise from failure of paired chromosomes or sister chromatids to disjoin at anaphase of cell division
Aneurysm: circumscribed dilatation of an artery
Aneurysmal: relating to an aneurysm. The term applied to a type of cyst that produce bony expansion simulating the expansion of an artery produced by a vascular aneurysm
Angiogenesis: development of blood vessels
Angioma: a swelling or mass due to proliferation with or without dilatation of vascular channels
Anhydrosis: absence of sweating due to absence of sweat glands
Ankyloglossia: tongue tie, usually due to a short lingual frenum or one attached too near the tip of the tongue, may be due to failure of separation of tongue from the floor of the mouth during embryogenesis
Ankylosis: stiffening or fixation of a joint as a result of a disease process
Anodontia: absence of teeth
Anomaly: deviation from the normal, anything structurally unusual or irregular
Antigen: a substance that can induce an antibody response
Antimongoloid slant: an obliquity of the palpebral fissures laterally
Muscles
Part 3
Prepared by
DR. Mohammed Alruby
Development of oropharyngeal function
Neuromuscular regulation of jaw positions and functions
Muscles controlling mandibular postures
- Muscles of mastication
- Submandibular muscles
- Extensor and flexor muscles of neck
Positions of mandible
Some clinical implications
Development of oropharyngeal function
1- Prenatal maturation:
= During prenatal life, the neuromuscular system does not mature evenly, it is not accidentally that the orofacial region matures a head of limb region
= In human fetus, by about the 8 week, generalized uniform reflex movement of entire body can be elicited by tactile stimulation
Diffuse spontaneous movements in response to as yet unidentified stimuli have been observed as early as 9.5 weeks
Localized specific and more peripheral responses cannot be produced before 11 weeks, and at this time, stimulation of the nose-mouth region causes lateral body flexion
By 14 weeks, the movements have become much more individualized. Stimulation of the mouth area, the general bodily movements no longer are seen but instead facial and orbicular muscle response are produced
Stimulation of the upper lip causes the mouth to close and often deglutition occurs
Respiratory movements of the chest and abdomen are seen first at about 16 week
The gag reflex has been demonstrated in human fetus of 18.5 weeks. By 25v weeks, respiration is shallow but may support life for few hours
Stimulation of the mouth at 29 weeks’ menstrual age has elicited sucking through complete suckling and swallowing is not thought to be developed until at least 32 week
2- Neonatal oral functions:
a- The mouth as sensory instrument:
= At birth, the orofacial region is a very active perceptual system, the infant finds the mouth nipple = more tactile than the visual sensation
At birth, the tactile sense already is more highly developed in the lips and mouth than in the fingers
= The neonate’s slobbers, drools, chew his toe, sucks his thumb and discovers the gurgling sounds can be made with his mouth
= oral function of the neonate is guided primarily by local tactile stimuli, particularly those from the lips and anterior part of the tongue
= the posture’s of neonate’s tongue is between the gum pads and often for enough forward to rest between the lips, where it can perform its role of sensory guidance more easily
= the mouth of infant is used for many purpose, the perceptual functions of the tongue, lips, and facial skin are mingled with the sensory function of taste, smell and jaw position.
= the sensitivity of tongue and lips is greater than other area of the body and the sensory guidance for oral functioning, including jaw movements is from remarkably large area
b- Infant suckling and swallowing:
= Infant suckling and swallowing have been the subjects of much research due to the effectiveness of these activities is a good indication of the neurologic ma
Muscles
Part 2
Prepared by:
Dr. Mohammed Alruby
Muscle function and malocclusion
Muscle development and skull form in relation to function
Facial balance, muscle balance, and orthodontic therapy
EMG response of muscles
Myofunctional therapy
Basic concepts of neuromuscular physiology
Muscle function and malocclusion
Muscle function is a factor in shaping the dental arches and is important in maintaining the stability of the teeth following orthodontic treatment
Muscle fibers contract in response to change in electrical potential of its investing membrane, proprioceptors located in the muscles and the periodontal membrane make possible a high degree of accuracy in bringing the teeth in contact
Class II malocclusion:
The muscle function is usually normal in class I malocclusion with the exception of class I Openbite
In class I cases, the teeth are in state of balance with environmental force, although the actual measurements of tongue and lip forces showed that, they are not equal at any area during particular function
Class I openbite:
= Usually caused by thumb sucking, retained infantile tongue swallowing or both, the child begins with finger habits of sufficient intensity and duration to deform the maxillary anterior segment forcing the incisors labially and allowing the tongue to move farther in forward direction
= the tongue continues to thrust instead of entering the transitional phase, a large part of this activity may be compensatory or adaptive to produce anterior seal with lower lip during swallowing
=such activity accentuates the openbite, prevent complete eruption of incisors and increase the overjet to the extent that the lower lip may cushion behind the maxillary incisors during rest and functional movements
- The upper lip become more hypotonic
- The lower lip become hyperactive
- Chin puckering can see with each swallowing
= the hyperactive mentalis muscle, retroclined, imprecate and flatten the mandibular anterior segment
= the tongue drop downward and mouth breathing become a dominate pattern, as the tongue thrust forward, it elongates in shape thus alter the balance with buccinator mechanism resulting in:
- Collapse of posterior segment
- V-shaped palate
- Buccal cross bite
This occurs also as a result of molding effect of the tongue upon the hard palate
Mouth breathing:
Is the good explain for these changes a result of underdeveloped nasopharyngeal structures and subsequently maxillary deficiency
Class II division 1 malocclusion:
= In contrast to class I class II div 1 involve an abnormal muscle function from beginning
= As abnormal muscle function in class II div 1 is a compensatory or adaptive and is secondary to skeletal relationship
= Because of large overjet, there is lack of the lip seal during rest and various functions so, mouth breathing is developed
= Some individuals translate the mandible forward to effect lip seal and to improv
Muscles
Part 1
Prepare by
Dr. Mohammed Alruby
Histology of muscles
Physiology of muscles
Muscles development
Orofacial muscles
- Facial muscles
- Jaw muscles
- Portal muscles
Methods of studying muscles
Muscle changes during growth
Muscle function and facial development
Histology of muscles
The structural and functional unit of the muscles is the muscle fiber
Muscle fiber: elongated cylinder measure about 10 to 80 microns in thickness and from 1 to 15cm in length
= Each muscle fiber contains an acidophilic granular cytoplasm (sarcoplasm) that rich in:
Glycogen, mitochondria, Golgi apparatus, protein (actin, myosin, tropomyosin),
Large number of myofibrils (sarcostyles) which responsible for muscle contraction
= the muscle fiber is covered by thick membrane called (sarcolemma) and surrounded by CT called (endomysium)
= the muscle fibers are coalescing together to form bundles; each bundles are covered by C T septa called perimysium
= the muscle bundles are coalescing together to the whole muscle which is covered by CT fascia called epimysium, these CT contain: blood vessel, lymph vessel, and nerves, that firmly attach the muscle bundles to each other and attach the whole muscle to its tendon
= the myofibrils (sarcostyles)are the contractile units of the muscle, in skeletal muscle they are transversely striated due to presence of dark and light bands
The dark bands are formed of thick myosin filaments rich in Ca, the light bands are formed of thin actine filaments rich in water, there is a pale line in at the center of dark band called (Henesen’s disk), There is dark line at the center of light bands called (Krauses membrane) or Z line
The distance between the two lines called (sarcomere) which is a contraction unit of the muscle.
