Mental Dental – Ortho

GROWTH AND DEVELOPMENT ............................................................................................................................................................ 2

HOW DOES GROWTH HAPPEN? ....................................................................................................................................................................... 3
CRANIOFACIAL GROWTH ..................................................................................................................................................................... 4
CRANIOFACIAL ABNORMALITIES ......................................................................................................................................................... 5
5 STAGES OF EMBRYONIC CRANIOFACIAL DEVELOPMENT ...................................................................................................................................... 5
ABNORMALITIES ............................................................................................................................................................................................ 5
DEVELOPMENT OF OCCLUSION ........................................................................................................................................................... 7
DIAGNOSTICS AND TX PLANNING ........................................................................................................................................................ 9
BIOLOGY OF TOOTH MOVEMENT ...................................................................................................................................................... 12
ADJUNCTS .................................................................................................................................................................................................. 13
DELETERIOUS EFFECTS .................................................................................................................................................................................. 14
MECHANICAL PRINCIPLES OF TOOTH MOVEMENT ............................................................................................................................ 14
TOOTH MOVEMENTS ................................................................................................................................................................................... 15
ANCHORAGE .............................................................................................................................................................................................. 15
ORTHODONTIC WIRES & BRACKETS .................................................................................................................................................. 16
MECHANICAL PROPERTIES............................................................................................................................................................................. 17
Wire Material and Geometry .............................................................................................................................................................. 18
BRACKETS .................................................................................................................................................................................................. 18
EARLY TREATMENT (PHASE I) ............................................................................................................................................................ 18
COMPREHENSIVE TX AND APPLIANCES ............................................................................................................................................. 20
GROWTH MODIFICATION .............................................................................................................................................................................. 20
DENT-ALVEOLAR APPLIANCES ........................................................................................................................................................................ 22
Mixed Dentition Appliances ................................................................................................................................................................ 23
Permanent Dentition Appliances ........................................................................................................................................................ 23
EXO VS NON-EXO ....................................................................................................................................................................................... 23
STAGES OF COMPREHENSIVE TREATMENT ........................................................................................................................................................ 23
RETENTION ........................................................................................................................................................................................ 24
RETAINERS ................................................................................................................................................................................................. 24
TYPES OF RELAPSE ....................................................................................................................................................................................... 24
ORTHOGNATHIC SURGERY ................................................................................................................................................................ 25
RELAPSE STABILITY....................................................................................................................................................................................... 25
ENVELOPES OF DISCREPANCY ......................................................................................................................................................................... 25

1
Growth and Development
Patterns of Growth and Development
Cephalocaudal Growth = Body parts closer to the cranium grow faster earlier while parts further from the
Gradient cranium grow more later on

“Brain blazes trail, and everything else needs to catch up later”

- Maxilla fully matures before the mandible as it is closer to the cranium

Scammon’s Growth - Lymphoid Tissues

Curves - Neural Tissues
- Maxilla
- Mandible
- General Body tissues
- Genital tissues

*Neural and lymphoid tissues grow lots really early on and taper or ↓ until
pubertal growth spurt*

**Also note that the Maxilla follows closer to the Neural growth curve vs
Mandible is closer to General Body Tissues-> Because its closer to the brain
(Cephalocaudal growth gradient)
Human Growth Curves Distance Curve = Tracks actual height each year (like the marking your height on the doorframe)
- Distance
- Velocity Velocity = Change in height (rate of change)

Growth Spurts:
- Girls peak ~ 12years old (9-13)
- Boys Peak ~14 years old (12-17)

Growth Timing
Chronologic Age Not the most accurate
Dental Age = State of dental development (how many teeth do they have)
- Also a poor method
Skeletal Age CVM Staging (Cervical-Vertebral Maturation) -> Can use lateral Ceph or Pan to assess this

Hand Wrist Method

- Not as popular anymore

Biologic Age Based on markers of maturation

- 1st menstruation seen after peak growth
- 2nd Sex characteristics
- Breast development

*Best indicator for maturity*

2
How does Growth Happen?
Sites Centers
= Location where growth is occurring = Site that has the ability to control its own growth
- Sutures, Surfaces, Mandibular Condyles etc - Synchondroses are the only true growth centers in the head
eg-suture surfaces condyles are growth centre

Modes of Growth
Endochondral Ossification = Interstitial Growth
- Growth from the inside -> results from increased length of bones
- Under more genetic control

*Cartilaginous model becomes replaced by bone*

- Chondrocytes nestled within cartilage

- Hyperplasia and rapid mitotic division of cells

- Hypertrophy of the cells (cells get bigger)

- Calcification and mineralization begins, and cells begin to die

- Osteoblasts secrete osteoid to create bone

Where:
- Epiphyseal plates of long bones
- Synchondroses of the cranial base
- Condylar cartilage of the mandible
Intramembranous Ossification = Appositional Growth
- Growth from the outside -> results in ↑ thickness/diameter of bone

-W/ more circumferential lamellae = ↑ diameter. But

Osteoclast remodelling keeps the thickness uniform

Influenced more from environmental stressors

Location:
- Sutures, Surfaces of cranial vault, maxilla etc

Growth Theories
**All 3 theories kinda worth together
Suture Theory = Direct genetic control determines how bone will grow and sutures are the growth centers
- Mostly debunked skull bone grow apart and bone
suture are growth sites not centre deposited
- Sutures are reactive, not proactive -> therefore they are sites in suture area as a result
Cartilage Theory = Cartilage pushes and pulls things apart.
- Some evidence for this - Cartilage is the growth center and bone follows
Functional Matrix = Environmental growth control
- Good evidence to this - Chewing speaking etc cause the nasal and oral cavities to get bigger
- Soft tissue matrix = growth center and bone/cartilage follows

3
Craniofacial Growth
synchondrosis is a temporary type of joint where the connecting
material between the bone is hyaline cartilage.
suture where two bones are joined together by fibrous
connective tissue.

