Primary Dentition

Outline
Anterior relationship and Angle classification
Development of primary dentition
Ideal occlusion in primary dentition
Deviations from normal
Maturation of oral function
Anterior relationship
Overbite:
o vertical overlap of the incisors
o Max always overlaps in normal occlusion, primary and perm.
Overjet:
o horizontal overlap of the incisors

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Anterior crossbite
o or reverse overjet
o when Man are in front of Max incisors
Open bite
o No overlap of the anterior teeth
Angle classification
Normal occlusion
Class I molar relationship:
o Mesiobuccal cusp of Mx 1st M occludes buccal groove of Mn
1st M
Class I malocclusion

o Molar relationship is correct, but there is

Crowding or
Space
Crossbite
Open bite

Class II molar relationship:

o Buccal groove of Mn 1st M is distally positioned relative to
mesiobuccal cusp of Mx 1st M
o Convex profile
Class III molar relationship:
o Buccal groove of Mn 1st M is Mesially positioned relative to
mesiobuccal cusp of Mx 1st M
o Concave profile

Development of Primary Dentition

Mineralization or calcification of primary teeth occurs in utero
Ground section of enamel has lines (similar to circles in wood)
o Reflect appositional growth of the enamel layers
Striae of Retzius & Neonatal line
A line forms if any disturbance or insult occurs.
o The darker the line, the more severe the disturbance; like
birthing. (neonatal line)
More obvious in perm. dentition
o b/c the child is more susceptible to things outside the womb
Location of neonatal line
Neonatal lines are not in the same position
o Primary incisors have a line closer to gingival 3rd

o Primary 2nd molars are closer to occlusal surface

Calcification:
All primary teeth start calcification before birth
Sequence of calcification (2nd trimester):
o centrals (14wks iu),
o 1st M, laterals, canines, and 2nd molars (18-19wks iu)
o Primary Crowns are complete 1.5-11 mos. Pp (postpartum)
o Permanent calcification begins (3-28 mos) ; 4yrs = crown
finished on M1

Age Terminology: Perinatal Period

There are two ways to determine perinatal age
o LMP last menstrual period
o Conception / Fertilization
This is usually 2 weeks after LMP
What orthos use to determine starting points
Problems with tooth development
2nd trimester = all primary
3rd trimester = all primary + 1st Molars
o Other growth disturbance examples
Just after birth prior to 1 month =
All primarys + M1
Disturbance ~ 3yrs
No primarys, ALL Permanents

Development of primary dentition

Prim. in boys are generally larger than those in girls, gender
difference is not as marked as in the perm.
o Did you get that, he said Perm have a greater difference
male to female than in Primarys
Anomalies less frequently in prim. than in perm.
Less than 1% have congenitally missing prim.
Most frequently missing:
o Mx laterals > Mx centrals > 1st prim M.
Eruption:
The precise time of each tooth eruption is not too important unless

it deviates greatly from the average.

Boys start earlier than girls on average. Which is opposite of the
permanent dentition

Teething
In infant, tooth eruption may be accompanied by a slight
temperature increase, mild irritation of gums, and general malaise.
Holy crap, thats putting it mildly.
Severe symptoms should not be associated. How about severe
crying, staying up all night letting the poor kid chew on a cold
washcloth or carrot til they finally fall asleep around 2am?
Precocious erupted primary teeth familial tendencies
Mn incisors (enamel hypoplasia)
Natal: present at birth
Neonatal: erupt during 1st Mo
o So this could be a problem for nursingum yeah ya think?
pre-erupted: 2nd to 3rd Mo
KEEP if normal, not supernumeraries
REMOVE if loose and aspirate

o Which begs the question: What definition of aspirate do we

have here? Think about it, its been used in a lot of classes
all meaning different things: swallowing something, pulling
back on the syringe etc.