During the muscle contraction there the Sarcomere is shortened due to sliding of the light bands over the dark bans. The energy required for contraction is derived from transformation of ATP ------ ADP
Physiology of muscles:
Man has 639 muscles, composed of 6 billion muscle fibers, each fiber has 1000 fibrils, which means that there are 6000 billion fibrils at work at one of time or another.
Elasticity: muscle can be stretched behind its original length and return to the original shape after relaxation (normal muscle can be elongated about 6/10 of its length
Contractility: it is the ability of muscle to shorten its length under nerve impulse, this contraction is stimulated by acetyl choline, glycogen is partially oxidized to provides energy and lactic acid that carried away by blood stream
Excessive accumulation of lactic acid can produce fatigue
Isometric contraction: (stretching): the muscle is simply resisting the external forces without actual shortening
Isotonic contraction: there is an actual shortening of the muscle, the strength of isometric contraction is much greater than that of isotonic contraction as the stre
diagnostic aids part 3, photograph and radiograph.docxDr.Mohammed Alruby
Diagnostic Aids
Part 3
{Radiographs and Photographs}
{BMR and EMG}
Prepared by
Dr. Mohammed Alruby
Radiographs
Means: A procedure that uses a type of high-energy radiation called x-rays to take pictures of areas inside the body. X-rays pass through the body onto film or a computer, where the pictures are made
Types:
Intra-oral radiographs:
Periapical radiographs:
It is necessary for any orthodontic diagnosis for the following reasons:
The pattern and amount of root resorption of deciduous teeth
Presence or absence of permanent teeth, their size, shape, position and relative state of development
Congenital absence of teeth or presence of supernumerary teeth
Character of alveolar bone, lamina dura, and periodontal membrane
Morphology and inclination of permanent teeth roots
Pathological oral condition such as thickened periodontal membrane, periapical infection, root fractures, cysts, retained deciduous teeth
Abnormal path of eruption of permanent teeth
Malposition of individual as: rotation, which requires a larger space on the arch
Very useful in mixed dentition analysis
Recognition of exact position of impacted tooth by using method of parallax: that determine whether the unerupted tooth is located labially or palatally. Two periapical radiograph is taken with the film in the same position in each exposure, but the tube is moved in second exposure about 10cm. if the impacted tooth is moved in the same direction as the tube so the tooth is impacted palatally and the reverse is versa.
Bit-wing radiographs:
Is used mainly for detection of proximal cries, but it is of little value in orthodontic diagnosis
Occlusal film:
Occlusal projection is useful to locate the supernumerary teeth at the midline (mesiodens) and to determine accurately the position of impacted maxillary cuspids
Extra-oral radiographs:
Cephalometric radiographs:
Lateral cephalometric radiographs
PA cephalometric radiographs
Lateral oblique cephalogram:
The patient is directed by 45 degree and take the shot
Since dentofacial structure will be superimposed in the true lateral cephalometric projection, the lateral oblique direction is designed to gives a more accurate recording of the actual tooth position in either the left or right buccal segments depending on which side is approximately perpendicular to the central rays
The lateral oblique cephalogram combines most of advantages of the lateral views, intra-oral periapical survey and panoramic radiograph plus a standard cephalometric registration that makes possible measurements of bone size and eruptive movements so it is of particular size in analysis of developing dentition
Submental vertex cephalometric:
Is used to assess mandibular asymmetry in the transverse and anterior-posterior plane. It is an important aid in detecting asymmetry in the symphysis, body, ramus, and condyle of the mandible. In many cases of asymmetry, this view is important for evaluation of mandibular displacemen
Diagnostic Aids
{Study cast, Cast analysis}
Part (2)
Prepared by
Dr. Mohammed Alruby
Study cast
Definition: it is a positive replica of the teeth and their supporting structure, it should be reproducing accurately all the anatomical details of the teeth, alveolar process, mucobuccal folds, palate, frenal attachment as well as the exact relationship of the mandibular to the maxillary dental arch
Good models begin with good impression, orthodontic impression should displace the lips and cheeks, so that, the full depth of mucobuccal sulci is recorded. This over extension of impression is obtained by building up the tray periphery with wax or by using special orthodontic trays
The position of maximum intercuspation should be recorded by getting the patient to bite through softened wax, that is important for:
1- Recording the proper intercuspation specially in cases of poor occlusal fit due to extraction or tongue thrust. So it is wise to check the occlusion in the mouth and compare it to the occluded cast to insure that the model is correctly articulated
2- Trimming of the upper and lower cast together without change in occlusal relationship or fracture of teeth
Occlusal registration of wax bite:
= the position of maximum intercuspation as well as the centric relation must be registered
= a piece of soft wax large enough to cover the occlusal surface of maxillary teeth is shaped to the form of maxillary arch, then gently pressed against the maxillary teeth
= the patient instructed to relax and mandible is guided to most posterior and superior position of condyle within the glenoid fossa, while the teeth come into occlusion
= if there is shifting during closure due to cuspal interference, this mean that the occlusal position is not coincide with centric occlusal position, in this case, in this case two bites are taken one for usual occlusal position, and the other for centric occlusion
Ideal requirements of orthodontic study models:
1- They are symmetrical and pleasing to the eye and so that a symmetrical arch form can be readily recognized
2- The dental occlusion shows by setting the models on their backs
3- Clean, smooth, bubble free, with sharp angles where the cuts meet
4- Glossy in finish.