Cranial Vault (1) = Top of skull that encases the brain

- At birth the bones are separated by loose CT (Fontanelle) -> allows the head to pass through the
birth canal
Intramembranous ossification at fontanelles and sutures + internal and external
surfaces
- Growing brain pushes the cranial bones apart during development

Cranial Base (2) = Ethmoid, Sphenoid, and Occipital Bones (These begin as cartilage)
- Endochondral Ossification occurs at synchondroses

Synchondroses:
- Intersphenoid -> Inactive by 3yrs
- Spheno-ethmoid -> Inactive by 7
- Spheno-occipical -> Inactive later
Maxilla (4) = Intramembranous ossification at sutures:
- Posterior and Superior to maxilla

Resorption of the anterior maxilla

Apposition at the Palate, alveolar ridges and tuberosity

Result: Downward and forward translation away from the cranial base
Mandible (3) Embryonic development, lateral to 1st Pharyngeal arch (Meckles Cartilage):

Intramembranous ossification -> Creates embryonic Ramus and mandible (beside Meckles cartilage)
Endochondral Ossification -> Creates Condylar cartilage, this cartilage persists
as a growth site as the mandible grows down and forward
- The ramus and Condyle then fuses at 4 months in utero

Meckels Cartilage disintegrates to form the malleus and Incus of the ear, and
sphenomandibular ligament
- Is not replaced by bone

in maxilla there is apposition at tuberosity In the Adult Mandible:

to make space for 2 and 3 molar - Endochondral ossification as condylar cartilage proliferates and produces bone
as mandible grow downward and forward to make space for
due to condylar cartilage growth
- Intramembranous ossification occurs to remodel the surface 2nd and 3rd molar
apposition occur on posterior of ramus - Resorption on the anterior ramus
- Apposition on the posterior ramus, chin, coronoid and
alveolar ridges
Results:
- Downward and forward growth pattern

Growth Rotation
- Can rotate open, or closed
- If Condylar growth = same rate as molar eruption -> Down and Forward
- If condylar growth > molar eruption -> Closing rotation
- Short Face, Deep Bite tendency
- If condylar growth < molar eruption -> Opening rotation
- Long Face, Skeletal open bite tendency

planes of growth
width(tansverse)-10-12 year
length(anteroposterior)-14-16
height(vertical)-18-20

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Craniofacial Abnormalities
5 Stages of Embryonic Craniofacial Development
Stage Time (in Utero) Abnormalities
Neural Crest Problems 1. Germ Layer Formation Day 17 Fetal Alcohol Syndrome
2. Neural Tube Formation Days 18-23 Anencephaly
3. Migration of Neural Crest Cells Days 19-28 Hemifacial microsomis
Treacher Collins Syndrome
(Mandibulofacial dysostosis)
Lack of Fusion 4. Organ System Formation Days 28-38 (Week 4-5) Cleft Lip
4a. Primary Palate Week 6 Cleft Palate
4b. Secondary Palate Week 6
Suture Problems 5. Final Differentiation of Tissues Day 50-Birth Crouzon’s Syndrome
(Craniosynostosis),
Achondroplasia

Types of Birth Defects

Syndrome = Pattern of anomalies that occur together in a predictable fashion due to single etiology (usually genetic)
- Like a recipie from a cookbook
Sequence = Group of related anomalies that stem from s single major anomaly that alters the development of its surrounding
structures
- Like a row of dominoes

Abnormalities
Fetal Alcohol Syndrome Cause:
- Exposure to high levels of ethanol during early development
S/S
- CNS problems -> Deficiency in neural plate tissues (abnormal brain development and microcephaly -> small
head)
- Midface deficiency -> Smooth philtrum, thin upper lip, small parpebral fissues
- ↑ chance of cleft lip

Teratogen = any agent that interferes with early development

Treacher Collins = Genetic mutation altering development of neural crest cells affecting the development of facial bones and tissues
Syndrome
(mandibulofacial S/S:
dysostosis - Underdeveloped mandible
- Downslanted palpebral fissures
- Cleft Palate (35%)
- Microtia (Small Ear)

antigonial notch is deep

Hemifacial Microsomia = Loss of neural crest cells during migration

S/S:
- Ear and mandibular ramus are deficient on the affected side

5
 Trisomy 21 (Downs = Non-disjunction leading to extra chromosome 21
Syndrome)
S/S:
- Midface Deficiency
- Upslanted palpebral fissures
- No ↑ caries risk
- ↑ perio risk

Cleft Lip & Palate Cleft = failure of fusion of tissues during early development

Cleft Lip:
- Weeks 4-6 weeks in utero
- Lack of fusion btwn Medial Nasal Prominence + Maxillary Prominence Anteriorly
- Usually off midline, and usually unilateral (can be bilateral though)

+/-

Cleft Palate:
- Weeks 6-8 in utero
- Lack of fusion btwn Medial Nasal Prominence + Maxillary Prominence Posteriorly
- Primary Palate carries Lateral incisor to lateral incisor -> This is why cleft palate Patients typically are
missing their laterals
- Complete Cleft Palate -> Primary and secondary palate both fail to fuse
incomplete palate-palatal shelves fail to fuse with one another in between(green part)
*Tend to be Class III w/ deficient maxilla complete palate-in addition to above palatal shelve fail to fuse with primary palate

Pierre Robin Sequence 1. Micrognathia (small Mandible) ->

2. Glossoptosis = backwards displacement of the tongue posteriorly ->
3. Cleft Palate (tongue displacement prevents the fusion) ->
4. Breathing and feeding difficulties

Crouzon Syndrome Autosomal Dominant inheritance

Craniosynostosis = Early closure of skull sutures

- Usually premature fusion of both sutures at top of skull + Maxilla

S/S:
- Brachycephalic (Short Skull)
- Midface deficiency
- Frontal bossing (prominent forehead)
- Hypertelorism = Wide separated eyes
- Proptosis = Bulging eyes
- Class III Occlusion
Alpert Syndrome Autosomal Dominant Inheritance
(Acrocephalosyndactyly)
Craniosynostosis as well
- Similar features to Crouzon…except (see below)

S/S:
- Acrocephalic (Tall Skull)
- Byzantine Arch (narrow palate with high vault)
- Syndactyly (Fusion of fingers and toes)
Hurler & Hunters = Build up to Glycosaminoglycans (GAGs) in lysosomes due to enzyme deficiency
Syndrome
(Mucopolysaccharidosis) “Hurl…vomiting…GAG”

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Development of Occlusion
4 stages:

Gum Pad Stage Ends with the eruption of the 1st primary tooth
(Birth to 6 months) Future positions of teeth can be seen in elevations and grooves
present on the alveolar ridges
- Lateral Sulcus (more prominent groove) separates
primary canine from primary 1st molar
Primary Dentition First Primary tooth coming in to first Permanent tooth coming in
(6m to 6yr)
Typically:
- Minimal OB and OJ (sometimes edge to edge)
- Spacing is normal

