Classification of malocclusion

Angle's classification
•It is based on the arch relationship in the
anteroposterior (sagittal) plane.
•the key relationship in Angle's classification is that of the
first permanent molars.
 •in normal occlusions, the anterior buccal groove of
the lower first permanent molar occlude with the
mesio-buccal cusp of the upper first permanent
molar.
Angle's classification
• Class I. (Normal or neutro-occlusion)
Mesiobuccal cusp of U6 occludes in the buccal grove of L6.
Discrepancies of ≤ ½ a cusp width were also regarded as Class 1.
( Note: In Class I cases, the upper permanent canine occlude into the
embrasure between the lower canine and first premolar)
• Class II. (Disto-occlusion)
Mesiobuccal cusp of U6 occludes anterior to the buccal groove of L6.

• Class III. ( Mesio-occlusion)

Mesiobuccal cusp of U6 occludes posterior to the buccal groove of L6.
Molar Relationship
• Class I Molar relationshipMesiobuccal cusp of the permanent
maxillary first molar occludes in mesiobuccal developmental groove
of first permanent mandibular molar,referred as class I molar
relationship
• Class Il Molar relationship Distobuccal cusp of the permanent
maxillary first molar occludes in mesiobuccal developmental
 groove of first permanent mandibular molar termed as class II
molar relationship
• Class Ill Molar relationship Mesiobuccal cusp of maxillary first
permanent molar occludes interdentally between first permanent
and second mandibular molar are said to be Ill molar relationship
• Canine Relationship
• Class I canine relationship It means, mesial inclination of the cusp
of the upper canine, which overlaps the distal incline of the
cusp of lower canine
• Class Il canine relationship Distal incline of the cusp of upper
canine overlaps the mesial incline of the cusp of lower canine is
termed as class II canine relationship
• Class Ill canine relationship Lower canine is forwardly placed
compared to upper
• canine, hence there is no relationship between upper and lower
canine that exist and is referred as class Ill canine relationship
Canain relationship
Anterior teeth relationship
• Overjet
This is measured from the labial surface of
the most prominent incisor to the labial
surface of the mandibular incisor. This
would normally be 2–4 mm. If the lower
incisor lies anterior to the upper incisors,
then overjet is given a negative value.

• Overbite
This measures how much the maxillary incisors overlap the mandibular
incisors vertically.
Andrews’ six keys of occlusion
Ideal position of teeth
Key 1 Molar relationship – the distal surface of the distal marginal ridge of the
upper first permanent molar occludes with the mesial surface of the mesial
marginal ridge of the lower second molar. The mesiobuccal cusp of the upper
first permanent molar falls within the groove between the mesial and middle
cusps of the lower first permanent molar

Key 2 Crown angulation or mesiodistal tip – the gingival portion of the long
axis of each tooth crown is distal to the occlusal portion of that axis. The
degree of tip varies with each tooth type

Key 3 Crown inclination or labiolingual/buccolingual torque – for the upper

incisors the occlusal portion of the crowns labial surface is labial to the
gingival portion. In all other crowns, the occlusal portion of the labial or buccal
surface is lingual to the gingival portion
Key 4 Rotations – there should be an absence of any tooth rotations within the dental arches

Key 5 Spacing – there should be an absence of any spacing within

the dental arches

Key 6 Occlusal plane – the occlusal plane should be flat

• Intraoral features of
Angle's Class I
malocclusion
• Molar relationship
Class 1
• Canine relationship
Class 1
• Incisor relationship
Class 1
• Spacing in arch
May be present
• Additional features
Crowding
• Spacing
• Rotation
• Missing tooth
• Bimaxillary protrusions
• Midline diastema
Aetiology
Skeletal
• In Class I
malocclusions the
skeletal pattern is
usually Class I, but
it can also be Class
II or Class III with (Class I incisor (b) Class I incisor (Class I incisor
the inclination of
the incisors
compensating for relationship on Class
the underlying I relationship on a
Class II relationship
skeletal on a Class skeletal
pattern
 discrepancy, i.e. dentoalveolar compensation.
relationship on Class I relationship on a Class II relationship on a
skeletal pattern skeletal pattern III skeletal pattern.