Trimming of study models:
There are two types of trimming:
a- Angle trimming:
The purpose of angle trimming is to added an appropriate proportional bases to the anatomical portion of dental casts which is important in:
- Registration of centric occlusion by having the posterior and lateral border of both casts on the same plane, so that cast may place on any side without change in its relationship
- Giving an idea about the relationship of the teeth to the alveolar process and basal bone
- Giving harmonizing appearance of the right and left sides of the cast which any a symmetry can be detected
- Detection of occlusion from any side, anterior as well as lateral sides
Principles:
1- The floor of the base is trimmed
diagnostic aids part 1 diagnosis, examination, BMR, EMG.docxDr.Mohammed Alruby
Introduction:
Proper treatment plane depends on prompt diagnosis, good clinician should have a bird’s eyes to first identify the problem and find its etiology
Definitions:
= Grabber and Rackosi: defined diagnosis as:
Recognition and systemic designation of anomalies, the practical synthesis of the finding, permitting therapy to be planned and identification to be determined
=a continuous evaluation process in orthodontics starting right from the first interaction with the patient continuing through different stages till end of treatment and course follow up visits
Goal of orthodontic diagnosis:
Is to produce a comprehensive description of the patient’s problem and then to synthesis the various elements of description into a rational problem list
Diagnostic aids:
Data required for orthodontic diagnosis are derived from routine essential diagnostic aids and also from supplemental aids when needed, Graber categorized the diagnostic aids into essential and supplemental aids
Essential:
- Case history
- Study models
- Certain radiographs: periapical, bite wing, panoramic radiograph
- Facial photographs
- Intra-oral photographs
Supplemental:
- Specialized radiographs: occlusal of maxilla and mandible, lateral cephalogram
- Hand &wrist radiograph
- Electromyography
- Endocrine test
- Basal metabolic rate
Case history:
Complete case history includes all the relevant information derived from the patient and parents and essential for planning
Personal details:
Name:
The patient’s name should be recorded for the purpose of identification and communications
Calling the patient by his/her name not only establishes a good report but also imparts confidence in the patient mind about treatment providers
In case of children, it might help to know their pet problems
Age:
= certain malocclusion occurring during growth period are transient and self-correcting
= growth modification procedures such as functional appliances can be carried out during growth periods
= surgical respective procedures such as orthognathic surgery are best carried out after cessation of growth
= chronological age is important for the maintaining of shedding and eruption time tables as well
Gender:
= recording gender of the patient is important for treatment planning, females are observed to precede males in growth related events such as onset of growth spurt, eruption of the teeth and onset of puberty
= gender may also have a bearing on patient’s compliance toward certain types of orthodontic treatment
Occupation and address:
Occupation of patient / or parents gives an idea about socioeconomic condition which might affect the selection of orthodontic appliances and can give an idea about awareness
Address of patient determine the sociality of the patient and this effect on the treatment because some countries have normally bi-maxillary protrusion and also determine the awareness of patient about treatment and oral hygiene
Patient behavior:
Behavior of patient depend on: patient
Smile: is the most pleasant and wanted expression by each one of us.
Smile: is amused facial expression with the corner of mouth turned up and exposed front teeth
Facial expression, postures of lips, occlusion and arrangement of teeth, buccal corridor, shape of teeth, gingival color, texture, contour and other several aspects constitute component of smile
Most of patients come to us to improve their smiles, the orthodontic studies stress on skeletal structure than soft tissue structure, and the smile still receives relatively little attention
Nature of smile:
1- Posed smile: voluntary, static, sustained, social smile not elicited by an emotion
2- Un-posed smile: spontaneous, involuntary, dynamic, natural, and not sustained characterized by greater lip elevation
Smile types: smile styles:
1- Commissures smile: the corner of the mouth turned upward called Monalisa smile
2- Cuspid smile: the upper lip is elevated, the entire lip rises like a window shade
3- Complex smile: the upper lip moves superiorly as in cuspid smile and lower lip moves inferiorly
Evaluation of posed smile:
variables Normal smile Not good smile
Smile arc Consonant Non consonant
Smile index Average Increased / decreased
Morley’s ratio 75 – 100% (normal) Disturbed
Buccal corridor Average Obliterated / excessive
Smile line Average High / low
Occlusal plane No canting Canting occlusal plane
Important definitions:
Smile arc:
the curvature formed by an imaginary line tangent to the incisal edges of the teeth, modified in varying degree of curvature in relationship to the lower lip
Range: from no curvature to an accentuated curvature was in relation to the lower lip, so quantification differed for each model
Buccal corridor:
the amount of dark space displayed between the facial surfaces of the posterior teeth and the corner of the mouth, calculated as the total dark space on both sides of the mouth as a percentage of the total smile width
Range: from 6% to 26.5 in approximately 0.5% increments
Maxillary gingival display or gummy smile:
The amount of gingival show above the central incisor crown and below the center of the upper lip. Negative number indicate gingival exposure. Positive number indicate tooth overlap by the lip
Range: from 1mm of gingival display (-1) to almost 7mm of tooth coverage for the female models, and approximately 2mm of gingival display (-2) to 6mm tooth coverage for male models
The variation between the models was due to differences in sizes and coordinating the images for different faces
Maxillary midline to face:
The relationship of maxillary dental midline (measured between the central incisors) to the midline of the face, defined by the center of the philtrum and the facial midline
Range: the maxillary midline was moved to the left of the face in approximately 0.25 mm increments. The right and left buccal corridor was maintained throughout the movement of the dentition. The maximum deviation show is 6mm
Maxillary to mandibular mid
orthodontic biology of tooth and supporting structure.docxDr.Mohammed Alruby
The goal is to examine the relationship between orthodontic biomechanics and the underlying biological process
When orthodontic force is applied to the crown of the tooth it is transmitted through the roots to the periodontal ligament and alveolar bone
Histology of supporting structure:
- Periodontal ligament
- Alveolar bone
I- Periodontal ligament:
A- Cellular component:
• Forming cells:
Osteoblast: bone forming cells
Fibroblast: PDL fibers forming cells
Cementoblast: in layer adjacent to the roots
• Resorptive cells:
Osteoblast: large cell rich acid phosphatase enzyme that demineralize the bone and disintegrate of organic matrix
Fibroblast: disintegrate fibers
Cementoblast: resorb cementum
• Progenitor cells: undifferentiated mesenchymal cells UMC: small cells with closed nucleus and little cytoplasm & monocytes
• Epithelial rest of malassez: arise as a result of breakdown of epithelial root sheath at the time of cementogesis
• Defensive cells: as macrophages & mast cells
B- Periodontal fibers:
1- Collagen fibers:
the main bulk of PDL fibers and found in 5 groups:
- Alveolar crest group: from cervix to alveolar crest
- Horizontal group: from cementum to bone horizontally
- Oblique group: the main attachment that run obliquely from cementum to bone in an apical direction
- Apical group: circumscribed the apex and responsible for resistance to rotation
- Inter-radicular group: inter-mediate plexus, observed midway between bone and root
- Supra-alveolar group:
Dento-gingival
Dento-periosteal
Transeptal
Circular
Alveolo-gingival
2- Oxytalan fibers:
Immediate elastic fibers that resist dissolution by acids unlike collagen
Run from cementum or bone to blood vessels
Play a role in supporting the blood vessels against distortion and compressive strain
c- Ground substances:
organic matrix surrounding the PDL elements, it is chemically composed of CHO linked with protein. CHO- protein complex commonly divided into two groups: proteoglycan and glycoprotein
ground substances of periodontal ligament is in a continuous state of remodeling process
d- Neurovascular elements:
myelinated: pain sensation
non-myelinated: blood vessels wall
PDL functions:
- Supportive
- Nutritive
- Remodeling
- Sensory
II- Alveolar bone:
= in human, marrow spaces are rare in the buccal and lingual plates, these spaces decreased with age
= wider spaces are lined with a layer of fenestrated compact bone when PDL fibers are anchor these fibers is called bundle bone
N: B:
= collagen turn over in PDL is higher 4 times than skin and 2 times than gingiva and this due to the forces in PDL is multi-directional takes vertical and horizontal component
= lake of marrow spaces implies that bone resorption takes more time so that the tooth movement in mesial and distal direction occur more than labial and lingual sides
= the resorptive cells increase as the marrow spaces increase
N: B:
The new deposited tissue during tooth migration have 3 stages:
Stage I osteoid:
is the pr
Successful infection prevention program
A successful infection prevention program depends on:
1-Developing standard operating procedures.
