MALOCCLUSION

Dept. of Orthodontics
Ragas Dental College
ORTHODONTICS INCLUDES THE STUDY OF GROWTH AND
DEVELOPMENT OF JAWS AND FACE PARTICULARLY AND
THE BODY GENERALLY , AS INFLUENZING THE POSITION
OF THE TEETH ;THE STUDY OF ACTION AND REACTION
OF INTERNAL AND EXTERNAL INFLUENCES ON THE
DEVELOPMENT , AND THE PREVENTION AND
CORRECTION OF ARRESTED AND PEVERTED
DEVELOPMENT

An occlusion in which there is

malrelationship between the arches in any of the
planes of space or in which there are anomalies
in tooth position beyond the limits of normal
Line of Occlusion

Classification of Malocclusion

Etiology
ETIOLOGY
 Specific Causes of M.O.

Disturbancesinembryologicdevelopment
Skeletalgrowthdisturbances
Muscledysfunction
AcromegalyandHemi-mandibularhypertrophy
Disturbancesofdentaldevelopment

GeneticInfluences

EnvironmentalInfluences

Equilibriumtheoryanddevelopmentofthedentalocclusion
Functionalinfluencesondentofacialdevelopment

EtiologyinContemporaryperspective

Changingviewsofetiologicpossibilities
EtiologyofcrowdingandMalalignment
EtiologyofSkeletalproblems
M.O.isadevelopmentalcondition
Moderatedistortionofnormaldevelopmentandnotbypathologicprocess
Complexinteractionamongmultiplefactorsthatinfluencegrowthand
developmentandoccasionallyasinglespecificcauseisapparent(eg)
Mand.DeficiencysecondarytochildhoodfractureoftheJaws.

M.O.

SpecificCauses HereditaryInfluences EnvironmentalInfluences

 Specific causes

Disturbancesinembryologicdevelopment

Geneticdisturbancestospecificenvironmentalinsults.

Teratogens LowLevel - specificdefects

Highlevel - lethaldefects

Teratogens Effect
.Aspirin,cigarettesmoking
(hypoxia) Cleftlipandpalate
Dilantin,valium

Aminopterin Anencephaly

CMV Microcephaly,hydrocephaly,
Micropthalmia

Xradiation Microcephaly

Vitamin`DexcessPrematuresutureclosure

Ethylalcohol Mid-facedeficiency
 Skeletal growth disturbances

Fetalmouldingandbirthinjuries.

Intra-uterinemoulding-
Pressureagainstthedevelopingface
Armpressedacrosstheface-Severemaxdeficiency
Decreasedamnioticfluidvolume-headtightlyflexed
againstchest-Mandibledeficiency

Extremesmallmandibleusuallyassociatedwithcleftpalate
(e.g.)pierrerobinsyndrome.

Pierrerobinsyndromewithdefectsincartilageformation-
SticklerSyndrome


Birth Trauma to the mandible

Forcepsdelivery-MightdamageTMJ-Internalheamorrhage,lossof
tissueandasubsequentunder-developmentofthemandible.

Injurytothemandibleduringatraumaticdeliveryappearstobearare
andunusualcauseoffacialdeformity.

Hencechildrenwithdeformitiesinvolvingmandiblearemorelikelyto
haveacongenitalsyndrome(e.g.)TreacherCollinsandcruzons
syndrome.
 Childhood fractures of the jaw

Condylarneckofthemandibleismorevulnerable.

Condylarprocesstendstoregeneratewellafterearlyfractures.

Prognosisisbetter,theearlierthecondylarfracture,becauseofthe
greatergrowthpotential-earlyinlife.

Itleadstoasymmetricgrowth.

ThoughitisapotentialcauseforsevereM.O.itdoesnotmakealarge
contributiontothetotalpoolofpatientswithmalocclusion.

MaxdownwardbyCranialbaseandforwardbyNasalseptum
Mandpulledforwardbysoft-tissuematrix.
Hence,enoughsoft-tissuescarring-Restrictsthegrowth-Asymmetrical
growth
 Managementofcondylarfractures-

Surgicalreduction- Scarring
Conservativemanagement-Earlymobilizationofjawsto
Minimizeanyrestrictiononmovement

Asymmetric mand deficiency

Oldcondylarfractures
Rheumatoidarthritis
Hemifacialmicrosomia
(congenitalabsenceoftissue).