Interdental = Space between primary incisors

Spacing - Normal space -> Permanent incisors fill the gaps when they
erupt. Without this space we get permanent crowding

Primate Spacing Max: Between Primary Lateral and Canine

Md: Betwwn Primary canine and 1st primary molar

Leeway Spacing = Difference of the combined M-D width of primary C, D, E and the M-D
with of the Permanent 3, 4, 5
- This gains us space -> Permanent premolars are smaller than
the primary molars they replace

Mx: 1.5mm per side (3mm total)

Md: 2.5mm per side (5mm total)

Primary Molar Relationships:

- Relationship of the Mandibular terminal plane to the maxillary terminal plane
- Terminal plane is what guides the Permanent 6’s and can be used to predict the Molar occlusion

Mesial Step Flush Terminal Plane Distal Step

(49% of cases) (37% of cases) (14% of time)
- Leads to Class I, but could also - Likely leads to End-End, but also - Leads to Class II almost 100%
be Class III (10% chance) Class I, II or III (Wild card)

Mixed Dentition Stage Ends with the exfoliation of the last primary tooth
(6yrs – 12 yrs) - Interdental, Primate and Leeway spaces all close
- Molar relationship will “transition” to Class I, II, III -> From the Terminal plane relationship

Ugly Ducking Stage

- 11-12 years old
- Hallmark = Diastema between 11, 21 (< 2mm)
- Space is closed with the mesial eruption of the max. canines -> If Diastema is
>2mm then the canines may not close it fully

Anterior Transition
- Permanent tooth buds are Lingual and Apical to the primary counterparts
- Incisors tend to erupt lingually -> EXCEPT for Max. Centrals (Pushed labially by the tongue and they erupt)
- Canines tend to erupt labially as well

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 Posterior Transition
- Permanent 1st molars are guided into position by the terminal plane
- Flush Terminal plane becomes Class I by differential teeth shift and
differential jaw growth
- Early mesial shift of 1st molars to close the primatE space
(around 6 years old)
- Late mesial shift of the 2nd molars to close Leeway space
(around 12 years)
- Late mandibular growth (cephalocaudal growth pattern)

Mixed Dentition Space Analysis

Compares space available and space required for incoming permanent teeth (predict M-D width of the unerupted
buccal segment = 3, 4, 5) -> Arch Dimension (Space available) vs Tooth Dimension (Space required)
- Crowding = “-“
- Spacing = “+”

**Need Lower 4 incisors all erupted before you can do this method**
Tanaka-Johnston Method = Sum width of mandibular incisors (put into equation)
- Maxillary: Sum of 4 Md incisors/2 + 11 = 1 buccal segment (canine both
premolars
- Mandibular: Sum of 4 Md incisors/2 + 10.5 = 1 buccal segment
Moyer’s Method = Sum with of Mandibular incisors -> Refer to the prediction table
Permanent Dentition = Only permanent teeth in arch
(12 years – death or
edentulism) Curvatures:
- Curve of Spee = Sagittal plane
- Curve of Wilson = Frontal plane
Ideals:
- OB: 10-20%
- OJ: 1-3mm
- Occlusion: Class I

Late Lower Incisor Crowding:

- Anterior crowding that progressively gets worse in 20’s-40’s -> Due to late mandibular
growth. This growth results in added pressure on lower incisors from the lip which tips
them lingually to escape the lip

Arch Dimension Changes

Inter-canine width
= ↑ as permanent teeth erupt (Particularly in labial and lateral eruption of the canines)
(Cusp tips of 3-3) - Stabilizes once canines have erupted (Age 10-12)
Inter-molar width
= ↑ as molars erupt then stabilizes
(6-6) - More expansion in the Max Vs Md because Upper molars erupt divergently
while lower erupt convergently to form curve of wilson
Arch Length = ↓ during transition from mixed to permanent more decreases in mand. due to more
- Leeway space closes as the 1st molars migrate mesially leeway space
Arch Perimeter = ↑ in Max, ↓ in Mand. during transition from mixed to permanent
- Combination of labial + lateral eruption of the canines (expands the arch) and
the loss of Leeway space.
- More Leeway in the Mand = overall ↓ arch perimeter
- Less Leeway space in Max but more lateral eruption of canines =
overall ↑ in arch perimeter
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8
Diagnostics and Tx Planning
Ackerman-Profit Diagnostics

Category What it assesses

Facial Proportions and Lip Posture
Esthetics Smile Arc
Alignment and Crowding
Symmetry Spacing
Rotations
Transverse Posterior Crossbite
Midline
Anteroposterior Overjet
Angles Class
Vertical Overbite
Curve of Spee

Orthodontic Exam

Teeth (Intraoral) Malocclusion

- Broad term, referring to “bad” bite
- 15% of adolescents and adults have severe crowding -> Carries genetic disposition
as it relates to tooth vs arch size

Molar Classification
1. Class I Normal occlusion (30-35%)
- Max 1st molar MB cusp in the B groove of Md 1st molar
- All teeth are aligned nicely in the arch
2. Class I Malocclusion (50-55%)
- Same Angle Class I
- Teeth do not line up along the arch of occlusion (rotations, spacing, crowding)
3. Class II Malocclusion (15%)
- Mx 1st molar is too far forward, or mand. 1st molar is too far back
- Teeth may or may not be nicely arranged
a. Subdivision 1 = Proclined U1’s, excess OJ
b. Subdivision 2 = Retroclined or Upright U1, Excess OB
4. Class III Malocclusion (1-5%_
- U6 is too far posterior, or L6 too far anterior

Incisor Overlap
Overjet Overbite
Normal: 2-3mm Normal: 1-2mm
- Horizontal overlap - Vertical overlap
- Labial surface to labial surface btwn L1 and U1 - Incisal edge to incisal edge
(just the thickness of the U1 - Deep (Excess OB) or Open
provides 2-3mm) (space btwn incisal edges)
- Excess (>3mm) or Reverse (L1
on above
infront of U1) the cingulum of
upper incisor

Crossbite
Anterior (AKA Reverse Overjet) Posterior (AKA Scissor Bite)
= Max. anterior teeth are lingual to the mandibular = Max. posterior teeth are lingual to the mandibular, or
anterior teeth are completely buccal to the mandibular teeth

scissor bite

Bolton Analysis
= Measures tooth size discrepancy by comparing U and L teeth
- Teeth that are too large may need Interproximal Reduction (IPR)
- Teeth that are too small may need buildups (peg laterals)