2- Evaluating practices and providing feedback to dental health care personnel (DHCP).
3- Routinely documenting adverse outcomes (e.g., occupational exposures to blood) and work-related illnesses in DHCP.
4- Monitoring health care associated infections in patients.
Standard Precautions
Standard Precautions: are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where health care is delivered. These practices are designed to both protect DHCP and prevent DHCP from spreading infections among patients.
Standard Precautions include:
1- Hand hygiene.
2- Use of personal protective equipment (e.g., gloves, masks, eyewear).
3- Respiratory hygiene / cough etiquette.
4- Sharps safety.
5- Safe injection practices (i.e., aseptic technique for parenteral medications).
6- Sterile instruments and devices.
7- Clean and disinfected environmental surfaces.
Each element of Standard Precautions is described in the following sections. Education and training are critical elements of Standard Precautions, because they help DHCP make appropriate decisions and comply with recommended practices.
1- HAND HYGIENE:
1- Perform hand hygiene.
a. When hands are visibly soiled.
b. After bare hand touching of instruments, equipment, materials, and other objects likely to be contaminated by blood, saliva, or respiratory secretions.
C. Before and after treating each patient.
d. Before putting on gloves and again immediately after removing gloves.
2. Use soap and water when hands are visibly soiled (e.g., blood, body fluids); otherwise, an alcohol-based hand rub may be used.
2- PERSONAL PROTECTIVE EQUIPMENT (PPE):
1- Provide sufficient and appropriate PPE and ensure it is accessible to DHCP.
2- Educate all DHCP on proper selection and use of PPE.
3- Wear gloves whenever there is potential for contact with blood, body fluids, mucous membranes, non-intact skin or contaminated equipment.
a- Do not wear the same pair of gloves for the care of more than one patient.
b- Do not wash gloves. Gloves cannot be reused.
c- Perform hand hygiene immediately after removing gloves.
4- Wear protective clothing that covers skin and personal clothing during procedures or activities where contact with blood, saliva, or OPIM (other potential infectious materials) is anticipated.
5- Wear mouth, nose, and eye protection during procedures that are likely to generate splashes or spattering of blood or other body fluids.
6- Remove PPE before leaving the work area.
3- RESPIRATORY HYGIENE / COUGH ETIQUETTE:
1- Implement measures to contain respiratory secretions in patients and accompanying individuals who have signs and symptoms of a respiratory infection, beginning at point of entry to the facility and conti
The way to infection control in dental clinics
Introduction:
The unique nature of dental procedures, instrumentation and patient care settings require specific strategies directed to the prevention of transmission of diseases among dental health care workers and their patients.
Disease: impairment of normal functioning, manifested by signs and symptoms.
Infection: state produced by an infected agent in or on a suitable host, host may be or may not have signs or symptoms.
Carrier: individual harbors the agent but does not have symptoms (person can infect others).
Factors that allow or aid infection:
= The presence of pathogenic micro-organisms.
= There must be a portal of entry via which the organisms invade and colonize the susceptible host.
Medical history
A thorough medical history should be taken and up-dated at subsequent examinations. Medical history screening is essential in alerting the clinician to medical problems that could, in conjunction with dental treatment, adversely affect the patient.
Protective measures
Protection can be achieved by a combination of immunization procedures, use of barrier techniques and strict adherence to routine infection control procedures.
(a) Immunization:
All dental health care workers are advised to be immunized against HBV unless immunity from natural infection or previous immunization had been documented
(b) Protective coverings:
=Uniforms:
Uniforms should be changed regularly and whenever soiled. Gowns or aprons should be worn during procedures that are likely to cause spattering or splashing of blood.
=Hand protection:
Gloves must be worn for procedures involving contact with blood, saliva or mucous membrane. A new pair of gloves should be used for each patient.
If a gloves damaged, it must be replaced immediately. Hands should be washed thoroughly with a proprietary disinfectant liquid soap prior to and immediately after the use of gloves.
Disposable paper towels are recommended for drying of hands.
Any cuts o abrasions on the hands or wrists should be covered with adhesive waterproof dressings at all times.
=Protective glasses, masks or face shields Protective:
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1. 1
Dr. Mohammed Alruby
Class III malocclusion
Prepared by:
Dr Mohammed Alruby
الباطل بين المعركه تكون عندما فضيله الحياد
ولكن والباطل
بين المعركه تكون عندما جريمه الحياد يكون
والباطل الحق
2. 2
Dr. Mohammed Alruby
Introduction
Types
Factors affect development of class III
Differential diagnosis
Objective treatment and its limitation
Principle of treatment
Treatment mechanics
Classification of class III
Treatment of maxillary deficiency
Treatment of mandibular excess
Camouflage treatment of class III
Treatment approach for camouflage treatment
Growth modification of class III malocclusion
Treatment of modifications modalities
3. 3
Dr. Mohammed Alruby
Introduction:
= According to Angle, class III is a type of malocclusion in which the lower molars and dental
arch occludes mesial to the maxillary one
= Lisher introduce the term malocclusion for Angle class III
= the unilateral arrangement of class III is called class III subdivision
Prevalence:
Class III is the least common type of malocclusion in many communities occurring less than 5% in
British population, ((Foster and Day 1974)) 5: 10 % among European population, this ratio tends
to increase by age
= also class III show racial variation, it was about 1% among Jewish and 7% among American
negro
= although class III is infrequent but it presents the most difficult treatment in orthodontic practice
= it is probably true to say that greater proportion of class III are beyond correction by orthodontic
treatment (Foster)
Types of class III: Moyers types:
There are three distinct types of class III or mesio-occlusion
1- True Angle class III, skeletal type:
It is skeletal dysplasia involving mandibular hypertrophy, or deficient midface or both
This type is called skeletal class III
2- Pseudo class III or apparent class II:
It positional mal-relationship, reflex functional mandibular protraction
3- Dental class III:
It is an abnormal axial inclination (lingo-version) of maxillary incisors with no real class
III features
The main etiologic factors influencing development of class III:
1- Skeletal factors:
a- Anterior posterior discrepancies:
Position:
The upper jaw is positional backward in relation to the lower jaw or in relation to the cranial base
The lower jaw is positional forward in relation to the upper jaw or in relation to the cranial base
Size:
The upper jaw is too small; the lower jaw is normal
The upper jaw is normal; the lower jaw is too large
The upper jaw is small and the lower jaw is large
b- Lateral discrepancies:
Responsible for buccal cross bite associated with class III which may be unilateral or bilateral
Discrepancies in relative width of upper and / or lower arch may cause unilateral or bilateral
cross bite
Narrow maxilla or wide mandible or both, also the lateral discrepancies may be sequelae for
anterior posterior discrepancies, for example when the maxilla too small, it will be collapsed and
does not diverge posteriorly resulting in posterior cross bite
c- Vertical discrepancies:
It is responsible for the degree of over bite or open bite that may accompanied the skeletal class
III
4. 4
Dr. Mohammed Alruby
Maccollin 1955 divided class III according to facial height and value of gonial angle into 2 groups
- Group 1: characterized by
short maxilla
large mandible
increased facial height
high gonial angle
presence of some degree of open bite
- Group 2: characterized by:
Normal maxilla
Large mandible
Normal or reduced facial height
Normal or reduced gonial angle
Presence of some degree of deep reversed bite
= the skeletal factors determine the severity of the occlusal problem and provide the main
limiting factors for treatment