Primary tooth resorption

Eruption of perm. is not the only factor to cause prim. tooth
resorption.
o Can resorbed w/out permanent successors
Primary tooth resorption can be expedited by inflammation and
occlusal trauma,
delayed by splinting and absence of a permanent successor
Ideal occlusion in primary dentition
20 Primary Teeth
Ovoid arch form
Midline coincide
All Mx teeth overlapping Mn
Spacing (spaced anterior teeth & primate space)
o Generalized
o Primate Space alleviates later crowding
Mesial to canine
Distal to canine
Near vertical relationship of anter. (0-2mm overbite/overjet)
Straight/mesial step terminal plane
o If the 2nd molar is positioned distally to the = can lead to
Class II relationship
o Straight plane exists b/c the 2M is larger MD than 2M
Deviations from normal
Crossbite

o Anterior or Posterior
Bilateral True (narrow compared to )
True - This means there is no jaw shift when in
centric occlusion
Unilateral True
True have a straight Frontal View; and a curved Lateral
View
o Functional Crossbite (Pseudo)
Mn shifts laterally and anteriorly
Needs early correction, asymmetry of jaw
Have a stepped Frontal and Lateral View

Ankylosis (of Primary Molars)

o Fusion of bone to dentin and /or cementum
o Clinically
- tooth fails to erupt; bone fails to develop
- almost impossible to move orthodontically
- usually involve primary (Mn) molars
- 20% related to congenitally missing teeth
Occurs 2x more often with than
o The earlier occurs, the more occlusion is affected
Need to consider:

1) loss of arch perimeter or length

2) extrusion of opposing teeth

3) interference with the eruption of perm.

4) inhibition of alveolar bone development

Problem with arch perimeter

o arch perimeter or arch circumference (A)

o arch length/depth (B)
o arch width (C/D) distal of 2M across

o caries of primary teeth

o loss of individual or multiple primary teeth
Exfoliation problem
o Exfoliation should be:
- bilaterally within 6 mos of contralateral teeth
- should occur before the perm. tooth erupts
- in same order as eruption of permanent teeth
Eruption problem
o Asymmetric eruption
Number
- congenitally missing

0.1-0.4% prim (3.9-6.3% perm. Excluding 3rd M)

- supernumeraries

0.5%-prim (1%-perm)
Excessive Space
o Potential causes
- frenum attachment
- supernumerary teeth
yeah, I diagnosed a kid with a mesioden, this
dude had a HUGE friggin gap b/t his incisors.

Maturation of oral function

Physiologic functions of the oral cavity:
o respiration,
o swallowing,
o mastication, and
o speech
Chewing patterns
Adult: opens straight down
Baby: opens laterally
Transition occurs when perm. canine erupts
Open bite cases retain infantile chewing pattern and they
might still suck their thumbno joke
Speech
Gradient from anterior to posterior
First sounds are m, p and b
t & d later
s & z even later with some posterior tongue control
r is the last and requires more tongue control o which reminds mecan you trill your rs?

Mixed Dentition

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Outline

Dev. of mixed dentition

Ugly duckling stage

o Can have space in the incisors, and crowding in the incisors

o

Deformities may improve or eliminate during eruption of the

permanent teeth

Leeway Space
o Differences between 1 and 2 molars that can lead to class I
relationship in perm dentition.

Transition of molar relationship

The eruption pattern is more important than the eruption sequence.

Mixed Dentition

Prim. And Perm teeth in the mouth

Early eruption of 1st M and/or permanent incisors

o 6-8yr erupt as a group
o ~ 8 no perm eruption for a couple of years then @ 11 you go to
late

Late eruption of at least one PM or Can

o ~ 11yr, eruption of PM and can

o one two phase ortho tx.

One phase starts at late mixed
Two Phase starts at early mixed; then monitor growth;
then start second phase

Perm. teeth eruption

Dental age vs. chronological age

o Weak correlation
o

Ex. could reach dental age of 12, but could be chonologically 10F or
14M

Eruption sequences more important than time

o Mx - M1, I1, I2, P1, P2, C, M2, M3 (6,1,2,4,5,3) 7,8*

o Mn - M1, I1, I2, C, P1, P2, M2, M3 (6,1,2,3) 4,5,7,8*

Root formation at time of eruption

Root completion 2-4yrs after eruption

o How long do they take? ~ Inc & PM 3yr; C 2yr; M 4yr
o At the time of eruption

Inc & PM about formed

C about 2/3 formed

Variation of eruption

If Eruption of M2 before C or PM
o Decrease of available space

Asymmetrical eruption
o Normal if < 6mos.