9
Face (Extraoral) Vertical 3rds
- Upper 3rd -> Hairline to glabella
- Middle 3rd -> Glabella to subnasale
- Lower third -> Subnasale to menton
- Asymmetric growth of mandible can change this, this is mostly what is changed with
ortho
Horizontal 5th
- Middle 5th -> Inner canthus to inner canthus
- This line should be in line with the ala of the nose
- Medial two 5ths -> Inner canthus to outer canthus
- Interpupilary distance should correspond with the commissures of the lips
- Outer two 5ths -> outer canthus to lateral helix
- Should be coincident with the gonial angle of the jaw

Skeletal Classifications
Class I Jaws well-related to N-Vertical

Class II Prognathic/protrusive maxilla (10%)

Retrognathic/retrusive mandible (85%)
Combination of both (5%)
retrusive are common
Class III Prognathic Mandible (20%)
Retrognathic Maxilla (60%)
Combination (20%)

Facial Profile
- Facial plane formed by glabella, subnasale, and soft tissue pogonion

1. Straight -> Usually Class I

2. Convex/Posterior Divergence -> Usually Class II
3. Concave/ Anterior Divergent -> Usually Class III

Profile Angles
Nasolabial Angle = Between Nose and upper Lip
- Should be: 90o

Mentolabial Angle/Fold = Btwn lower lip and chin

- Should be 120o

Cervicomental Angle = Btwn chin and neck

- Should be 90-120o

Lips (3 P’s)
Position = Rickets E Plane (line drawn between nose and chin)
- Lower lip should be behind, Upper lip should be on the line
- Protrusive or Retrusive lips

Posture = Lip competence at rest

- Competent or incompetent
- Incompetent = 3-4mm separation at rest + Mentalis strain
on closure

Proportions = How much vermillion is shown?

- Thick lips or thin lips

10
 Incisor Display
- At Rest: 2-4mm show is ideal complete seal is okay
- On Smile: 75-100% incisor w/ 1-2mm gingival show is ideal

Buccal Corridors
= Dark space between Max posterior teeth and corner of the mouth upon smiling
- Wide = lots of space
- Medium
- Narrow = very little space

Radiographic (Ceph) Reference Points:

Bolton Point (Bo): Highest point in the upward curvature of the occipital bone
Basion (Ba): Lowest point of the anterior margin of Foramen Magnus (points towards the Dens, or C2)
Articulari (Ar): Inner section between zygomatic arch and posterior border of ramus
Porion (Po): Highest point of the external auditory meatus
Condylion (Co): Post posterior superior point on the condylar head very tough to see in cephalometric
Pterygomaxillary fissure (Ptm): Base of fissue that runs along the back of the maxilla
Sella (S): Midpoint of sella turcica
Orbitale (Or): Inferior portion of the orbit
Na (N): Anterior point of the nasal bone
Anterior Nasal Spine (ANS): Sharp projection of the maxilla anteriorly
Posterior Nasal Spine (PNS): Usually below ptm, sharp projection of the palatal
bone
A Point: Inner most point on the contour of the maxillary bone
B Point: Inner most point on the contour of the mandible
Pogonion (Pog): Most anterior point of the chin
Menton (Me): Most inferior point of the chin
Gnathion (Gn): Point in between Me and Pog
Gonion (Go): Midpoint of the contour of the angle of mandible

Reference Planes:
- S-N: Cranial Base
- Po-Or: Frankfort Horizontal
- ANS-PNS: Palatal Plane L6-L1:
- Occlusal Plane
- Go-Gn: Mandibular Plane

**Sassouni Analysis -> These should all intersect at the back of head (Occiput)**
- If they intersect earlier -> Hyperdivergent
- If they intersect later -> Hypodivergent

Ceph Analysis
= Evaluate relationship of the jaws and dental units to each other

SNA = Maxilla to Cranial Base

- Large angle = Prognathic Max
- Smaller angle = Retrusive
SNB = Mandible to cranial base
- Larger Angle = Protrusive
- Smaller Angle = Retrusive
ANB = Maxilla to mandible
- <0o = Class III
- 2o = Normal Class I
- >4 = Class II

Ceph Superimposition
= Evaluate the skeletal and dental changes that occur over time -> Due to growth or Tx

11
Biology of Tooth Movement
1. Apply force to the tooth
2. PDL is stressed
a. Compression side: ↑ Osteoclasts = Resorption
b. Tension side: ↑ Osteoblasts = Apposition
3. Bone remodels
4. Tooth Moves

Force Magnitude

primary mesenger are

calcitonin and pth

sterile-necrosis occur without any pathogen

in undermining resorption there is loss of bone and in

frontal resorption there is loss of root

Resorption
- Light force: Frontal/Direct resorption -> Steady movement, ↓ pain
- Heavy Force: Undermining/Indirect resorption
Force Distribution = Amount of force delivered to a tooth and the area of PDL over which the force is distributed are
important to determining the biologic effect

Force/Area = Pressure
- Every PDL ligament has some sweet spot of pressure that stimulates cells without completely
occluding the blood vessels

Uncontrolled Tipping = Crown goes in the direction of force, but root goes in the opposite
- Heaviest pressure on the root apex and crest of the alveolar bone
Ideal Force: 50g
- 50% of the force is on one side and 50% on the other

Example: Finger Springs, Round light wires

Controlled Tipping = Tooth is both partially tipped and also partially translated
- Root apex doesn’t tip opposite to the same degree as in
uncontrolled
Ideal Force: 75g
- 75% of the force is being felt on 1 side, and 25% on the other

Bodily Movement = Crown and root are being moved at same rate in the same direction
- Entire PDL is loaded, so there is equal compression along 1 side of
the root
Ideal Force: 100g
- 100% of the force is being felt on 1 side

12
 Root Torque = Crown barely moves, and the root moves in the direction of the force
- Ideal uprighting force: 75g

heavy force most

commonly seen
so undermining Rotation = Rotation about long axis of the tooth
resorption is
unavoidable - Compresses the areas similar to in tipping due to irregularly
shaped roots
- - Ideal rotating force: 50g