2- Dental factors:
Premature loss of deciduous molars:
May be responsible for production of pseudo class III
The loss of deciduous molar in a critical period of development cause the patient to protrude his
mandible to cut and eat foods on his frontal teeth, so that the lower incisors teeth slide over the
labial surface of maxillary one, causes retroclination of maxillary incisors and proclination of
mandibular incisors with the development of anterior cross bite and deep reversed over bite which
exaggerated by mandibular over closure
3- The muscular factors:
In pseudo class III, the normal muscle reflex acts to maintain the mandible in protruded position
The large tongue plays a part in protruding an open bite in cases of small maxilla
4- Hereditary:
Skeletal class III shows functional tendency, the classic example is the Hapsburg family
Diagnostic criteria
Extra-oral examination:
1- Profile: straight or concave
2- The vertical facial balance:
Sassoni classified class III inti two groups;
- Class III open bite cases: in such cases, there is an increased in the lower anterior facial
height, large gonial angle, presence of open bite
- Class III deep bite cases: characterized by: reduced lower anterior facial height and low
gonial angle, presence of deep bite
Among the above 2 groups there is a variety of class III may be present
3- Size and position of maxilla:
In some cases, the maxilla is normal, the mandible is long and Prognathic, but in some times
there is a combination of small retrognathic maxilla and large Prognathic mandible may
be found
5. 5
Dr. Mohammed Alruby
4- Soft tissues:
Lips:
In classic Hapsburg family the upper lip is short and lower lip everted
In most cases the lips are sealed together at rest except in class III open bite combination
where’s the lips may be a part in such cases the gingiva will exposed on smiling
Chin:
The chin is prominent and printed in class III open bite, prominent and round in class III
deep bite
Intra-oral examinations:
Tongue size:
In class III, the tongue usually matches the size of lower arch, in most cases the tongue is large
and may cause opening of mandibular incisors
Tongue position:
In case of large tongue, wide mandible, small deficient maxilla, the tongue usually occupies a low
posture
Tongue behavior:
As a result of its large size and its low posture, it will behave abnormal function
It may thrust between the upper and lower incisors during rest and swallowing causing an anterior
open bite, in addition the lack of its molding effect on the palate, may produce narrow maxilla and
high V shaped palatal vault
The large tongue in class III cases present a major limiting factors in reducing the lower parameter
by retroclination of mandibular incisors
Gingiva:
Gingival recession and periodontal disease are often seen in the lower anterior segment due to
cross bite and disuse atrophy of the gingiva
Dental examination:
Angle classification: the lower dental arch and the body of the mandible occlude mesial to the
maxillary one
Overjet:
Reversed in most cases, it may be zero in edge to edge bite cases
Overbite:
Reversed in most cases
Cross bite:
There may be edge to edge bite or anterior cross bite. Posterior cross bite is also common which
may be unilateral or bilateral
Missing teeth and impaction:
In cases of deficient, the maxilla is narrow, collapsed and there may be congenital missing of
lateral incisors and 2nd
bicuspid and impaction of cuspids and third molars is common. There is
commonly seen in cleft palate cases
On the other hand, the lower arch is wide, the lower teeth are normally aligned, the lower 3rd
molars are rarely impacted
Mandibular path of closure from rest position to occlusion:
= in class III cases the path of mandibular closure from rest position to occlusion is primarily
straight however forward displacement of mandible may occur due to over closure particularly in
pseudo class III where the loss of deciduous molars and sliding of mandibular incisors on the
labial surface of maxillary one facilitate over closure and forward displacement of the mandible
6. 6
Dr. Mohammed Alruby
= in cases of narrow maxilla some lateral shift to the right or to the left may occurs, this shift
developed early due to premature contact at the area of deciduous canine
Habits:
Thumb and finger sucking:
Thumb sucking in class III may be helpful rather than hindering factors, thumb sucking maintains
the upper incisors over the lower one despite of class III relationship and thus prevent development
of anterior cross bite and prevent occurrence of pseudo class III malocclusion
But in sometimes it is responsible for production of anterior open bite particularly in class III open
bite tendency
Tongue thrust:
As mentioned before, when the maxilla is narrow and collapsed the tongue assumes a lower
position and may be thrust between the upper and lower incisors ----------- anterior open bite
Class III due to micro-maxilla:
- Narrow collapsed maxilla with high palatal vault
- Crowding of maxillary incisors
- Impaction, congenitally absence of teeth particularly in cleft palate cases
- Narrow nasal aperture
Class III due to macro-mandible:
- The lower lip is tight against the mandibular incisors, tipping them lingually
- Edge to edge bite or anterior cross bite
- Symphysis is high and narrow
- The chin is pointed and prominent
- Long styloid processes are found
- The mandibular dental arch is wide and mandibular teeth are well aligned – impaction of
lower 3rd
molars rarely occurs
- Gingival recession and periodontal disease of lower anterior segment
Class III with open bite:
- Is primarily open bite with palatal deficiency or large mandible
- This combination has the most worse prognosis: if correction of open bite attempted by
rotating the mandible upward, the chin protrusion will increase, on the other hand, if
correction of class III is attempted by rotating the mandible downward and backward, the
open bite will increase
- Even surgery in such cases is of little value because the posterior teeth will be interfering
with closing the lower face height
- Probably combined prosthetic and surgical approach would be indicated
The alternative treatment: Lefort I for impaction of maxilla and surgical rotation of the mandible
followed by orthodontic treatment
Class III with deep bite:
- It is primarily deep bite associated with small maxilla and / or large mandible, this
combination has probably favorable prognosis
- If the maxilla is deficient, the opening of mid palatal suture by rapid maxillary expansion
may be provides satisfactory enlargement of maxilla
7. 7
Dr. Mohammed Alruby
- If the mandible is Prognathic, it is downward and backward rotation may reduce class III
and deep bite at the same time
Cast analysis
a- Upper arch:
If class III occurs due to deficiency in maxilla, the maxilla appears narrow tapered, collapsed with
high V shaped palatal vault
Crowding of maxillary incisors is common features
Retroclination of maxillary incisors
On the other hand, the maxilla may be of normal size in such cases the mandible will be larger
than normal, in both cases crowding is common features in maxilla also retroclination of maxillary
incisors
b- Lower arch:
In cases of deficient maxilla, the lower arch is of normal size, the lower teeth are well aligned and
rarely crowded, in case of large mandible and large tongue, spacing of lower incisors can be seen
The lower anterior teeth are proclined in case of cross bite, but may be retroclined in true class III
malocclusion due to hyper active mentalis muscle, this commonly seen in edge to edge bite cases
Cephalometric analysis
SNA: may be normal or reduced
SNB: may be normal or increased
ANB: less than 2 degree or reduced
SN –pog: usually increased due to chin prominence or more than 80 degree
Facial angle; increased
Angle of convexity: reduced to negative value
Gonial angle: increased in class III open bite cases and normal or less in class III deep bite cases
FMP: as in gonial angle
U1 to FH: reduced
L1 to MP: increased
U1 to L1: increased
According to Sassoni:
- Class III patient having a small cranial base angle bringing the glenoid fossa and condyles
more anteriorly relative to sella turcica
- Class III may be associated with deficient maxilla or large mandible (small SNA or large
SNB)
- Larger gonial angle and steep mandibular plane resembling an open bite cases
- The palate is tipped upward posteriorly and downward anteriorly
1- Pseudo class III:
Shows normal values for the basic skeletal criteria.