Ideal occlusion in primary dentition

Midline conincide

All teeth overlapping teeth

Near vertical relationship of anteriors

Spacing b/t teeth

Straight/ mesial step terminal plane

Ovoid arch form

20 primary teeth

Spacing is normal in primary dentition

Abnormal : no spaces

Ugly duckling stage

Mx incisors flare laterally

o Normally a mesial inclination

Due to lateral Inc influence

Diastema
o Tend to close with eruption of laterals or canines
o 2 mm or less may close spontaneously

Mild crowdig of Inc

o Permanent Inc are much bigger

Incisor Liability discrepancy in size b/t the primary and permanent

incisor teeth

May be overcome by:

o 1) Interdental spacing
o

2) Incisors & canines erupt labially, esp. Mx

o 3) Incisors procline labially,

4) Repositioning of canine

Decrease of Arch length & perimeter

Both Arches show perimeter & length decrease during the transition stage
o Especially Mandibular

Decrease of 2-3 mm

Maxillary, length remains close to same,

But width increases

o Due to perm inc and canines increase of 5mm

o And about 2-3 mm

Changes in Arch Dimensions

The dental arch perimeter are used to

Align the permanent incisors which typically are crowded upon

eruption

Leeway Space
o Difference b/t prim molars and perm premolars (mesial-distally)

o After loss of prim. 2nd molars there is a late mesial shift of perm 1st
molars

(larger in )

As the larger incisors erupt, they find space by increasing the arch width
by pushing the primary canines distal
o However length of arch does not change

This is possible in the mandible because the space is distal of the primary
canines (space meaning, primate space)

In the maxilla, the primate spaces are mesial of the primary canines

Space for cuspids and premolars

Adjustment of the molar occlusion

Transition of molar relationship

o Straight / mesial step / distal step = terminal plane Steps

o b/c the lower primary 2nd molar is larger than the upper

Shift of teeth b/c of leeway space helps to achieve Class I

Growth of Mandible

Growth graph

Growth spurts : height > mandible > maxilla @ age 14

Minimal Growth > Differential Growth

Distal Step

Flush

End to End > Class I

Mesial Step

Class II > End to End relationship

Class I > Class II >Class III

Body Changes

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Late Mixed / Early Permanent Dentition

Occlusal development
o Primary canines and molars are exfoliating
o Perm canines and molars are erupting
Secondary sexual chracteristics appear & adolescent growth spurt
takes place
o Accelertion
in overall facial growth
differential growth of jaws
Growth Prediction
Need to know when the growth spurt is taking place to maximize
effect of ortho tx on skeletal malocclusion
o Prognathic Cl III skeletal
o Retrognathic Cl II skeletal
Ortho Tx. Late Mixed Dentition
Effect of puberty on ortho tx.
o Prepubertal growth spurt physical changes affect the face and
dentition
Make retrognath pt easier to work on
Make prognath pt harder to work on
64% chance of predicting developmental age from real age
50% chance of predicting dental development from real age
Developmental Parameters
Correlation b/t real age and developmental age

Physical growth status correlates well w/ skeletal age

o Varies from real age
Dental age is a poor correlation w/ other dev. indicators & real age
Must assess
o Skeletal, behavioral, and other dev. ages in planning dental
tx.

Methods of Determining maturity

1. Secondary Sex charcteristics
Adolescent Hormonal Changes
Hypothalamus Releasing Factor to Ant Pituitary Gonadotropins
to adrenal glands & sex organs Sex hormones (estrogen and
testosterone) produced in varying quantities depending on gender
Sex hormones stimulate 2nd sex characteristics
o Acceleration of body growth
Genital growth,
Jaw growth
Shrinkage of lymphoid tissue
o Neural growth essentially done at age 6, not effected by
growth hormones
BoardPearls
Growth of jaw is intermediate b/t neural and general body curves
follows the general body curve more closely than
acceleration in general body curve parallels an increase in sexual
organ and involution of lymphoid tissue

Adolescence Velocity Curves

Boys are two years later than girls

Timing of Puberty
o Puberty longer for boys than girls
o 2nd sex charac provide physiologic calendar of adolescence
that correlates w/ individuals growth status
not all characteristics are readily visible, but most can
be evaluated in a normal, fully clothed exam