Extrusion = Pulling tooth gently out of its socket

- Compresses the areas similar to tipping due to irregularities in root
shape
- Ideal Extruding Force: 50g

Intrusion = Pushing a tooth gently into its socket

- Exceptionally light force down the long axis of tooth
- Ideal Intruding Force: 10g

Force Duration - Threshold for tooth movement is 4-8hrs (this is how long it take cAMP to build
up enough to amplify the inflammatory response to actually move the tooth)
- Only an issue for appliances that are removable

Force Decay:
Continuous - Force stays constant (slight decrease as tooth moves,
but it is reset with re-activation of the wire

Ex: Light Wire

Interrupted - Force slowly declines to 0. Decays faster than

continuous, mostly due to materials

Ex: Elastic chain

Intermittent - Force abruptly declines to 0 whenever the patient

takes out the appliance

Ex: Clear Aligners

Adjuncts
Regional Acceleratory **Altering inflammatory response to ↑ tooth movement**
Phenomenon
Regional = Inflammation at both the cut site and adjacent bone
Acceleratory = Intensified bone response due to agitated inflammatory mediators

Propel: Punches holes in the bone through gingiva

Wilkodontics: Full thickness flap is raised, punching holes and
then covering with bone graft followed by applying ortho force

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Deleterious Effects
*More force = more negative side effects

Mobility = PDL temporarily widened

- Controlled inflammation
- This gets out of hand when compounded with uncontrolled inflammation -> This is why we don’t do ortho while Pt
has Periodontitis
Pain PDL undergoes necrosis, ischemia and remodeling
Inflammation = Usually from poor OHE
- Rarely does it come from nickel allergy
Pulp = Loss of vitality
- Only associated with traumatized teeth and really extreme movement
Root Resorption = Cementum adjacent to the hyalinized PDL can undergo resorption
- Happens in basically every case, but in 3% does it become an issue

Risks:
- Heavy Force
- Larger defects
- Apical Defects
- Genetics
- Single Roots
- Traumatized teeth
- Movement into the cortical plate
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Mechanical Principles of Tooth Movement

Center of Resistance = Fixed Point that a force must pass through in order to move the object in a straight line
- In a free floating object, it corresponds with the center of mass

Teeth are not floating in free space -> Center of resistance is around the center of the
root (Half way between the alveolar crest and the apex of the root)
- Periodontally Compromised tooth -> CoR moves more apically
- Apical Root Resorption -> CoR moves more coronally
Center of Rotation = Unfixed point around which an object rotates
- Point which a body appears to have rotated when compared between the initial and final
position
- Depends on where the force is being applied

**Because the Center of Resistance of a tooth is inaccessible clinically, orthodontic movements use the
Center of rotation around the brackets more **
Moment (Mf) = Tendency of a force to cause a body to rotate about a specific axis
- Measured at some distance from the center of resistance

Moment = Force x Distance

Couple (Mc) = Pair of equal and opposite noncollinear forces
- Creates pure rotation
- Needs 2 points of contact (Square wire in ortho bracket)

Mc = Force of 1 point x distance between 2 forces

RAE

First Order = Rotation

Second Order = Angulation

Third Order = Inclination

Moment of Force: When an archwire is engaged in a bracket and applies a force at a distance from the tooth's
Mc is a couple of forces not include Mf center of resistance, it creates a moment causing the tooth to tip or rotate.
Couple: By using a rectangular wire fully engaged in a bracket, a couple is created. This can control the 14
tooth's rotation around its long axis (e.g., rotational correction or root torque).
Tooth Movements
Uncontrolled Tipping Mc/Mf = 0
- Finger Spring - No couple here
= Center of rotation is slightly apical to center of resistance
- Crown moves in the direction of force and root goes the opposite

Controlled Tipping Mc/Mf = Between 0-1

- Brackets - Mc>Mf Mc<Mf

= Center of rotation is moved apically away from the center of resistance

- Root stays where it is and the crow tips in the direction of the force

Bodily Movement Mc/Mf = 1

- Mc = Mf

= Tooth moves bodily (translates) and the center of rotation is displaced infinitely far away from the center
of resistance (Because there is no rotation)
- Move the crown and root equally in the same direction
Root Torque Mc/Mf >1
- Mc > Mf

= Root apex moves more than the crown and the center of rotation is displaced in the other
direction
- Crown barely moves and the root moves in the direction of force
- Very hard to accomplish
Rotation Mc/Mf doesn’t exist
- Mf = 0

= Rotation of the rooth is about its long axis

- Center of rotation is at the center of resistance, this is caused by the couple moment alone

bracket act as intermediate component to transmit forces from archwires,springs,elastics

Anchorage
= Resistance to unwanted tooth movement

- Based off Newton’s 3rd law -> for every action there is an equal and opposite reaction
- Light Force has a less anchorage toll -> Less unwanted tooth movement to worry
about

*Winner of the “Tug of war” depends on the PDL surface area

➔ The anterior teeth have ↓ PDL surface area and will thus move more than the posterior unit

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 Reciprocal Anchorage = If both units have equal anchorage values (PDL surface are is the same btwn two units) -> They will both experience
equal and opposite tooth movement
- Movement of 1 tooth can be pitted against the same contralateral tooth/unit -> Like in Diastema Closure

Reinforced Anchorage = Adding more teeth to anchor unit so the reaction force is distributed over ↑ PDL area
- Headgear can be used to augment anchorage, but poor Pt compliance and heavy intermittent forces are not
awesome

Skeletal Anchorage = TADs (Temporary Anchorage Devices) -> act like ankylosed teeth
- Bone screws/plates more invasive multiple screws more anchorage
- Particularly useful for distalizing and/or intruding molars

Earliest age: 11 -> bone has matured enough

tad can be utilized for distalizing or intruding molar

Anchorage Demand

Maximum Anchorage = No movement of the posterior teeth, and distalizing/retroclining the anteriors

Ex: 1st premolar Exo + anchor on both molars

Moderate Anchorage = Equal movement between posteriors and anteriors

Ex: 1st premolar exos + Anchor only 1 molar. Anterior and Posterior meet in the middle

posterior teeth allowed to move 1/4 to 1/2 of spacev

Minimum Anchorage = No movement of the anterior teeth and mesializing the posteriors

Ex: 2nd premolar Exo / Skeletal anchorage

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Orthodontic Wires & Brackets