Hence,condylar#atanearlyagegoodprognosis.
 Muscle dysfunction

Itaffectsthejawgrowthbytwoways

1. Pointofmuscleattachment.
2. Importantpartofthetotalsofttissuematrix.

Apartofmusculaturelostdue

1. Unknowncause
2. Birthinjury
3. Motornervedamage

ExcessivemusclecontractionTorticollis-Sternocleido-Mastoid
muscle-Twistingofthehead-Restrictsthegrowth

 Decreasedtonicmuscleactivity

1. Musculardystrophy
2. Cerebralpalsy
3. Muscleweaknesssyndromes
4. WillleadtoincreasedAnteriorfacialheight-Distortionoffacial
proportionsandmandform-Excessiveeruptionofpostteeth-Const
maxarchanterioropenbite.
 Acromegaly and Hemi-mandibular Hypertrophy

Acromegaly -Anteriorpituitarytumor-increasedgrowthharmone-
Excessivegrowthofmandible-cIIIIM.O.
Tumorisremoved(or)irradiated.

Hemi-mandibular hypertrophy -

Unilateralexcessivemandibulargrowthoccursinpatients
(metabolicallynormal).
Etiologyunknown
Mostcommoningirls15-20years.
Condylarhyperplasia
Treatment
excessivegrowthmaystopspontaneously
removaloftheaffectedcondyle&Reconstruction

 . Disturbances of Dental development

Congenitally missing teeth

Disturbancesduringtheinitialstagesoftoothformation:Intiationandproliferation.
Anodontia(e.g.)Ectodermaldysplasia.
Oligodontia(e.g.)Ectodermaldysplasia.
HypodontiaButlersfieldtheory
LateralInc.
IIndPremolar
IIIrdmolar

Malformed and supernumerary teeth
Abnormaltoothsizeandshape-disturbanceduringmorpho-differentiationstageofdevelopment
(e.g.)MaxlateralInc,MaxIIndPromolar.
Toothsizediscrepancy.
Germination Fusionoftoothbuds-Commonpulpchamber.
Fusion -Separatepulpchamber-joinedatdentin.
Supernumerary(or)extratooth-Disturbancesinintiationandproliferationstageofdental
development.
MesiodensMaxMidline
Supernumerarylateralinc
Supernumerarypremolars

Multiplesupernumeraryteeth-(e.g.)cleidocranialdysplasia.

Interference with Eruption-

supernumeraryteeth,scleroticboneandheavyfibrousgingival
obstructseruption-(e.g.cleidocranialdysplasia).
Rootresorptionofprimaryteeth

. Ectopic Eruption
Malpositionofthetoothbudwillleadtotheeruptionofthetoothina
wrongplace-EctopicEruption.
(e.g.) MaxIstMolartoomesial
MandIIndpremolarsEruptdistally-Endupinramus
Maxcanine -Longpathwayoferuption

Transposition
Early loss of primary teeth

-Mesialdriftofposteriorteeth-eruptsmesially&occlusally

-Distaldriftoftheanteriorteeth(e.g.)prematurelossofC
1. Activecontractionofthetrans-septalfibresingingiva.
2. Pressuresfromlipsandcheeks.

-Decreaseinthearch-perimeterandarch-lengthleadingto
crowdingandmal-alignment.

-Preventionbyspacemaintainer.

 Traumatic displacement of teeth

DentalTraumacanleadto

Damagetothepermanenttoothbudsfromaninjurytotheprimaryteeth.

Driftofthepermanentteethaftertheprematurelossoftheprimaryteeth.

Directinjurytopermanentteeth.

Traumatotheprimaryteeth

1.Duringpermanenttoothcrownformation-Enameldefects
2.Duringroofformationofpermanenttooth-Rootformationmaystop-
shortenedroots
- Dilaceration-Distortionofrootformatananglewhichaffects
theeruption
TREATMENT
Traumatically displaced tooth buds in children should be
repositioned as early as possible, so that, the root formation is
continuedwithoutanyobstruction.

Traumatothepermanentteeth

1. Damagetotheroots
2. Alveolusfracture

-Afteranaccidentortraumathetoothusuallycanbemovedtotheoriginal
position easily, because after healing (2-3 weeks) ankylosis may
develop.
Genetic Influences

A strong influence of inheritance on facial features is

obvious at glance (e.g.) The "HAPSBURG JAW" the prognathic
mandibleoftheGermanroyalfamily.

M.O.couldbeinheritedbytwoways
1.Inheriteddisproportionsbetweenteethsizeandjawsize.
2. Inherited disproportions between size and shape of the U/L
Jaws.

Primitive human populations showedlessfrequentM.O.

comparedtomoderngroupsandarecharacterizedbygeneticisolation
anduniformity.

It can be concluded that greater increase in out-

breedingthatoccurredasahumanpopulationgrewandbecamemore
mobile was the major explanations for the increase in M.O. in recent
centuriesanditwassupportedby"STOCKARD"experiments.

Theclassicwaytodeterminetheinfluenceofinheritanceis
by

1.Comparingthemono-zygoticanddizygotictwins.
2.Comparingthemother-child,father-childandsibling
pairs.

Lauwerynsetal,40%ofdental&facialvariations
leadingtoM.O.canbeattributedtohereditaryfactors.