Aetiology

Skeletal
• Marked transverse skeletal discrepancies between the arches are
more commonly associated with Class II or Class III occlusions, but
milder transverse discrepancies are often seen in Class I cases.
Increased vertical skeletal proportions and anterior open bite can
also occur where the anteroposterior incisor relationship is Class I.
Soft tissues

• In most cases of Class I malocclusion, soft

tissues is not an aetiological factor,

• Except in bimaxillary protrusion, where the

upper and lower teeth are proclined due to
pressure from the tongue in the presence of
the lack of lip tone.
Dental factors
• Dental factors are the main aetiological influences in Class I malocclusions.
• The most common are tooth/arch size discrepancies, leading to crowding or,
less frequently, spacing. The size of the teeth is genetically determined and
so, to a great extent, is the size of the jaws.
• Environmental factors can also contribute to crowding or spacing. For
example, premature loss of a deciduous tooth can lead to a localization of
any pre-existing crowding.
• Local factors also include displaced or impacted teeth, and anomalies in the
size, number, and form of the teeth, all of which can lead to a localized
malocclusion.
However, it is important to remember that these factors can also be
found in association with Class II or Class III malocclusions.
Diagnosis of Class I Malocclusion
• Clinical
• Examination:
Extra-Oral Examination :
Diagnosis of Class I Malocclusion
• ✓ Profile of the patient: for adults it should be straight neither

convex (class II) nor concave (class III ).

• Clinical Examination:
Diagnosis of Class I Malocclusion
• Extra-Oral Examination :
• ✓ Digital examination: by 2 finger technique. Patient was sitting in upright
position, with no head tilt and the Frankfort plane was parallel to the floor
and the patient looking at the horizon for a far distance object
(physiological natural head position). The teeth were in maximum inter-
digitation. By index finger to palpate the anterior
surface of the basal part of the midline of the upper
jaw (point A) and the middle finger to palpate the
anterior surface of the basal part of the midline of the
lower jaw (point B). If two fingers tips are equal at
same vertical level or the finger slightly anterior to
middle finger, the pattern was a skeletal class l.
•
Diagnosis
Clinical of Class I Malocclusion
• Examination:
Intra-Oral Examination :

• ✓ Upper and lower incisors in class I relationship.

• ✓ Upper and lower molars relationship in class I relationship.
• ✓ Any crowding, spacing, deep bite, open bite, crossbite should be
noticed and local factors
Study Models (Cast Examination) recognized.
•
Diagnosis of Class I Malocclusion
• The main benefit from it is the pretreatment record and space
analysis
Diagnosis of Class I Malocclusion
Diagnosis of Class I Malocclusion
• Radiographic Examination:
• Routinely we take OPG and cephalometric radiograph. In the
cephalometric the ANB angle is the most important indication
of skeletal pattern and it is about2-4° for skeletal class I, which
is the usual for class I occlusion but it is possible to find a class
II or class III skeletal pattern associated with class I
malocclusion.
Diagnosis of Class I Malocclusion

Aims of Treatment :

• 1. To improve aesthetics of the teeth and function of the teeth and

jaws.

• 2. To relieve crowding, close spacing and produce alignment of the

teeth within the arches.
Diagnosis of Class I Malocclusion
• 3. If necessary, to reduce a deepened overbite and improve the
interincisal angle.
Treatment Planning
As there is no antero-posterior arch discrepancy in Class I
malocclusion, the treatment usually involves correction of local
irregularities.
Treatment of the upper and lower arches must be
coordinated. The general aims of treatment will be relief of
crowding and alignment of the teeth. As a rule it is simplest to
plan treatment of the lower arch first then to build the upper
arch around the lower. Usually the size and form of the lower
arch must be accepted if the result is to be stable.
Diagnosis of Class I Malocclusion
As a general rule in class I case, if extractions are being
necessary in the lower arch, matching teeth should be
extracted from the upper arch. However if there is any
asymmetrical problem (e.g. a midline shift) then asymmetrical
extraction pattern may be required. Usually the absence of any
teeth will necessitate modifications to the treatment plan.
Problems Associated with
Class I Malocclusions
1/Crowdin
g
Diagnosis of Class I Malocclusion
• Crowding is by far the most common complaint for
which patients seek orthodontic treatment, especially
that of the anterior region which compromises facial
aesthetics. Crowding may be associated with
Class I, Class II and Class III malocclusion
• Arch length—Tooth material discrepancy where, tooth
material is more than the arch length can lead to crowding.
Crowding may be seen in anterior or posterior regions of one
or both the dental arches. It may be mild or severe, unilateral
or bilateral, localized or generalized.
Diagnosis of Class I Malocclusion