Wire = Does all the work

Bracket = Tooth handle that allows the wire to grab the tooth

2 Phases of the orthodontic wire:

Activation = Loading
- The amount of force applied to engage the wire into the bracket slot -> putting the wire in the mouth
De-Activation = Unloading
- Letting the wire return to its original shape -> This applied the force that moves the
tooth

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Mechanical Properties
Definitions are kind of separate depending on if you are referring to Loading or Unloading

Strength = Stiffness x Range

Loading Unloading
Strength = How easily it will break = How much force it can deliver
- Stronger the wire, the higher potential it has to deliver more
force
Strength is related to 3 points on the stress strain curve:

Proportional Limit:
- Point where linear relationship ends. Wire will no longer bounce back to
original shape beyond here

Yield Strength:
- Measurable permanent deformation begins here
- Do not want to reach this during loading of the wire

Ultimate Tensile Strength

- Maximum stress the material can handle while loading, or the maximum
force it can deliver while unloading
strength-how much force it can deliver (maximum)
Stiffness = How flexible it is = How much force it will deliver as it returns back to its original shape

= Slope of the elastic portion of the stress-strain curve

- The steeper the slope is = Stiffer the wire more vertical curve material require more
- Shallower the slope = more flexible more horizontal curve force to deform
stifness inverse of springiness or flexibility

Range = How far you can deflect the wire while maintaining = How far (and how long) the wire will remain active for
its elasticity

= Horizontal axis of the Force-Deflection curve up until the Yield Point

- If you deflect beyond this point, it will not return to its original point

Long range: More active for longer time

Short range: Active for less time, will need to recall the patient sooner

Resilience = Area under stress-strain curve, up to the proportional limit

- Represents energy storage capacity of the wire
- Amount of plastic deformation the wire can tolerate

strength =stiffness *range

Formability = Area under the stress-strain curve from yield strength to the failure point
- Amount of permanent deformation the wire will tolerate before it breaks

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 during early treatment
during final treatment
Wire Material and Geometry
- ↑ Strength and Stiffness: NiTi (Weakest, most flexible) < TMA < SS (Strongest and stiffest)
- ↑ Diameter = ↑ strength, ↑ stiffness, ↓ Range
- ↑ Length (between brackets) = ↑ range, ↓ strength, ↓ stiffness
- Rectangular is stronger and stiffer than round
- Beam is stronger and stiffer than cantilever

Brackets
Original Edgewise Brackets
Edgewise = slot is open horizontally
1st Order Bend Bucco-lingual position

2nd Order Bend Mesiodistal position

3rd Order Bend Bucco-lingual inclination

wire should be rectangular to form couple to provide torque

Preadjusted Edgewise Brackets

Prescriptions Each bracket has its own “prescribed” tooth. The 1st, 2nd, and 3rd order bends are built into the shape of the bracket
itself so you don’t need to bend the wire at all

**Important that the bracket is placed in the

center of the facial surface of the clinical
crowd for it to do its prescribed action**

Types of Brackets
Metal Brackets - Unaesthetic
- Made of SS
- Elastics hold the wire in place within the slot

Ceramic Brackets - More esthetic (can match the tooth shade) -> usually chosen by adult patients
- More brittle and prone to fracture though
- ↑ friction between the bracket and wire makes it harder to adjust wire position
Self-Ligating Brackets -
Built in door locks the archwire into the slot -> don’t need the ligature/elastics as in metal
brackets
- ↓ friction between elastic and bracket -> Potential ↓ Tx time as a result
- More Expensive
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Early Treatment (Phase I)

= During Mixed Dentition

Purpose - Improve overall oral environment (improve malocclusions etc)

- Correct problems that are easier to fix early (Take advantage of growth, compliance, and pliable sutures)
- ↓ complexity of Tx in the permanent dentition phase

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 Posterior Crossbite Transverse issue -> typically a narrow maxilla

** Tx early if there is a functional shift as it can cause skeletal asymmetry as Pt grows into a malocclusion**
- If no functional shift -> can Tx later

Tx: Palatal Expansion (Quad Helix, Hyrax etc)

- As Pt gets older the suture becomes harder and hard to expand so Tx
early
Anterior Crossbite AP Dimension -> can be 1 or a few teeth, or the entire sextant

A few teeth (Dental issue likely) -> Results in wear and gingival strain (Recession)
- Tx: 2x4 braces or an active retainer (finger spring etc)

Full Underbite (Skeletal Class III Malocclusion)

- Tx: Reverse Pull Headgear
Severe OJ AP Dimension issue
- ↑ Risk of Trauma
- Psychosocial, esthetic concern

Tx: 2x4 appliance (tip anterior teeth back) or Class II Headgear to slow maxillary growth at sutures
Anterior Open Bite Causes:
- Thumb Sucking Habit
- Narrow Maxilla w/ posterior crossbite
- Proclined Max. incisors and retroclined mandibular incisiors
- Tongue Thrust Habit
- Pt positions tongue anteriorly during swallowing
- Proclined incisors w/ generalized spacing
Tx: Habit appliance (Tongue Cage)
Palatal Impingement Can cause:
(Deep Bite) - Pain and discomfort
- Soft tissue trauma and damage to gingival attachment
Tx:
- Maxillary Bite Plate (Thick acrylic that protects the top of the mouth and intrudes the lower anteriors)
Impacted Teeth 3rd Molar = #1 impacted tooth
Max. Canines = #2 impacted tooth
- Around 10 you should be able to feel the bulge of erupting canine, and primary C should be getting mobile
Kurol’s Rule:
- Canines NOT past the midline of the lateral incisor = 91% chance of eruption
- Canines beyond the midline of the lateral incisor = 64% chance of eruption
3 H’s:
- How High is it?
- Is it Horizontal?
- Has it crossed the midline of the lateral
Moderate Crowding **Not a huge deal in mixed dentition because leeway space**
avoid tongue pressure
(> 4mm) - Don’t Exo teeth in mixed dentition

Tx: -> Focused on maintaining space for permanent dentition

- Lip Bumper, LLHA lower lingual holding arch-prevent tiping back
Severe Crowding Mostly in cases in of small jaw and large teeth
> 8mm Tx:
- Serial Exo -> C-D-4 (consecutive removal of primary teeth to facilitate the unimpeded eruption of permanent
teeth
**Contraindicated if Pt has a skeletal deficiency**
Process: if done ealry
premolar delayed
1. Start when Maxillary permanent laterals are erupting and we see a lack of space -> Exo C’s erruption
2. Exo D’s -> Encourage the eruption for 1st permanent premolar (wait until root is mostly developed)
3. 4’s erupt -> Exo them -> Gives space for Perm. Canines to erupt in good position and in attached gingiva

dewel-cd4
tweeds-dc4
nance-d4c

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_________________________________________________________________________________________________________________________