Secondary Sex Characteristics

Females pubertal growth 3.5 years
o Stage 1 start to year 1
breast buds and pubic hair
Peak velocity of physical growth occurs about 1
year after stage 1 around beginning of stage 2
o Stage 2 year 1-2.5
Bigger boobs, darker hair down there, armpit hair
growth
Purchase of a personal razor
o Stage 3 year 2.5-3.5
Onset of menstruation growth spurt almost done
Broadening of hips, adult fat distribution, boobs done
growing
Male pubertal growth 5 years
o Stage 1 start to 1st yr
Fat spurt
o Stage 2 year 1-2
Fat , pubic hair, growth of penis, growth spurt
begins
o Stage 3 year 2,3 year 4
Aux. hair, facial hair on upper lip, muscle growth,
less fat, harder body form, peak velocity in height

o Stage 4 years 3,4 year 5

Height growth ends, hair on chin, darker hair down
there, and more muscle strength

Impact of Puberty
Growth in height endochondral bone growth at epiphyseal plates
Sex hormones
o Stimulate cartilage to grow faster
o Increase rate of skeletal maturation

Earlier sexual maturation relates to early cessation of growth

Ortho needs to be earlier in girls to take advantage of the growth
palate
Growth in jaw usually correlates w/ growth in height
o Cephalocaudal gradent of growth evident at puberty
Differential jaw growth
More growth in lower jaw than in upper
o Height chart
Growth in jaw similar ~ easier to track in office

2. Hand Wrist Films

bones
o ossification of bones ~ standard for skeletal development
o 30 small bones w/ a predictable sequence of ossification
yeah, so theyre all numbered, but I cant figure out a
pattern to it, so I am not going to remember which is
which.
Information gathered from films

o Maturity progress
o Repeated films can graph development
o Final stage = epiphyseal diaphysial fusion of the last bone in
which it occurs
o Distinguish nutritional status
o Reveals imbalances in skeletal development
o Discloses scars of interrupted growth record of past illness
Correlations
o Maturational stages and statural height
o Facial growth and general skeletal growth
Esp. mandibular growth
Max rate of circumpubertal facial growth occurs slightly
SMA
o
o

later than peak growth in statural heightwtf

Skeletal Maturation Assessment 1982
Correlated skeletal growth of hand and wrist to facial,
maxillary and mandibular growth peak velocities
4 stages of bone maturation
6 anatomical sites
thumb, third & fifth fingers and radius
11 discrete adolescent SMIs covering the entire period
of adolescent development are found on these 6 sites
4 Stages of SMA
Width of Epiphysis
Ossification
Capping of Epiphysis
Fusion
6 anatomical sites

o Skeletal maturity Indicators SMI

Width of epiphysis as wide as diaphysis

Third finger

Proximal phalanx
Middle phalanx
Fifth finger
Middle phalanx
Ossification
Adductor of sesamoid of thumb
Capping of epiphysis
Third finger
distal phalanx
middle phalanx
Fifth finger
Middle phalanx
Fusion of Epiphysis and Diaphysis
Third finger
Distal phalanx
Proximal phalanx
Middle phalanx
Radius

Hand Wrist Observation Scheme

o Ossification
Y Fusion
Y Fusion
N Capping
N Width
Results
o Maxilla and mandible growth tend to lag behind skeletal
growth
o Acceleration of growth velocity Mx and Mn
Males b/t SMI levels 6 & 7
Females b/t SMI levels 5 & 6
o Maximum growth rate
Males level 7
Females level 6
Current Literature
o Flores 2004 says yep hand wrist does correlate
o Verma 2008 says no it doesnt
o Basically, why do you need to do hand wrist exams when the
CVM measures it close enough

3. Cervical Maturation
Measuring Maturity
Skeletal Age based on cervical vertebrae
Advantage
o Separate radiograph not needed less radiation
o As accurate as hand wrist films
Cervical Vertebrae

o Change from birth full maturity

o Vertebral growth
Cartilaginous layer on the superior and inferior surfaces
of each vertebrae
1928 Study on cervical vertebrae growth
1972 Skeletal age assessment utilizing cervical vertebrae
o mapped maturation stages of cervical vertebrae
1995 skeletal maturation evaluation
o developed index
o Six stages of maturation
Initiation, Acceleration, Transition, Deceleration, Maturation,

Completion
2002 Baccetti improved version of CMV for Assessment of
Mandibular growth
o based on C-2,3,4
o analyzed at the six intervals T1-T6 (combined first stage)
o Peak occurs b/t stage II and III