Lateral cephalogram should take for such patient with condyles in most retruded position within
the glenoid fossa using wax bite insitue
There is a mild deficiency in maxillary dento-alveolar length can be seen in the profile analysis,
this due to retroclination of maxilla, there is mild skeletal class III relationship
The vertical analysis will be normal
2- Skeletal class III:
a- Midface deficiency:
8. 8
Dr. Mohammed Alruby
Cephalometric analysis of such cases display the following morphologic criteria:
- Class III maxilla-mandibular relationship
- Reduced SNA angle
- Normal SNB angle
- The profile analysis shows maxilla and normal mandibular length but the mandibular
dento-alveolar unit may be increased due to proclination of mandibular teeth
- vertical analysis demonstrates normal lower face height but mildly deficient upper face
height and maxillary height
b- mandibular prognathism:
such as display the following cephalometric criteria:
- normal SNA angle
- increased SNB angle
- decreased cranial base angle
- increased face height
- normal upper face height
- in severe mandibular prognathism there may be an increase in maxillary dento-alveolar
unit by tipping of maxillary incisors labially to obtain function with the excessively
protruded mandibular incisors
- large gonial angle and steep mandibular plane
c- mid face deficiency and mandibular prognathism:
it is combined type for which treatment is differ and prognosis is somewhat better than serious
mandibular prognathism.
Differential diagnosis of class III
= true class III should differentiate from pseudo class III, the patient should examine for the
following items:
1- profile: it is concave in both types, but is improved as the mandible drop from occlusal to
rest position only in pseudo class III
2- TMJ palpation: palpation by tip and index finger during opening and closure is diagnostic,
the condyles are felt outside the glenoid fossa during closure in pseudo class III cases
3- Path of mandibular closure: there is forward displacement, over closure and sometime
lateral shifting of the mandible from rest to occlusion in pseudo class III
4- Molar relationship: in true class III malocclusion, there is a distinct class III relationship
in both postural and occlusal position, while in pseudo class III, there is shift from class I
in postural position to class III in occlusal position
5- The child with pseudo class III can be forced to bite back in edge to edge bite which is
impossible for true class III cases
6- In case of pseudo class III there is reversed deep bite and mandibular overclosure, there is
also anterior cross bite
** Mc callin 1955 differentiate 3 types of class III malocclusion:
Type 1 deficient maxilla:
- Small maxilla
- Increased anterior facial height
- Long mandible with high FMP and gonial angles
- Tendency toward open bite
Type 2: mandibular prognathism:
9. 9
Dr. Mohammed Alruby
- Normal maxilla but long mandible
- There is true mandibular prognathism
- Normal or low FMP and gonial angles
Type 3: pseudo class III:
- History of premature loss of deciduous molars
- Mild skeletal class III pattern
- Reversed deep bite and mandibular overclosure
- Anterior cross bite
- The condyles can felt outside the glenoid fossa
- The patient can bite back into edge to edge bite
Factors affect treatment planning of class III
1- Skeletal relationship, incisal inclination and overjet:
Careful assessment of skeletal relationship, incisal inclination and overjet is very important to
determine the type of tooth movement that used either tipping or torque movement
For example: if the case is dental class III on skeletal class I or mild class III with small reversed
overjet and minimal incisor inclination, the tipping movement of upper incisors forward and / or
the lower incisors backward and may be quite sufficient to correct the incisors relationship while,
in sever class III cases where there is a large reversed overjet, tipping movement of incisors is
unsatisfactory and greater inclination of incisors is required to correct the condition.
So the torque or bodily movement is required, on the other hand if bodily movement of incisors is
fails to overcome the effect of skeletal discrepancy, the condition is beyond the scope of orthodontic
treatment and surgical re-positioning of the jaws is required
2- Incisor overbite:
Incisor over bite is important to determine type and direction of the tooth movement, possibility
and prognosis of orthodontic treatment
1st
condition:
Case with deep reversed over bite and small reversed overjet can be treated by simple tipping of
upper incisors forward and / or lower incisors backward
The prognosis is good
2nd
condition:
Case with edge to edge bite, tooth movement is preferred to be bodily, because tipping movement
of incisors tend to open the bite. Some extrusion is required to obtain normal overbite
3rd
condition:
Case with minimum to moderate open bite
Bodily movement and extrusion are required
4th
condition:
Case with severe anterior open bite
The problem may be beyond orthodontic treatment and required surgical intervention
3- Tongue size and function:
Tongue size is important to determine whether the mandibular incisors can be retroclined during
treatment or not, and whether the lower arch parameter can be reduced or not
Assessment of tongue size and function determines whether there is physical barrier against
correction of anterior open bite
10. 10
Dr. Mohammed Alruby
4- Crowding or spacing:
In upper arch crowding is common finding, assessment of the degree of crowding is important to
determine the mode of space creation
In cases of minimum crowding expansion is sufficient to relieve crowding, but in cases of severe
crowding, extraction of U5 may be necessary but as a general rule, extraction in the upper arch
should be avoided and if necessary should be delayed after expansion and re-evaluation
== crowding is less common in the lower arch but if extraction of L4 is occurs with construction
of maximum anchorage is necessary
== if the lower arch is spaced, this indicate large size of tongue and extraction is contraindicated
because the suspected failure in space closure
Objectives of treatment and its limitation
1- Correction of crowding:
== upper arch:
In class III cases, crowding is common finding in the upper arch, as a general rule, extraction in
the upper arch in class III cases should be avoided as possible, but if should be carried as in cases
of severe crowding, it should be delayed as far back as possible, until correction of incisors
relationship is completed. Then the case is re-evaluated, if crowding is so great the extraction of
U5 is done and relief of crowding takes place.