Harris and Johnsonconcludedthattheheritability

of skeletal characteristics was relatively high than dental
characteristics(Low).

Strong inheritability seen in CI-III M.0, CI II- div II

M.O,cleftlipandpalateandlongfacepattern.
 Environmental Influences

Environmentalinfluencesduringgrowthanddevelopmentofface,
jaws and teeth consists largely of pressure and forces related to
physiologicactivity.
Relationshipbetweenanatomicformandphysiologicfunction.

Equilibrium theory

It states that an object subjected to unequal forces will be

acceleratedandtherebywillmovetoadifferentpositioninspace.

Equilibrium effects on dentition-

thedurationofforce,becauseofitsbiologicresponse,ismore
importantthanitsmagnitude(minof6hrs)toaffectthetoothposition.
 Possible equilibrium influence Force magnitude Force duration

Tooth contacts
mastication very heavy very short
swallowing light very short

Soft tissue pressures of lip,cheek,tongue

swallowing moderate short

speaking light very short

resting very light long
External pressures
Habits moderate variable
Orthodontics moderate variable
Intrinsic pressures
PDL fibres light long
Gingival fibres variable long
conclusion

1. Intermittent pressures (or) forces have little (or) no effect on the

teethposition/sizeandshapeofthejaws.

2. Density of the bone in the alveolar process and throughout the

basalareasofthejawsshoulddifferasafunctionofmasticatoryforces,butshape
shouldnot.

3. Masticatory forces and soft tissue pressures during swallowing

andspeakingdoesnothaveanymajorinfluenceontoothposition.

4. Major equilibrium influences for the teeth should be the light but
longlastingpressuresfromtongue,lipsandchecksatrest.

5. Significant equilibrium effects should be expected from the

elasticity of gingival fibres and from the metabolic activity within the periodontal
ligament.

6. Themajorequilibriuminfluencesonthejawsshouldbepositional
changesaffectingthefunctionalprocess,includingthecondylarprocess.
Functional influences on Dentofacial development

MASTICATORY FUNCTION

Itcouldaffectintwoways

1. Greater use of the jaws, with higher (or) prolonged biting force
couldincreasethedimensionofthejawsanddentalarches.Lessuse
of the jaws might lead to under-development of dental arches and to
crowdingandirregularteeth.
(e.g) Eskimos with broad dental arches as an adaptation to
extremestress.
Theeffectonarchwidthisnotclear.
 Difference in muscle strength - biting force is a etiology for long and
shortfaceproblems?

Itwasconcludedthat,theforceexertedbymasticatorymuscleis
notamajorenvironmentalfactorincontrollingtootheruptionandnotan
etiologicfactorformostpatientswithdeep(or)openbite.

There can be a definite effects on growth if the

musculature is abnormal (e.g.) Muscular dystrophy and related
syndromes.

-Sucking Habits

- Tongue thrusting

- Respiratory Pattern
ETIOLOGY IN CONTEMPORARY PERSPECTIVE

Changing Views of Etiologic Possibilities

1. EdwardAngleandhiscontemporariesstatedthatM.O.wasadisease
ofcivilizationandblameitonimproperfunctionoftheJaws(19th
Century)

2. Classical(Mandelian)geneticsdevelopedrapidlyinthe1stpartofthe
20thCenturystatedthatM.O.isprimarilytheresultofinherited
dentofacialproportions.

3. Inthe1980'stherewasastrongswingbacktowardtheearlierview.

4. In21stCentury-Amorebalancedviewemerged.Itwasconcluded
thattheetiologyofmostorthodonticproblemsaredifficulttoisolate,
becauseseveralinteractingfactorsprobablyplayedarole.
Etiology of crowding and Alignment

-MinorClassIproblems,especiallynon-skeletalcross-bite,oftenare
causedprimarilybyalterationinfunction.Majorproblemsusuallyhave
anadditionalgenetic(or)developmentcomponent.

Etiology of Skeletal problems

Malformation(or)MalrelationofJaws.
Inheritedpatterns,defectsinembryologicdevelopment,trauma,and
functionalinfluences.
Mandretrogandprog,Maxdeficiency-inheritanceplaysmajorrole
andtheconditionmadeworsebyenvironmentalefforts.
Altered function:VerticalgrowthproblemsusuallyAnterioropen
bite-Thumbsucking-TongueThrusting-Respiratory
problems.
Openbite-Blacksanddeepbite-whites.

MALOCCLUSION

GeneticComponent
OrInheritance
Developmentalproblems
Alteredfunction
ECTODERMAL DYSPLASIA
MASSETER MUSCLE DYSFUNCTION
ACROMEGALY-ANT PITUITARY TUMOR
ACHONDROPLASIA
EQUILIBRIUM THEORY
TREACHER COLLINS SYNDROME
HEMIFACIAL MICROSOMIA
ADENOID FACIES