Peak at green line

Growth Timing in Ortho

Future
o Molecular kits personalized medicine
Dx. growth problems
Personalized developmental status & growth factors and
signaling molecules
o Specific growth discrepancies presicesly targeted
Orthopedic approaches alone
Combination systemic and local interventions

Early Permanent Dentition years

16:12:00

26/11/2010

Growth Pattern in the dentofacial complex

Nasomaxillary Complex
o Passive displacement
Primary dentition years
Sutural growth b/t Cranial base and NMC pushes the
NMC Forward
Slows w/ completion of neural growth ~ age 7
o Active growth of maxillary structures and nose
Surface remodeling resorption and apposition
Grows downward and forward
Bone added in posterior and superior

Nasal Growth
o Passive displacement
Nose grows more rapidly than the rest of the face
in size of nasal cartilaginous septum
Proliferation of lateral cartilages alters the shape of the
nose and adds to the overall increase in size
o Nasal dimensions increase at a rate about 25% greater than
growth of the maxilla

Mandibular Growth
o Relatively steady rate before puberty
Ramus 1-2 mm/yr
Body length increases 2-3 mm/yr
o Juvenile and pubertal growth spurts demonstrate growth
acceleration
o Prominence of chin due to forward translation of mandible
and resorption above the chin

Timing of Growth
o Sequence - growth is completed in maxilla and mandible
Width before adolescent growth spurt
Length during / after puberty
Height during / after puberty
Boys 20; girls 16
Dental Changes During Facial Develoment
Path of eruption of maxillary teeth
o Downward and forward

Translocation
o Teeth moving with jaw
o of total maxillary growth during adolescent growth spurt

Path of eruption of mandibular teeth

o Upward and forward
o Both jaws rotate upward in front
Mandible > maxilla
Mandible decreases in arch length more than
maxilla

Short face individuals - DEEP bite

o Due to excessive (forward,upward) rotation of the mandible
o Low mandibular plane angle

Long Face individuals open bite

o Mn backward rotation

Perm pulp chamber size; eruption > older age

Gingival attachment is above CEJ at eruption

Downward migration of gingival attachment results from vertical

growth of the jaws and eruption of the teeth as opposed to
downward migration of the gingival attachment from perio dz.

Active vs Passive Eruption

Passive Eruption old theory
o Gingival migration of the attachment w/o any eruption of the
tooth
o As long as gingival is healthy, this does not occur

Active eruption current theory

o Eruption of the dentition that is compensating for the
simultaneous vertical jaw growth

Facial types: Class I, II, III Growth Patterns

Classifying Facial Types
o Common Systems
Headform Type
Facial Profile
o Dolicephalics
Long narrow facial pattern
Nasomaxillary complex (NC) is in a more protrusive
position relative to mandible
NC is lowered relative to mandibular condyle which
causes downward and backward rotation of mandible
high angle
Occlusal plane rotated in a downward-inclined
alignment
Tendency towards mandibular retrusion and a Class II
molar
o Brachycephalics
Relative posterior position of maxilla
Horizontal length of NC is relatively short
Overall, tendency toward a prognathic (concave) profile
and a CL III molar

Mesocephalics

o Intermediate headform
o Tendency toward a Cl I molar

Facial Profiles
Convex Cl II
o Retrognathic
Concave Cl III
o Prognathic
Straight
Orthognathic

Ortho: Growth and Development

12/1/2009
Etiology of Orthodontic Problems
Dr. Ingrid Reed
Malocclusion
35% of the population has a normal occlusion
5% of the population have a malocclusion of known cause
60% cause unknown

Relative discrepancy b/t size of teeth & size of jaws

Disharmon facial skel probs

Environmental factors

Causes

Specific causes
Disturbances in embryonic development
Skeletal growth disturbances
Muscle dysfunction
Any force on the teeth and bone will cause movement
Acromegaly & Hemimandibular Hypertrophy (Endocrine Problems)
Disturbances of Dental Deveelopment
Genetic Influences
Environmental Influences
Teratogens
Cleft lip and palate maternal use of
Aspirin
Cigarette smoke (hypoxia)
Dilantin
6 Mercaptopurine (immunosuppressive drug)
Valium
Central midface deficiency Fetal alcohol syndrome
Ethyl alcohol
Disturbances of Dental Development
Congenitally missing teeth
Sometimes runs in families but there is no known gene that is the cause of
this congenitally missing teeth
Malformed and supernumerary teeth
Inteference with eruption
Ectopic Eruption = tooth bud itself is not in the right place
Early loss of primary teeth
Traumatic displacement of primary teeth affects the permanent tooth buds
Genetic Influences
Familial tendencies
There hasnt been a genetic link but you usually see it in more than one
member of a family.
Class III 1/3 of children with Class III had parent with same problem
There are genetic links but not specific genes that can be associated with it.