1/Crowding
Diagnosis of Class I Malocclusion
• Etiological Factors:
✓ Discrepancy between the size of the teeth and the size of the
arches or there is malformed or supernumerary teeth.
✓ Environmental factors (early loss of deciduous teeth or caries
in the interproximal area).
✓ Late lower incisor crowding.
When planning treatment for crowding the following should be
considered:
• the position, presence, and prognosis of remaining permanent
teeth
Diagnosis of Class I Malocclusion
• the degree of crowding which is usually calculated in
millimeters per arch or quadrant
• the patient’s malocclusion and any orthodontic treatment
planned, including anchorage requirements
• the patient’s age and the likelihood of the crowding increasing
or reducing with growth • the patient’s profile
Crowding can be classified according to the severity into:

• A. Mild crowding (less than 4 mm per arch)

• B. Moderate crowding (4-8 mm per arch)

Diagnosis of Class I Malocclusion
• C. Severe crowding (more than 8 mm per arch)
Treatment
Relief of Crowding by Creating space:
The amount of space that will be created during treatment
can also be assessed. The aim is to balance the space required
with the space created. Space can be created by one or more
of the following:
• Extractions
• Distal movement of molars
• Enamel stripping
Diagnosis of Class I Malocclusion
• Expansion
• Proclination of incisors
• A combination of any or all of the above
2/Late lower incisor
crowding
• In most individuals inter-canine
width increases up to around 12 to
13 years of age, and this is followed
by a very gradual diminution
throughout adult life. The rate of
decrease is most noticeable during
Diagnosis of Class I Malocclusion
the mid to late teens. This reduction in inter-canine width
results in an increase of any preexisting lower labial
crowding, or the emergence of crowding in arches which
were well aligned or even spaced in the early teens.
Therefore, to some extent, lower incisor crowding can be
considered as an age change.
Late lower incisor crowding
• Certainly, patients who have undergone orthodontic
treatment (including extractions) are not immune from
lower labial segment crowding unless prolonged retention is
employed.
Diagnosis of Class I Malocclusion
The etiology of late lower incisor crowding is not
fully understood. Most authors acknowledge
that the etiology is multifactorial including :
1. Forward growth of the mandible (either horizontally or
manifesting as a growth rotation) when maxillary growth
has slowed, together with soft tissue pressures, which
result in a reduction in lower arch perimeter and labial
segment crowding.
Diagnosis of Class I Malocclusion
2. Soft tissue maturation.

The etiology of late lower incisor crowding is not

fully understood. Most authors acknowledge
that the etiology is multifactorial including :
Diagnosis of Class I Malocclusion
3. Mesial migration of the posterior teeth owing to forces from
the interseptal fibers and/or from the anterior component of
the forces of occlusion.
4. The presence of an erupting third molar pushes the dentition
anteriorly,
i.e. the third molar plays an active role.
5. The presence of a third molar prevents pressure developed
anteriorly (due to either mandibular growth or soft tissue
pressures) from being dissipated distally around the arch, i.e.
the third molar plays a passive role.

Reviews of the many studies that have been carried out indicate that the third
permanent molar has a statistically weak association with late lower incisor
Diagnosis of Class I Malocclusion
crowding. However this crowding can still occur in patients with congenitally
absent third molars.

3/ Spacing
• Definition : is the presence of extra space in the dental
arch associated with spaces (gaps) between the teeth.
Diagnosis of Class I Malocclusion
Etiological
Factors
1. Arch length—Tooth
material discrepancy,
where arch length is
more than the tooth
material can lead to
spacing (Fig. A).

2. Oral habits: Thumb

sucking (Fig. B i and
ii).Tongue thrusting.
Diagnosis of Class I Malocclusion
Etiological Factors
3. Abnormal tooth form: Peg-shaped maxillary
permanent lateral incisors (Fig.C i and ii).
4. Abnormally large tongue exerting pressure on teeth
may cause spacing: Macroglossia
Diagnosis of Class I Malocclusion
Etiological Factors

5. Abnormal tooth size: Microdontia (Fig. D).

Diagnosis of Class I Malocclusion
6. Anomalies in number of teeth: Oligodontia Partial
anodontia. (Fig. E) 7. Bony pathologies like cystic
lesions, odontomes.
8. Congenitally missing teeth. (Figs F i and ii).