The rest of extraction space can be closed by bringing the maxillary 1st
molars forward using class
III elastics, this also help in correction of anterior posterior molars relationship
Mild and moderate crowding: of upper arch can be relieved by enlarging the maxilla through
expansion using palatal spring, S spring or expansion screw
== lower arch:
Crowding of lower arch is not common but if present, extraction of 1st
premolar or even incisors
can be done to relief crowding and if possible to reduce the anterior posterior dimension of the
lower arch
The major limiting factor to do this is the large size of tongue which prevent retraction of
mandibular anterior segment, and cases failure in closure of the extraction space. So the careful
assessment of the tongue size should be made before taking such decision
2- Correction of reversed overjet (anterior cross bite):
Correction of reversed over jet or anterior cross bite can be carried out by proclination of
maxillary incisors and / or retroclination of mandibular incisors
The major limiting factors to this correction are:
- Anterior posterior jaw relationship
- Presence of open bite
- Large tongue
In more severe skeletal class III discrepancies, the incisors cannot move sufficiently to overcome
the effect of dental base relationship
In the presence of open bite, even if the incisors moved sufficiently to produce correct incisors
relationship they will not be mentioned in that position without a positive incisal overbite, so that
open bite could be causes relapse of the condition
Finally, the tongue may be interfering with retroclination of mandibular incisors and this prevent
any corrective treatment.
3- Correction of incisal overbite:
11. 11
Dr. Mohammed Alruby
a- Correction of deep reversed bite:
Depends mainly on the correction of reversed overjet
If the incisors can be placed in correct anterior posterior relationship during growth period, the
deep bite can be reduced into a normal value by vertical development of buccal dento-alveolar
segments
b- Correction of anterior open bite:
It is much more difficult and limited by: tongue size and behavior, vertical dimension of the face
A minor degree of open bite may be corrected by extrusion of upper and / or lower incisors
Severe anterior open bite is a result of skeletal discrepancy and cannot be treated by orthodontic
alone
4- Correction of buccal segment relationship:
a- Anterior posterior relationship:
If being necessary the correction of molar relationship, can be achieved by moving the maxillary
1st
molars forward into the extraction space of U5 (in case of U5 extraction for correction of severe
maxillary crowding using inter-maxillary class III elastics)
But in cases of mild to moderate crowding which can be relieved by expansion
Extraction should be avoided and it is thought un-necessary to correct the anterior posterior
molars relationship. The limiting factors is the degree of anterior posterior skeletal discrepancies
b- Correction of buccal cross bite:
1- Unilateral cross bite:
Slight narrowness of the maxillary arch may result in unilateral buccal cross bite. It is desirable
to correct unilateral cross bite which involve initial premature contact and causes deviation in the
path of mandibular closure (translocated closure). Lateral expansion of upper arch may correct
the case
2- Bi-lateral cross bite:
In cases of narrow collapsed maxilla where there is bilateral cross bite, the dento-alveolar
maxillary expansion is unsatisfactory because it cannot compensate the lack of width of maxillary
base (lateral skeletal discrepancy) so, it is thought that: bilateral symmetrical cross bite in which
the mandibular closure is not deviated are often accepted.
The rapid maxillary expansion by splitting of mid-palatal suture is satisfactory
Early treatment of class III
1- Treatment of pseudo class III:
= The main objectives in the treatment of postural class III is the correction of incisors
relationships and prevent translocated mandibular closure.
= In primary dentition and early mixed dentition, pseudo class III can be treated by occlusal
equilibration and restoration of missing deciduous molars
Steps and purpose of occlusal equilibration:
First locate and removes all teeth interferences, this may involve grinding of primary teeth and
moving of permanent teeth which causes interference.
This important to removing of all areas of premature initial contact which may causes translocated
mandibular closure and / or lateral deviation of the mandible. Grinding takes place by using of
articulating papers and abrasive stone and it is better to try it first on the dental cast.
Do not grind the permanent teeth in mixed dentition but it is better to be moved orthodontically
since the areas removed may be needed later for the occlusal stability after growth is completed
12. 12
Dr. Mohammed Alruby
= the results of this treatment is satisfactory in primary dentition but less favorable in mixed
dentition
**** If the results of occlusal equilibration are unsatisfactory we can use alternative mechanics:
= Again we say the main objectives is to move the maxillary incisors forward and / or the
mandibular incisors backward. Which teeth should be moved is depend upon the axial inclination
of incisors
Proclination of maxillary incisors:
= This can be achieved by using of removable maxillary appliances involving palatal spring, S
spring, or expansion screw
= Addition of acrylic posterior bite plane is necessary to open the bite anteriorly
Retroclination of mandibular incisors:
= This can be done by using of short labial arch on mandibular incisors or by using of fixed
appliance utilizing inter-maxillary traction
= There must be sufficient space for retroclination of mandibular incisors and the limitation
caused by tongue must born in mind
= Another form of mechanics is using of inclined plane fixed on mandibular incisors and using
maxillary short labial arch to prevent forward movement of maxillary incisors
Proclination of maxillary incisors and retroclination of mandibular one at the same time:
= This achieved by using inclined plane as acrylic inclined plane that cemented on the mandibular
incisors using a stiff mix of zinc oxide eugenol
= on closing the mouth, the mandible is forced to be retruded and thus the mandibular incisors
move lingually and the maxillary incisors moves labially
= the level of appliance should be ground carefully so that all teeth are in even contact with it, this
permit an even distribution of load and prevent traumatic occlusion.
= periodic observation of the appliance is necessary for this purpose; the child is instructed to eat
semisolid foods for at least one week
= if marked improvement not seen quickly with 3 weeks, the case must be re-assessed for mis-
diagnosis
Remember:
The continuous forward mandibular displacement due to pseudo class III if untreated early, it will
enhance mandibular growth at the condyles resulting in mild class III skeletal pattern in
adolescent, so that the treatment is more difficult in older children
2- Treatment of mid face deficiency:
The early treatment of mid face deficiency can be achieved by using functional appliance which
produce satisfactory results in many cases. In mid face deficiency ------- Frankel functional
regulator III or reversed activator can be used
** Levin et al reported patient treatment from skeletal and dental class III by full time wear 2 -5
years and retention for 3 years has a significant change in maxillary and mandibular position with
more lingual tipping in lower incisors
== In severe mid face defect Delaire face mask is the appliance of choice
Good results can be obtained by this device which translate the maxilla forward, improve the
skeletal profile and restrain mandibular growth
With splint attached to maxillary arch, the success of treatment is declined at age 10 to 13 years
of age
13. 13
Dr. Mohammed Alruby
** suited in children with minor to moderate skeletal problem, it is better to delay the maxillary
protraction until molars and incisors can involve in anchorage
** do maxillary expansion if needed, there is no reason to expand maxilla just to improve
protraction
** the maxillary splint has hooks for attachment to face mask that is located at canine – primary
molars area above the occlusal plane, so the force vector near the center of resistance of maxilla.