**Malocclusions
Relative discrepancy between size of teeth and size of jaws
Biggest most common = discrepancy
Results in crowding or spacing
Disharmonous facial skeletal problems = maxilla and mandible dont grow at the
same rate
Tongue thrust results in an open bite
Disproportion between teeth and jaws
Class II/III superimposed crowding or spacing
Figure 1-4
Classified by the MB cusp of the maxillary first molar

Class I MB cusp is in the B groove of the mandibular first molar, if this

doesnt happen the other teeth wont fit together

Class I Malocclusion molar Class I but other problems in the anterior

Class II Malocclusion maxillary molar mesial to the mandibular molar,

increase in overjet usually

Class III Malocclusion maxillary molar distal to the mandibular molar

Functional Components of the Face

The cranium and cranial base is considered a stable point after the age of 7, it runs
from sella in sella turcica to the junction of the nasal and frontal bone. Grows until
age 6.
Where the maxilla grows the teeth go with it, so if the maxilla grows forward the
maxillary teeth will be forward
No teeth = no alveolar process (alveolar process and the teeth go hand in hand)
All of these parts must fit together to have a good facial profile and for the teeth to
be in the right occlusion.
Disharmonious Skeletal Relationships

Class I Bimaxillary protrusion = both jaws are forward, molars in Class I

relationship but everything else if forward

Class II disharmony between the maxilla and the mandible

o

Maxillary excess, normal mandible

Normal maxilla, retruded mandible

Combo (maxillary excess with retruded mandible)

Class III
o

Normal maxilla, prognathic mandible

Retruded maxilla, normal mandible

Combo

Class I/II/III look at the skeleton in a A-P direction

Looking in the transverse direction: look at the maxilla ( you can change it, you
cant change the mandible)

Constricted = maxilla too narrow compared to the mandible

Deep bite/Open bite

Class I

Straight, orthonagthic facial profile

Class I dental relationship and Class I skeletal relationshipCephalometrics

Harmony of the face and teeth

Bimaxillary Protrusion

Class I molar relationship but everything else forward resulting in convex

facial profile

Whole anterior complex forward even though Class I molar relationship and
Class I skeletal relationship

Both jaws too far forward

Class I Crowding

Constricted Maxilla and Crowding Cross bite on one side

Skeletal harmony but disharmony between size of the teeth and the size of
the arch (tooth to jaw relationship)

Tx: Ext of 4 PMs

Class II Division 1

Skeletal Problems maxilla and mandible not in harmony (maxillary excess or

mandibular retrusion)

Division 1 = protruding incisiors and large overjet

Overjet = horizontal overlap of the teeth

Class 1 Class 2 increase overjet

Tx: corrected to Class I molar relationship and has better facial profile

Class II Division 2

Disharmony between maxilla and mandible in the A-P direction

Maxillary incisors define it as this the teeth are retruded (tucked in)
o

Difference between Division 1 and 2: Incisor position

Division 1: teeth protruded, large overjet

Division 2: teeth retruded, associated with deep bite

Ortho alone cannot fix a retruded mandible, you would need surgery

Class III

Maxillary molar is distal to the mandibular molar

Not just the teeth but everything changes usually have a long face with a
cross-bite or edge-to-edge occlusion

Will have a protruded chin

Anterior crossbite = maxillary incisors behind the mandibular incisors

Even when corrected these people have somewhat of the same appearance
because you cant change the bone, but you can correct the relationship of
the teeth

Class III with Spacing

Jaw too big, there isnt enough tooth mass to fill the whole space

Two problems: skeletal disharmony between the maxilla and mandible, and
the teeth are too small to fill the jaws