Clinical Features of Class I Malocclusion with Spacing

9. Premature loss of permanent teeth.
10. Soft tissue abnormalities: Abnormal labial frenum attachment. (Fig. G).
11. Prolonged retention of deciduous teeth.
• Spacing may be present in one or both the dental arches (Figs A i and
ii).
• Spacing maybe localized or generalized (Fig. B).
• Spacing may be unilateral or bilateral (Fig. C).
Diagnosis of Class I Malocclusion
• Spacing between two
permanent maxillary central
incisors in the midline is often
referred to as midline diastema
( Fig. D )

4/ midline diastema
• A median diastema is a space
between the central incisors,
which is more common in the
upper arch.
• A median diastema may result
from any of several possible
causes:
Diagnosis of Class I Malocclusion
• ✓ Normal physiological stage in the early mixed
dentition (Ugly Duckling stage).
• ✓ Midline supernumerary tooth.
• ✓ Tooth size discrepancy, peg shaped lateral
incisors.
• ✓ Hypodontia, commonly with congenitally
missing lateral incisors.
• ✓ Rarely, frenal attachment appears to prevent
the central incisors from moving together in these
cases, blanching of the incisive papilla can be
observed if tension is applied to the frenum, and
on radiographic examination a V-shaped notch of
Diagnosis of Class I Malocclusion
interdental bone can be seen between the incisors indicating the
attachment of the frenum .
Management
• It is important to take
a periapical
radiograph to
exclude the presence
of a supernumerary
tooth which if
present, should be
removed before
closure of the diastema is
undertaken.
Management
• As median diastemas tend to
reduce or close with the
eruption of the canines,
management can be subdivided
as follows:
• ✓ Before eruption of the
permanent canines intervention
is only necessary if the diastema
is greater than 3 mm and there is
a lack of space for the lateral
incisors to erupt.
Management
• ✓ After eruption of the
permanent canines space
closure is usually
straightforward. Usually
fixed appliances are required
to achieve uprighting of the
incisors after space closure.
Management
5/ Rotation
• Movement of teeth around their
long axis is termed as rotation.
• Rotation may involve a single
tooth, multiple teeth and one or
both the arches. It may be mild or
severe.
• Rotated anterior teeth occupy
less space, whereas rotated
posterior teeth occupy more
space in the arch. Thus, some
Management
amount of space is gained
followed by derotation of
posterior teeth; while correction
of rotated anterior teeth
requires space creation.
Treatment of Class I
Malocclusion with
Rotation
Management
✓ Removable orthodontic
appliance incorporating "Z"
spring along with la bow
(couple force system) can be
used to treat mild rotation.
✓ When there is severe
rotation of a single or multiple
teeth, fixed orthodontic
appliance is the treatment of
choice.
Management
• There is high risk of
relapse associated with
de-rotated teeth due to
stretching of the elastic
supra-crestal fibers in
gingiva. Thus precision
detachment
(circumferential supra
crestal fiberotomy)
followed by long-term
retention is often
Management
required to achieve
stability of the
treatment.

6/ Displaced teeth
Teeth can be displaced for a variety of
reasons including the following:

 Abnormal position of the tooth

germ: canines and second
premolars are the most commonly
affected teeth. Management
Management
depends upon the degree of
displacement. If this is mild,
extraction of the associated
primary tooth plus space
maintenance, if indicated, may
result in an improvement in
position in some cases.
Alternatively, exposure and the
application of orthodontic traction
may be used to bring the mildly
displaced tooth into the arch. If
Management
the displacement is severe,
extraction is usually necessary.
Displaced teeth / Class I
Malocclusion

Teeth can be displaced for a variety of

reasons including the following:

 Crowding: lack of space for a

permanent tooth to erupt
within the arch can lead to or
Management
contribute to displacement.
Those teeth that erupt last in a
segment, for example upper
lateral incisors, upper canines ,
second premolars, and third
molars, are most commonly
affected. Management involves
relief of crowding, followed by
active tooth movement where
necessary. However, if the
displacement is severe it may be
Management
prudent to extract the displaced
tooth.
Displaced teeth / Class I
Malocclusion
Teeth can be displaced for a variety of
reasons including the following:

 Retention of a deciduous
predecessor: extraction of the
retained primary tooth should be
Management
carried out as soon as possible
provided that the permanent
successor is not displaced.
Secondary to the presence of a
supernumerary tooth or teeth:
management involves extraction
of the supernumerary followed by
tooth alignment, usually with fixed
appliances. Displacements due to
supernumeraries have a tendency
to relapse and prolonged
retention is required.
Management
Displaced teeth / Class I
Malocclusion
Teeth can be displaced for a variety of
reasons including the following:

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Management
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Management
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Management
Management

7/ Midline shift
• Midline shift mean lack of
coincidence between the
maxillary and mandibular
Management
dental midline with each other
and/or with the facial midline.
Midline shift of 0.5mm may be
considered as normal.