Comprehensive Tx and Appliances

Growth Modification
Successful only during periods of growth Generally Speaking:
- Girls: 8-13 Class II
- Boys: 10-15
- Headgear restrains max growth
pubertal growth spurt - Functional appliances stimulate mandibular growth

Class III

- Reverse headgear stimulates maxillary growth

- Chin cup restrains mandibular growth

Headgear
- Best pre-pubertal
- Modifies Growth -> Needs to be warn 12-14hrs per day to be useful (Compliance!)
High Pull/Occipital Headgear Skeletal: Restrains Maxillary forward growth
- Class II Dental: Intrudes and distalizes Upper molars

*Best for Class II Open Bite*

- Class II: Restrains maxillary growth
- Open Bite: Intrudes Posterior teeth

Low Pull/Cervical Headgear Skeletal: Restrains Maxillary forward growth

- Class II Dental: Extrudes and distalizes upper molars

**Best for Class II Deep Bite**

- Class II: Restrains maxillary growth
- Deep Bite: Extruding molars
Reverse-Pull Headgear (Facemask) = Forward Pull on Maxilla
- Class III
Skeletal: Stimulates forward growth, Clockwise rotation of the mandible
Dental: Protraction of U1, Retraction of L1

**Best for Class III Maxillary Deficiency**

- Do it as soon as U1 and 1st molars erupt -> want the maxillary
sutures to be as pliable as possible

Chin-Cup = Restrains mandibular forward growth (in animal models)

- Class III - Not very effective in humans

**Best for Class III mandibular excess**

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 Functional Appliances
- Best during the Ascending portion of the growth spurt
- Influences the normal function of the mandible -> Typically places the mandible in a protrusive position (Class II)
Bionator - Removable Appliance

= Plastic between teeth guides the patient into an advancement of the mandible
(So teeth can clean the block of plastic)
- Labial bow also holds the lips back from retracting the teeth

Pros: Simple, durable, readily accepted by Pts’s

Activator - Removable

= Lingual flanges contact the lingual mucosa near the lower molars and encourages forward mandibular
posture to prevent impingement on the floor of mouth

- More uncomfortable than Bionator and not as well received

Twin Block - Can be fixed or removable

= Inclines on upper and lower blocks forces pt to advance mandible in order to close
soft tissue pull-
Pros: Provides more mandibular changes space behind
the condyle-
bone growth occur to
fill the space

MARA - Fixed Appliance

(Mandibular Anterior Repositioning
Appliance) = Much like the twin block the pt needs to reposition their mandible in order to close

Pros: Less bulky, more durable, and more stable than herbst
Cons: ↓ mandibular advancement vs twin block and herbst
Herbst - Fixed Appliance

= Piston and tube device (adjustable) the passively pushes the mandible forward as the
mandible forward as patient closes -> Not taking advantage of the pt’s musculature to
do the work

Pros: No compliance needed passive

Cons: Easily breaks

Others
- These are more Dento-alveolar modifiers vs growth modifiers
Forsus - Fixed Appliance
= Pushrod spring pushes the teeth

Pros: Non-compliance is a non-issue, More maxillary restriction (Vs Herbst)

Cons: Requies heavy upper and lower archwires

Pendulum - Fixed Appliance

= Banded to the Max 1st molars -> Distalizes and de-rotates molars
pendex-pendulum +palatal expander
- Acrylic button on the palate w/ coils the push the molars back

Pros: Non-compliance
Cons: Effects to the upper arch only
elastics are more of a dentoalveolar than growth modifiers

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Dent-Alveolar Appliances
Palatal Expanders removing for even1? one day might not
- Best during Ascending portion of growth spurt (while sutures are pliable) fit the other day
Schwarz (Split Plate) Removable
- Bad for non-compliant patients, transverse expansion can relapse very fast

= Jackscrew in the center, parents turn the key to expand (1 turn = 0.25mm
expansion)
- Mostly dental tipping, tipping teeth out

**Only use for mild posterior crossbite**

W-Arch Fixed
- Banded to the molars 1/3 skeletal epansion and 2/3 of dental expansion

= Compressed spring, activated when put in the mouth

- Delivers a few hundred grams of force -> slow expansion
Pros:
- More effective, comfortable and efficient than Schwarz (Split Plate)
Quad Helix Fixed
- Banded to molars

= 4 helical loops (2 anterior and 2 posteriors). Similar to the W arch, but the loops
allow us to dictate if we want more or less force in the anterior or posterior
(depending how the loops are activated)

Hyrax Fixed
- Popular today - Bands on the 1st Molars and 1st premolars

rapid palatal expander = Involves jackscrew expander (1 turn a day can provide 100N of force)

Pros: Effective skeletal expansion

Cons: Bulky and more difficult to place, remove, hygiene, compliance (needs
continued activation at home)
Haas Fixed

= Same as Hyrax except it has 2 acrylic pads to contact palatal mucosa (maximizes
the expansion)

Pros: More skeletal expansion

Cons: Really Really hard to keep clean
Transpalatal Arch (TPA) = Usually used for transverse anchorage to keep the arch width steady
- Can be modified to expand though

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Mixed Dentition Appliances
Mixed Dentition Appliances
Nance = Used for the Upper Arch
- Space maintainer (Prevents mesial drifting of molars) or anchorage during
movement to prevent mesial movemetn of molars

Lower Lingual Holding Arch Similar to Nance but for mandible

(LLHA) - Wire rests along the lingual of the mandibular incisors (works better than the acrylic
button as in the Nance)

Prevents mesial drifting of molars and lingual tipping of anteriors

Lip Bumper Used on the lower arch
- Labial wire attaches to tubes on the molar bands -> Acrylic bumper relieves
the lower lip pressure from the incisors and transmits it to the molars
- Tips the molars back and proclines the lower anteriors

Permanent Dentition Appliances

Aligners - Clear and Removable
= Series of trays manufactured according to a prescription written and to be warn by the patient
- Bonded attachments are often required to help in specific tooth movements

Braces - Fixed (Obviously)