Esthetically close the space in the anterior but leave the space in the
posterior because we cant increase tooth mass or make the jaws smaller

Esthetics with a class III in women is a big problem that is why some choose
surgery

Class I Unilateral Posterior Crossbite

Transverse problem

Constricted maxilla

Posterior Crossbite and Anterior Openbite

Upper arch inside the mandible in the posterior and no vertical overlap in the
anterior

Anterior openbite is usually associated with tongue thrust

o

They cant swallow properly so they put it between the teeth to create
a seal, this perpetuates the problem

You also have to do some tongue retraining to make sure the tongue
thrust goes away

Deep Bite
o

Overbite, 100% = dont see lower teeth at all; related to

Cephalometrics

Cleft Lip

Cleft lip failure of fusion of median and lateral nasal processes and maxillary
prominence 6th week of development

Usually notch in alveolar process of central and lateral

Affects anterior development

o

Once corrected scar tissue (not as bouncy) restricts the development

of the premaxilla

60% of patients with cleft lip have a cleft palate

Cleft Palate

Closure of the secondary palate elevation of the palatal shelves

Palate closes from the anterior to the posterior so you can have various levels
of failure of fusion

Most minor = cleft uvula

Cleft Palate

Constricted maxilla may be due to the surgery

Etiologic Factors

Maternal use of aspirin

Cigarettes

Dilantin

Valium

Use of immunosuppresent drugs

Cleft Lip
Scar tissue resilience will affect the anterior tooth development
Have all teeth because no cleft palate
Cleft Lip and Palate

See larger problems

The whole maxilla tends to be constricted which leads to anterior cross bite
or rotation in the area between the central and lateral

The cleft affects the eruption of the canine because there is no bone there for
it to come through

Bilateral Cleft Lip and Palate

The premaxilla is quite small but the mandible is fine

There is an affect on the eruption of the teeth and the width of the maxilla

Interesting Case: DOB 5-17-1995

Unrepaired cleft palate

They never treated the cleft palate so he will have eruption problems on that side
He has a fairly good A-P relationship between the maxilla and the mandible
There is a cross bite in the area of the cleft
Tx: tried to develop the arch form and move the teeth so that he could later have
the cleft closed
The lower teeth werent terribly out of alignment but there was some expansion due
to a crossbite
The appliance has a screw in the middle that is turned to push the two sides apart
The midpalatal suture doesnt fuse until about age 15 or 16 so with a patient with a
constricted maxilla you can widen it with an appliance as wide as you need until
that age
Skeletal A-P relationship is good

Disturbance of Dental Development

Congenitally missing teeth

o

Anodontia (none), oligodontia (missing more than 6), hypodontia (less

than 6)

Malformed teeth
o

3rd molars, maxillary laterals incisors (peg lateral or malformed), 2 nd

premolars

Rotated 180 degrees affects occlusion because wrong cusp is

occluding

Supernumerary teeth
o

Mesiodens most common

Other places

Affect eruption of permanent teeth

Ankylosis bone is no longer growing because the bone grew to the tooth

Ankylosed teeth appear to submerge, why? Because as the child grows the
ramus increases in height and the teeth and the alveolar bone grow with it (it
grows 10.25 cm between eruption and age 18). When you have a tooth that
is ankylosed the cementum is attached to the bone and everything stops.
The bone can no longer grow in that area. The teeth and bone adjacent to
this area continue to grow and make it appear that the tooth has submerged.
It will be below the margin of the occlusal plane. The problem with this is
that when there is not interproximal contact the tooth behind it tips over and
screws with the occlusion.

Supernumerary Teeth

There is a color difference between the permanent and primary teeth the
primary teeth are whiter (milk teeth)

Ectopic Eruption tooth is not coming in the right place

Malposition of a permanent tooth bud

Can lead to eruption in the wrong position

Can also be caused by retained primary tooth, crowding

Could also mean resorption of a tooth other than the primary that is
supposed to be resorped

Example: permanent lateral is causing the resorption of both the primary

lateral and canine

Most common Maxillary first molar

o

Causes resorption of the primary second molar and it doesnt come

into the mouth

Other common tooth that erupts ectopically and/or impacts Maxillary

canine (second most)

If it doesnt have the right vertical area and crosses over the lateral it causes
a problem, it wont come into the right path
o

The canine can move palatally where it will stay impacted or buccally
where it may erupt a little bit

The second primary molar is larger than the premolar that replaces it.