• Location:
• 1. Maxillary arch.
• 2. Mandibular arch.
• 3. Both.
Management
• Shift may be either to the right
or to the left of the facial
midline.
Midline shift / Class I
Malocclusion

•Causes: could be one or more

of the following:
Management
• ✓ Unilateral early loss or
extraction of deciduous teeth
particularly in crowded arch.
• ✓ Unilateral late eruption or
early eruption of incisor teeth in
crowded arch.
• ✓ Abnormally large or small
anterior teeth in one side of the
arch.
Management
• ✓ Unilateral loss, absence or
extraction in permanent teeth,
particularly the anterior
• ✓ Faulty orthodontic treatment.
• ✓ Extra supernumerary teeth
particularly when unilateral.
• ✓ Abnormalities and pathology
of facial skeleton.
• ✓ Abnormal relation of jaws due
to: a. Premature contact
(deflecting contact and
Management
mandibular displacement
(laterally) b. The maxillary arch is
of a similar width to the
mandibular arch (i.e. it is too
narrow), resulting in mandibular
displacement and cross bite
(unilateral).
Midline shift / Class I
Malocclusion
• Treatment :
Management
• ✓ Lower arch - Do not require
any treatment.
• ✓ Upper arch - slight shift in well
aligned arch should be accepted
But gross shift will be unsightly
and need treatment.
• ✓ Any persisting causative factor
should be removed and
unilateral loss in arch will have to
be balanced by extraction of the
Management
same tooth form the other side
of the arch.
• ✓ To correct shift: fixed
orthodontic appliance is usually
used. But removable appliance
can be used where distal tipping
movement of few teeth should
correct the shift.
• ✓ Midline shifts associated with
mandibular deviation due to
premature contact or unilateral
Management
cross bite should correct itself
after premature contact is
eliminated or crossbite is
corrected.
• ✓ Midline shift associated with
abnormalities or pathology of
facial skeleton is better accepted.
8/
Bimaxillary
Management

Proclination
( protrusion
)
• As the name suggests,
bimaxillary proclination is the
term used to describe
occlusions where both the
Management
upper and lower incisors are
proclined.

• Bimaxillary proclination is seen

more commonly in some racial
groups (for example Afro-
Caribbean)

• Bimaxillary proclination can

also occur in association with
Management
Class II division 1 and Class III
malocclusions.
Bimaxillary Proclination/ Class I
Malocclusion

• When bimaxillary proclination

occurs in a Class I malocclusion
the overjet is increased
because of the angulation of
the incisors
Management
• Management is difficult
because both upper and lower
incisors need to be retroclined
to reduce the overjet.

(a) Class I
incisor
relationship
with normal
axial
Management
inclination
(inter-incisal
angle is
137°); (b)
Class I incisor
relationship
with
bimaxillary
inclination
showing
increased
overjet
(inter-incisal
angle is
107°).
Management
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Management
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Management
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Management
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• Retroclination of the lower

labial segment will encroach
on tongue space and therefore
has a high likelihood of relapse
following removal of
appliances.
Management
• For these reasons, treatment
of bimaxillary proclination
should be approached with
Bimaxillary Proclination/ Class I Malocclusion
caution and consideration
should be given to accepting
the incisor relationship.
• If the lips are incompetent, but
have a good muscle tone and are
likely to achieve a lip-to-lip seal if
the incisors are retracted, the
Management
chances of a stable result are
increased.
• However, the patient should
still be warned that the
prognosis for stability is
guarded. Where bimaxillary
proclination is associated with
competent lips, or with grossly
incompetent lips which are
unlikely to retain the corrected
Management
incisor position, permanent
retention is advisable.
9/ Vertical
Discrepancies

Variations in the vertical

dimension can occur in
association with any
Management
anteroposterior skeletal
relationship, Deep overbite and
open bite.
Management

10/ Transverse
Discrepancies:

A transverse discrepancy
between the arches
results in a crossbite and
can occur in association
Management
with Class 1, Class II, and class
III malocclusions.