Technique
- Enamel prophy -> Pumice removes the dental pellicle and ↑ wettability for bonding
- Etch -> Allows micromechanical bonding of resin to the enamel
- Prime -> Conditions enamel and chemically bonds to resin on the bracket
- Bracket positioning -> Center of the tooth crown, cure the adhesive

Exo Vs Non-Exo

Non-Exo Indications Exo Indications

- Minimal crowding or spacing - Severe Crowding
- Deep Bite (Non-exo, opens bite) - Minimal OB or Open bite
- Flat retrusive lips - Full protrusive lips
- Obtuse nasolabial angle - Acute nasolabial angle
- Anterior recession or thin tissue
- Camouflage

Stages of Comprehensive Treatment Adult Treatment

1. Alignment and Leveling
- More likely to opt for ceramic, lingual or invisible braces
2. AP Correction and Space Closure
- Periodontal conditions should be stable before ortho Tx
3. Finishing and Detailing
- Steel ligatures retain less plaque than elastics
- No growth modification possible

_________________________________________________________________________________________________________________________

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Retention
2 Types of relapse

Elastic Recoil Need to allow time for the reorganization of soft tissue fibers
- Short Term - PDL: Takes 3-4 months -> Full Time Retention
- Dental change - Gingival Fibers: 4-6 months -> Part time retention wear (night time)
- Supracrestal fibers: 1+ years

**Supracrestal fiberotomy (SCF) -> Recommended for teeth with severe rotation**
- This isn’t really done anymore though, pretty aggressive

Differential Jaw Growth = Late Mandibular AP and vertical growth can continue (in small amounts late into
- Long Term adult life) -> Leads to relapse
- Skeletal - Pushing teeth into an unstable position can expose them to cheek, lip, or
tongue pressure -> Causes malalignment over time
- This is why we use a bonded lingual wire on the mandible

Retainers
Hawley Retainer Acrylic on Palate -> Connects all the wires together, controls overbite
(Maxillary) Labial Bow -> Controls Incisor-Canine retention
Adams Clasps -> Controls Premolar – Molar retention

**Customizable to add finger springs or to use as space maintainer if needed**

Hawley Retainer Acrylic on Lingual (or labial)
(Mandibular) Clip on bar from 3-3 -> Usually where most retention is needed

Vacuum-Formed Retainer Clear Plastic

- More esthetic if wearing full time

**Separation of posterior teeth in occlusion may develop**

- Molars are never truly touching in ICP with the plastic in the ay
Lingual bonded retained **Indicated if >2mm of forward repositioning of lower incisors was done, or if large diastema closure of upper
incisors**
- There will be ↑ lip pressure that you need permanent retention to counteract

- Flexible wire attached to the lingual surface of each tooth OR rigid wire bonded to the 2 outside
teeth

Types of Relapse
Class II Relapse Plan for Relapse:
- Overcorrect by 1-2mm during the finishing stage

*More severe the initial class II and the younger the patient is at debonding = ↑ chance you will need headgear or
bionator w/ full time retainer wear*
Class III Relapse Plan for Relapse
- Overcorrect by 1-2mm during the finishing stage

**Continued mandibular growth is very likely and hard to predict/control**

- Surgical correction after growth may be the only answer
Deep Bite Relapse Prevent overeruption of incisors
- Use Upper Hawley retainer with anterior bite plate
Open Bite Relapse Prevent intrusion of incisors and over-eruption of upper molars
- Avoid oral habits (thumb sucking, tongue thrusting)
- Upper modified Hawley retainer w/ Posterior bite blocks
- Vacuum-formed retainer w/ thickened plastic over posterior occlusal surfaces to invade the freeway space
_________________________________________________________________________________________________________________________
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Orthognathic Surgery
- Indicated for the most severe skeletal discrepancies (unsuccessfully treated with growth modification or not possible with growth
modification
- Ex: Class III, Open Bites, Asymmetry

A-P Corrections LeFort I

- Maxillary advancement -> Class III Correction
- Maxillary setback -> Class II correction

BSSO (Bisaggital Split Osteotomy)

- Mandibular advancement -> Class II Correction
- Mandibular setback -> Class III Correction
Vertical Corrections LeFort I
- Maxillary superior repositioning -> Correct open bite and shorten face
- Maxillary inferior repositioning -> Correct deep bite to lengthen face
Transverse Maxillary Expansion (SARPE) aurgically assisted rapid palatal expansion
- Expansion after the maxillary suture has closed
Maxillary Constriction
- Limited

Mandibular Expansion (MSDO) mandibular syphysial distraction osteogenesis

- Limited because there are no sutures to distract make a cut at symphysis
Mandibular construction
Facial Esthetics Genioplasty
- Sliding genioplasty moves chin in all 3 directions
- Submental cut allows you to move the chin wherever you need

Relapse Stability
Soft tissue is to blame for applying relapse pressure

1. Maxilla Up
2. Mandible forward
3. Chin in any direction
4. Maxilla Forward
5. Maxilla up + Mandible forward
6. Maxilla forward + Mandible back
7. Mandible back
8. Maxilla down
9. Maxilla wide

Envelopes of Discrepancy
= Describes the amount of change in tooth position that can be achieved by:

- Orthodontic movement of teeth

- Growth modification of the Jaws
- Surgical reposition of the jaws

**Each envelope is additive**

Envelope of Tooth Movement (Dashed line is where the tooth starts, solid line is where the tooth ends up)
- Inner circle (yellow) shows the possibility of ortho alone
U1:
- Retraction: 7mm
- Protraction: 2mm
- Extrusion: 4mm
- Intrusion: 2mm
L1:
- Retraction: 3mm
- Protraction: 5mm
- Extrusion: 2mm
- Intrusion: 4mm

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 Envelope of Growth - Middle circle (green) shows the possibility if we take advantage of growth modifications
Modification
Restricting Class II Growth: 5mm
- When combined with ortho = 12mm
Restricting Class III growth: 3mm restriction of mandibular growth is hard
- When combined with ortho = 5mm to get

Envelope of Surgical Change - Setting the mandible back is the most significant change that can
be made

Post- Op Complications

BSSO - Damage to the IAN/Paresthesia

- Condylar Sag -> relapse
- Swelling
- Infection
- Bleeding

General Anesthesia Alectasis -> Lung collapse + Fever

Pneumatosis intestinalis -> Air in the intestines + Fever

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