Force 350 -450 gm / side for 12 to 14 hour /day
** in some cases need slight downward direction of elastic traction to improve the vertical defect
N: B:
Types of face mask:
- Delaire type: offer good stability, more bulky and can cause problem during wearing eye
glass and sleeping, appear to be ill fitted to face
petit type: more comfort during sleeping, less difficult to adjust
3- Treatment of mandibular prognathism:
In mild cases, the following appliances can be used:
a- Frankel regulator III or reversed activator: that designed to rotate the mandible downward
and backward and guide eruption of teeth, so that the upper posterior teeth erupt downward
and forward while eruption of lower teeth is restrained
= rotate the occlusal plane to direction that favor correction of class III
= bite registration done on mandible is in most retruded position
b- Chin cup:
= Extra-oral force is directed against mandibular condyle
= rotate the mandible downward and backward which can lead to increase in facial height
= strep can directed in several direction according to the type of malocclusion
= it has limited application because most of patient need surgery
Graber reported that the use of chin cup utilizing heavy extra-oral traction on mandible has the
following advantage:
- Rotate the mandible posteriorly
- Restrict the vertical condylar growth
- Decrease the gonial angle
- Slightly rotate the corpus of maxilla clock wise
The results are the improvement of skeletal profile and maintain of FMP angle within normal range
c- Reversed activator:
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Dr. Mohammed Alruby
This design rotates the mandible posterior and redirect the horizontal mandibular growth into
more vertical direction, so that reversed activator is suitable for correction of class III deep bite
4- Treatment of combined mid face of the mandible:
It is less difficult than mandibular prognathism alone. Devices which combines the mid face
retraction and mandibular retraction can be used as:
- FR III
- Activator – reversed
- Face mask
- Chin cup
Treatment of class III in adolescence
The general strategies for treatment of class III in adolescence includes:
- Forward displacement of mid face
- Inhibition of mandibular growth
- Redirection of mandibular growth
- Dental and alveolar repositioning
1- Treatment of mid face deficiency:
In mild case: Delaire suggested the use of face mask attached to fully banded maxillary arch to
apply heavy protraction force to produce forward mid face displacement
The direction of force is determined by steepness of occlusal and mandibular planes
In severe cases: surgical repositioning of maxilla is indicated
2- Correction of mandibular prognathism:
It is more severe problem than mid face deficiency, the treatment planning depends on the vertical
skeletal morphology of the face
In mild cases:
= When the freeway space is larger and the mandibular plane in not steep, the mandibular
prognathism can be treated by redirection of mandibular growth, dento-alveolar repositioning or
even face mask therapy. The lip length and function are important consideration in reducing the
vertical growth.
= Grabber reported success with chin cup treatment in mild class III in adolescence
= Combined FRIII or reverse activator with fully banded appliance in both arches is useful only
in mild cases
= Correction of mild to moderate class III in adolescence also can be achieved by fixed appliance
utilizing inter-maxillary class III traction to move the maxillary teeth forward and the mandibular
teeth backward
In severe cases:
Surgical repositioning of the mandible can be carried out
3- Combined mid face deficiency and mandibular prognathism
Combined treatment utilizing maxillary protraction and mandibular retraction as; FRIII or
reversed activator, face mask, and chin cup can be used in mild cases
Surgical correction repositioning of both arches is indicated in severe cases.
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Dr. Mohammed Alruby
Camouflage treatment of class III
These class III patients that often passed their pubertal growth spurt and major growth component
is completed. Skeletal deformity from mild to moderate, this treatment can also be used in mild
open bite cases
Factors affect camouflage treatment:
1- Growth:
After finishing of growth stage and all treatment need pass the growth period, the cases require
non- surgical treatment approach or extraction approach
2- Limitation of tooth movement:
In cases of class III malocclusion: dental compensation occurs mask the severity of underlying
skeletal discrepancies, so non-extraction treatment will enhance the dental compensation that can
affect the general condition
Excessive proclination of maxillary incisors and lingual tipping of mandibular incisors could result
root to close to palatal and labial alveolus which could compromise periodontal health
3- Psychology, treatment coast and relapse:
Camouflage treatment should consider patient willingness, motivation and expectation
Patient should a ware about the economies of treatment and expectation of limitation of results
Cases good for camouflage treatment:
1- Class III with mild to moderate severity
2- Absence of skeletal facial a symmetry
3- Hypodivergant class III pattern
4- Lack of posterior cross bite or mild posterior cross bite
5- Subjects who have passed the active growth period for orthopedic treatment of maxillary
protraction and chin cup therapy
6- Presence of good alveolar bone support in mandibular anterior symphysis and maxilla to
accommodate mandibular anterior retroclination / maxillary anterior proclination
Cases who not good for camouflage treatment:
1- Acute naso-labial angle which indicate further proclination of maxillary anterior could
worsen the profile
2- Limited possibilities of further retroclination of mandibular incisors
3- Large negative overjet
4- Class III genetic etiology because high tendency for relapse
5- Patient with skeletal facial a symmetry
6- Open gonial angle and open bite cases
Treatment approach for camouflage treatment:
1- Non-extraction approach;
Is used for cases that have minor crowding that can be resolved easily by arch expansion or
incisors proclination
- Expansion in both arches
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Dr. Mohammed Alruby
- Proclination of incisors
- Distalization of lower arch
- Using MEAW technique: this is Multiloop edge wise arch wires, that produced by Kin 1987
this arch wire has horizontal and vertical loops that allow more flexibility to the arch wire
which permit horizontal positions
2- Extraction approach:
Extraction is planned to allow relief of crowding and correction of negative overjet and overbite
Choice of extraction:
- Mandibular incisors:
In case of minor crowding or Bolton discrepancy but need to mismatch the midline between upper
and lower—lower bonded retainer is indicated
- Upper 2nd
premolars and lower 1st
premolar:
Classic form of extraction in class III case to allow relief of crowding and correct molar
relationship
- Only lower 1st
premolars
- Mandibular 2nd
molars:
That allow significant distal movement in lower arch by using intra-oral implant or by using
headgear cervical
Advantages:
1- Rapid eruption of 3rd
molars
2- Prevent late incisors crowding
3- Reduce the quality and duration of therapy with fixed appliance
4- Facilitate distal movement of 1st
molars and anterior dentition
5- Less residual space is left after end of treatment
6- Reduce probability of relapse
7- Maintain the facial esthetics
8- Avoid complication of surgical removal of third molars
Retention of treated cases
for correction of incisors relationship:
No retention is needed because the incisor will maintain their new position by normal overjet and
overbite and normal incisal inclination
for buccal cross bite:
No retention is needed if proper interdigitation of buccal segment is obtained
For individual teeth position, rotation:
Hawley retainer can be used
For anterior posterior skeletal relationship:
FR III or reversed activator that used in treatment can be used or construction of Hawley retainers.
As a general role in class III cases retention needs longer periods than other malocclusion
Effect of growth in class III treatment
It is generally considered that growth changes in class III are more likely to make the condition
worse than better.
Clinical experience suggests that the mandible tends to become more Prognathic than maxilla due
to growth changes
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Dr. Mohammed Alruby
Knott 1973 has reported that mandibular growth relative to cranial base progress after 17 years
of age, so that, must accept failure in some cases of mandibular prognathism particularly in boys
whose dramatic growth changes during and after treatment may represent serious problem in
clinical orthodontic. The sex difference is due to the retarded pubertal growth spurt in males
relative to females