If the premolar isnt lined up exactly under the primary molar it will fail to
resorb the mesial root of the primary tooth and the deciduous tooth will not
exfoliate on its own and will need to be extracted. Depending on the amount
of root formation the tooth may have to be brought in orthodontically.

Ectopic eruption can result in an impacted second molar.

Environmental Factors

Loss of arch perimeter

o

Caries

Early loss of primary teeth

Thumb and digit sucking

Tongue thrust

Mouth breathing

Early Loss of Primary Teeth

Maintain symmetry

Mesial drift of molars, distal of incisors and canines

Avoid loss of arch perimeter

o

Guaranteed to have crowding if you lose this

lower ligual arch

maxillary hayes nance

Loss of primary teeth without space maintenance creates a huge problem

orthodontically
Ankylosis
Loss of perimeter as anterior teeth tip in
The opposing teeth can supererupt and the adjacent teeth can drift into the space.
It can prevent the eruption of the permanent tooth.
Thumbsucking

Causes anterior open bite and constricted maxilla

Retroclining of mandibular teeth

Tx
o

Tongue cribs - reminders

Traumatic Displacement of Teeth

Results of trauma

Defect in crown

Dilaceration

26/11/2010 16:12:00
Eriksons -

Age Range

Common Characteristics

Dental Considerations

Emotional
Development
Stage
Development of

Birth to 19 months

Trust

Basic trust develops

If dental work is necessary

Depends on caring mother/mother

Parent present

substitute

Parent holds child

Physical growth can be retarded if

Children who havent developed

emotional needs are not met

basic trust will need special effort by

Strong bond creates separation

dentist and staff

anxiety
Development of

18 months to 3

Uncooperative behavior

Autonomy

years

Child developing autonomy

Child struggling to exercise free

Offer simple choices color of bib

choice

Allow parent to be present

Still dependent on patents in times

Complex dental treatment

of insecurity

Sedation or

General anesthesia

Continued development of

Usually first visit

autonomy

Exploratory visit with mom present

Development of

3-6 years

Initiative

Physical activity and motion

Extreme curiosity and questioning

Aggressive talking

Have child think whatever dentist

wants is his/her choice

and little treatment

After initial visit will tolerate

separation from mother and usually
behave better

Reinforce independence over

dependence

Mastery of Skills

7-11 years

Acquiring academic, social skills

Learning rules

started, phase I or functional

Competitionwithin a reward system

appliances

Decrease parents

Set attainable goals

Increase peer groups

Positievely reinforce success

Likely to faithfully wear headgear

Often orthodontic treatment is

and/or removable appliances

Development of

12-17 years

Intense physical development

Instructions explicit and concrete

Most orthodontics is done at this

Personality

Development of

Young adult

Intimacy

Guidance of the

Adult

Next Generation

Psychological development

Can exist outside family

Behavior management a challenge

Belonging to a larger group

Motivation is key

Complex stage

External

Time of stress and rewards

Internal

Establishment of ones own identity

Development of relationships

Trying to correct a dental

Factors of acceptance and success

Appearance

Personality

Emotional qualities

Intellect

orthodontics should be explored

Others

from the start

Successful parenting

Supporting services for the next

time

appearance they see as flawed

Feel change in appearance will

change outcome of relationships

Potential psychological impact of

generation

Attainment of

Late Adult

Opposite characteristics

Stagnation

Self-indulgence

Self centered behavior

Individual has adapted to the

Integrity

combination of gratification and

disappointment that every adult
experiences

Cognitive

Assimilation

Opposite is despair

Accommodation

Development
Theory of Jean
Piaget
Sensorimotor

Birth to 2 years

Goes from reflex activities to

behavior to cope with new situations

Concept of objects

Communication limited

Little ability to interpret sensory

data

Cognitive structures

Preoperational

2 to 7 years

Literal nature of language

Understand the world through

senses

Period of concrete

7-11 years

operations

Abstract ideas hard to grasp

Egocentrism

Animism

Improved ability to reason

Ability to see another point of view

Animism declines

Instructions must be very clear and

concrete

Period of formal

~11 years to

Abstract concepts and reasoning

operations

adulthood

Imaginary audience

Personal Fable