Transcript incipient malocclusion

BY: Dr. Richa Khanna
An incipient malocclusion is defined as a
condition which shows a tendency
to develop into a deviation from the normal
dentofacial or occlusal relationship
Types....
• DENTAL
• SKELETAL
• DENTO-SKELETAL
 To
prevent their establishment
 To refer at appropriate time.
 To minimize corrective treatment and its
duration.
The modern concept is......
........stressing on
prevention – oriented early detection of
problems

Incipient malocclusions are result of
developmental processes.....and not
pathologic
 Objective
signs and symptoms measured by
the dentist are morphologic characteristics
of malocclusion and NOT physiologic
measurements of function that help to treat
any illness
ALSO.....
While diagnosing......
Parents must be made to understand that a
normal occlusion may not develop always.....
AND....
How future problems could be prevented
and intercepted at INCIPIENT STAGE.
1.
GENERAL EVALUATION:

Initial patient interaction
Chief complaintFind out what is important for the patient,
that is the major concerns.
Medical history
Very important to elicit as orthodontic
problems are mostly developmental
Dental HistoryMay additionally help to elicit parents attitude,
awareness and any hereditary component



 Genetic
historyany history of orthodontic treatment
in siblings, close relatives or parents
themselves.
 Sociobehavioural
history
Difficult to elicit
Parents generally do not tell about
child’s emotional problems.
You may ask about school progress
rather.
Questions related to Quality of life
being affected may be put up.
It has three major areas:
-the patient's motivation for treatment,
-what he or she expects as a result of treatment,
and
-how cooperative or uncooperative the patient is
likely to be.
AGE
 GENDER
 PRENATAL HISTORY
Includes drugs, any illness, type of delivery.

2. STRUCTURAL ASSESSMENT
EXTRAORAL:
a. General
i. Physical growth status: Ht&Wt
To know present status and future potential.
ii. Body type
b. Facial features
i. Facial type
ii. Shape of Head
iii. Facial Profile
iv. Lip posture
v. Relative symmetry of facial structures.
c. TMJ
d. Speech difficulties if any.

 INTRAORAL
EXAMINATIONS:
Jaw relationship( ant-post, vertical,lateral)
b. Open mouth examination:
no. of teeth, any abnormality of size and
shape, restorations, oral hygiene, molar
relation, overjet, overbite, midline.
c. Soft tissues:
Gingiva, frenums,tongue, palate, tonsils,
oral mucosa in general,lips.
a.
 Tooth-Lip
Relationships: Mini-Esthetics:
Tooth-Lip Relationships
This includes:
- Relationship of the dental midline of
each arch to the skeletal midline of that jaw
(i.e., the lower incisor midline related to the
midline of the mandible, and the upper
incisor midline related to the midline of the
maxilla
 - vertical relationship of the teeth to the
lips, at rest and on smile( incisor display)
a.
b. Smile analysis:
- Amount of Incisor and Gingival Display.
- Smile arc , golden proportions etc.
3. FUNCTIONAL ASSESSMENT
RESPIRATION
Tests for checking respiration mode are:
a. Observation without informing the patient
b. Observation while asking the patient to breathe.
c. Mirror test
d. Cotton/Butterfly test
e. Water test


OCCLUSAL INTERFERENCE
Such interferences may lead to deviated paths of
closure, and hence imbalance of musculature. May
affect TMJ.
I.
a.



PREDENTATE PERIOD
Type of delivery:
Crossbite incidence is high in children born
with forceps delivery.
Also, abnormal arch dimensions, increased
height of maxilla and increased length of
mandible is seen
Narrow arches are more common.
b. Preterm birth:

Gestational age less than 37 weeks

Such children are under variety of metabolic
stresses.
 Following
problems in preterm infants may
be index for developing probable
malocclusion problems:
i. Palatal grooves and cleft formation
ii. Primary incisor defects.
iii. Delayed eruption of primary teeth
c. Neonatal jaw relationship:
 No precise relationship exists.
 Anterior openbite seen in gumpads is very
common...and is usually transient.
 Oral habits may influence duration of anterior
openbite.
d. Retained Infantile swallowing:
In the infantile swallowing reflex tongue lies
between gumpads and, mandible is stabilised by
an obvious contraction of facial muscles. The
buccinator is especially very strong
Infantile swallow disappears with eruption of
primary incisors normally.
Sometimes, a transitional state between an
infantile and mature swallowing can be seen
with an open bite.
When infantile swallow persists even after
eruption of permanent incisors, it leads to:
 Very strong contraction of lips
 And Facial muscles, particulary noticeable
are buccinator contractions.
e. Inadequate breast feeding OR early
weaning:
 Lead
to low impact muscle activity
 Problems in normal development of alveolar
ridges, palate.
 And, hence crossbites are frequent in
primary dentition.
 Early introduction of bottle may also lead to
such consequences.
II. DECIDUOUS DENTITION:
A.
DENTAL ARCHES:
What to look for:




Spacing
Crowding
Isolated teeth crowding
Relationship of crowding with any oral
habit
B. TRANSVERSE RELATIONSHIP:
What to look for:
 Midline discrepancies
--- large midline shifts are usually rare in
primary dentition
--- if present... Mandibular shift should be
suspected. It usually manifests as unilateral
crossbite
--- True cause should be looked for - Whether
developmental size discrepancy of jaws is
present

Crossbite
---- Should be treated immediately

Overjet
C. Vertical Dimension:
What to look for:
 Openbite
 Deepbite
D. Eruption problems
What to look for:


Delayed eruption
Missing tooth
E. Habits:
What to look for:
 Associated features
F. Primary dentition terminus
What to look for:
 Second primary molar relationship in non
spaced dentition

Second primary molar relationship in non
spaced mandibular and spaced maxillary
dentition.
If present with a
distal step
Leads to development
of disto-occlusion
immediately after
eruption of permanent
first molars
If present with a
flush terminal
relationship
Leads to development
of disto-occlusion if
maxillary first
permanent molar
erupts before
mandibular
G. Impacted primary teeth:
 Very rare—usually due to trauma...mostly
re-erupt
 Can cause delay in eruption of permanent
teeth
H. Congenital absence of primary teeth
What to look for:
 Agenesis of permanent successors
I. Infected primary teeth:
 These may cause Ankylosis or Enamel
defects in permanent successors.
 Infected teeth also may lead to single
side chewing and hence, hygiene and
malocclusion problems.
J. Retained primary teeth
What to look for:
 Lead to crossbites, ectopic eruption,
malocclusion.
K. Ankylosis of primary teeth:




Very common in primary molars
Can delay eruption of permanent teeth
Inhibit growth of alveolar process,
leading to development of a bony step.
Supraeruption of opposite teeth can also
occur
L. Loss of primary teeth:
 Can accelerate permanent successor
eruption if crown completion is complete
and root formation has started.
 Can delay permanent successor eruption
if crown completion is not complete
M. Premature loss of primary teeth
Lead to:
 Loss of arch length
 Tipping of adjacent teeth
 Supraeruption of opposing teeth
N. Supernumery teeth
M. Abnormal TMJ relationship
-- Leads to development of functional
malocclusions
N. Gingival Or Periodontal conditions leading
to premature loss of Primary teeth
BY: Dr. Richa Khanna
 Earlier
the tooth is lost greater the initial
space loss
 Studies
have reported 1.5mm per year in the
maxilla and 1 mm per year in mandible
 Studies
have also found that greatest space
loss occurs in first four months.(Many
controversial results are reported)
 Studies
2.5 mm
have found the total space loss upto
Kronfeld’s theory states that there are
neutral areas located:
 between the bicuspids in maxilla and
 just mesial to the first molar in mandible.
According to this theory :
 Teeth anterior to neutral zone have a
tendency to drift distally
 Teeth posterior to neutral zone have a
tendency to drift mesially
-- Given by Wright and Kennedy
 Oral musculature and habits
 Time elapsed since extraction
 Dental age, eruption pattern and bony
covering
 Available space
 Interdigitation
 Anamolies
 Sequence of eruption
Two most imporatant variables considered for calculating space
discrepancy in mixed dentition
Space requirement = Space needed for permanent canines + premolars
(calculated from mixed dentition analysis, after taking into account
incisor position, curve of spee, late mesial shift. )
Space available = distance between mesial contact point of permanent
molar and distal contact point of deciduous canine is done.
Space analysis is based on important assumptions:
(1) the anteroposterior position of the
incisors is correct (i.e., the incisors are neither
excessively protrusive nor retrusive),
(2) the space available will not change because of
growth; and
(3) all the teeth are present and reasonably normal in
size.
None of these assumptions can be taken for granted.
All of them must be kept in mind when space analysis
is done.
Besides these , curve of spee and late mesial shift should
also be taken into consideration
Crowding and protrusion are really different
aspects of the same phenomenon.
If there is not enough room to properly align the teeth,
the result can be
crowding,
protrusion,
or (most likely) some combination of the two.
For this reason, information about how much the
incisors protrude must be available from clinical
examination to evaluate the results of space analysis.
This information comes from facial form analysis (or
from cephalometric analysis if available).
The second assumption, that space available will
not change during growth, is valid for most but not all
children.
In a child with a well-proportioned face, there is
little or no tendency for the dentition to be displaced
relative to the jaw during growth, but the teeth often
shift anteriorly or posteriorly in a child with a jaw
discrepancy.
For this reason, space analysis is less accurate and less
useful for children with skeletal problems (Class II,
Class III, long face, short face
 It
uses radiographic measurements for
prediction of sizes of unerupted permanent
canines and premolars.
 The
technique can be used in maxillary and
mandibular arches for all ethnic groups
 Disadvantages:
-
-
This requires an undistorted radiographic
image
Even with individual radiographs, it is often
difficult to obtain an undistorted view of the
canines, and this inevitably reduces the
accuracy.
 It
is a correlational-statistical method

Utilises the correlation between the size of the
erupted permanent incisors and the unerupted
canines and premolars

The size of the lower incisors correlates better with
the size of the upper canines and premolars than
does the size of the upper incisors, because upper
lateral incisors are extremely variable teeth.

The data has been tabulated for white American
children by Moyers

To utilize the Moyers prediction tables,
mesiodistal width of the lower incisors is
measured
this number is used to predict the size of
both the lower and upper unerupted canines and
premolars.

No radiographs are required, and it can be used
for the upper or lower arch.

Values at 75% Confidence Interval from the tables
are found to be most accurate predictions.
 Disadvantages:
-
tendency to overestimate
More accurate for Europeans from which the
data is derived
It is a correlational-statistical method
 uses the width of the lower incisors to predict the
size of unerupted canines and premolars
 It requires neither radiographs nor reference
tables
 Very simple calculations

 Disadvantages:
- the method has good accuracy in Europeans
despite a small bias toward overestimating the
unerupted tooth sizes.
- May not be accurate for all population groups

It is actually a combination of radiographic and
correlational-statsitical method

They found strongest correlation from:
SUM OF WIDTHS OF CENTRAL AND LATERAL
INCISORS IN ONE QUADRANT
+
SUM OF WIDTHS OF TWO PREMOLARS OF SAME
QUADRANT AS MEASURED ON RADIOGRAPH
But these correlations were only for mandible
 From these predictions they devised a prediction
table

Which is the most easy and practical Mixed
dentition analysis
a. Radiographic method
b. Moyer’s
c. Tanaka – johnston
d. Hixon-Oldfather
Which Confidence interval of Moyer’s
prediction tables are used for accurate
predictions?
a. 25th
b. 50th
c. 75th
d. 100th
Neutral zone in the maxilla as given by
Kronfeld lies in:
a. Incisor region
b. Canine refion
c. Bicuspid region
d. Molar region
Which of the following is an indication of
Incipient malocclusion in Primary dentition?
a. Absence of spacing
b. Generalised spacing
c. Leeway spacing
d. Primate spacing
Which is the most important factor that needs
consideration while calculating space
discrepancy in a protruded well aligned
mixed dentition?
a. Upper canine position
b. Lower molar position
c. Lower incisor position
d. Upper premolar position
Disadvantage of Radiographic method of mixed
dentition analysis:
a. Distortion of radiographic image
b. Grayscale disturbances occur
c. Cannot be used in both the arches
d. Cannot be used in all ethnic groups
Consequences of forceps delivery on the
developing jaws and occlusion can be:
a. Openbite development
b. Tongue thrust development
c. Increase in facial height
d. Decrease in mandibular length
Which of the following is considered to be an
Incipient malocclusion warranting treatment
in future?
a. Adequate breast feeding
b. Openbite in predentate period
c. Retained infantile swallow
d. Spacing in primary dentition