Etiology of malocclusion

by:Anshdeep singh c.r.r.i

Introduction
Malocclusion may be defined as a significant deviation from what is defined as normal or ideal occlusion (Andrews,1972) The term normal occlusion' is arbitrary, but is generally accepted to be class I molar relationship with good alignment of all teeth

Classification

Grabers Moyers White & Gardiners Salzmanns

Moyers

Heredity Developmental defects of unknown origin Trauma Physical agents Habits Diseases Malnutrition

White & Gardiners

Dental base abnormalities Pre-eruption abnormalities Post-eruption abnormalities

Salzmanns
GENETIC ENVIRONMENTAL

DEVELOPMENTAL

CONGENITAL

FUNCTIONAL

Grabers

General Factors Local Factors

General Factors

Heredity Congenital Defects Environment Predisposing Metabolic Climate and Disease Dietary Problems Abnormal Pressure Habits and Functional Aberrations Posture Trauma and Accidents

Local Factors

Anomalies of Number of teeth Anomalies of Tooth Size Anomalies of Tooth Shape Abnormal Labial Frenum; mucosal barriers Pre mature Loss Prolonged Retention Delayed eruption of Permanent Teeth Abnormal Eruptive Path Ankylosis Dental Caries Improper Dental Restorations

Heredity

Genetically homogenous population tend to have normal occlusion as the Melanesians of the Philippine islands, in whom the malocclusion is almost non-existent. In heterogenous population , the incidence of jaw discrepancies and occlusal disharmonies is significantly greater.

Primary sites affected by genetically transferred dentofacial deformities

Neuromuscular system Dentition Bone & Cartilage Soft Tissues (except muscles)

Lip deformities

The lower lip plays more important role than the upper lip in function movements and in governing the position of lower incisors in normal function during swallowing, speech & smiling. The inherited pattern of lips can result in malocclusion. Abnormalities in lip form and lip line can cause malocclusion.

Tongue deformities
Tongue Size: Macroglossia Microglossia Tongues Positions In case of incompetent lips, tongue protrudes between the teeth to touch the lower lips. This allows nasal breathing n prevents full vertical development of incisors leading to open bite.

Dentition

Abnormalities
Size, shape, number of teeth Mineralization of teeth Path of eruption in primary position of tooth germ Sequence of eruption

Size

Microdontia

Macrodontia

Shape

Gemination

Fusion

Twinning

Number
Hypodontia
MSX1 & PAX9 genes are found to be involved in some families with non-syndromic autosomal dominant hypodontia .

Hyperodontia
Supernumary teeth,most frequently seen in premaxillary region with male sex predilection, are also genetically determined

Mineralisation

Inherited defects differ from exogenic induced disturbances

present in both deciduous & permanent teeth localized in either enamel or dentin arranged irregularly or as vertical ridges & grooves

Bones & Cartilage

Bone morphology or growth alter occlusal relation & functioning Factors

Bone size Shape of jaw bases Bone location Number of bones present Class II, division 2 Mandibular Prognathism Bimaxillay protrusion Skeletal open bites Mandibular retrognathism

Inherited skeletal malocclusions

Bone size

Macrognathism Micrognathism

Hypolasia of jaws occurs with craniofacial dysostosis, cleidocranial, dysostosis & crouzons diseases

Bone Location

Prognathism

Mandibular prognathism and class II division 2 are attributed to dominant inheritance.

Best known example of familial mandibular prognathism is referred to as the Hapsburg jaw.

Retrognathism

Soft Tissues

Anomalies of Frenum

Ankyloglossia

Hemifacial microsomi

Genetic Syndromes

Achondroplasia Pierre Robin syndrome Craniofacial dysostosis Treacher Collins syndrome Downs syndrome Gardners syndrome Marfan syndrome Cleidocranial dysplasia

Congenital Deformities

Caused by developmental damage during fetal period Cleft lip & Palate

Cerebral palsy Torticollis Congenital syphilis

Cleft lip & Palate

Most frequent congenital deformity Incidence 1:700 live births Can be caused by the use of teratogens like , aspirin, dilantin, 6-mercaptopurine, valium and cigarette smoke. In Unilateral cleft, teeth on the affected site are in lingual cross bite Teeth are frequently crowded in cleft

Cerebral palsy

Paralysis or lack of muscular coordination attributed to intracranial lesion Commonly result of birth injury Lack of motor control causes abnormal function in mastication ,deglutition ,respiration & speech. Thus affects normal occlusion .

Congenital syphilis

Peg shaped laterals Mulberry molars Notched incisors Enamel hypoplasia Delayed eruption Narrow maxillary arch

Prenatal influence

Uterine posture , fibroids of mother , amniotic lesions German measles , maternal diet , metabolism , drug like thalidomide induced deformities

Postnatal influence

Forceps delivery can injure the TMJ Disabling accidents produces malocclusion Milwaukee braces wear produces malocclusion

Maxillary incisors are tipped labially Mandibular incisors fit into deep palatal grooves

Predisposing metabolic climate & disease

Exanthematous fever disturbs developmental time table and often leave permanent marks on surfaces of teeth. Endocrine disorders Infectious diseases

Endocrine disorders

Prenatally , manifest as hypoplasia of teeth. Postnatally , retard or hasten , but do not disrupt the direction of facial growth. May affect the rate of ossification of bone , eruption of teeth & resorption of primary teeth.

Infectious diseases

Nasopharyngeal diseases & impeded nasal breathing. Enlarged adenoids causes

Increased anterior facial height narrow and high palate Retroclined incisors Increased lower facial height Open bite & cross bite

Gingival and periodontal diseases

Causes loss of teeth Ankylosis of teeth

Nutritional deficiency
Malocclusion caused by disturbed developmental time table in : - Rickets Vit. D deficiency - Scurvy Vit. C deficiency - Beri beri Vit. B1 deficiency Malocclusion is caused due to

Premature loss of teeth Prolonged retention Poor tissue health Abnormal eruptive paths

Abnormal pressure habits

Habits are learned patterns of muscle contraction.

Thumb & digit sucking Tongue thrusting Lip biting & sucking Nail biting

Posture

Stoop shouldered child with head hung so that the chin rests on chest may have mandibular retrusion. Child resting his head on his hands or sleeping on his arms , fists can have malocclusion Poor posture accentuates an existent malocclusion

LOCAL FACTORS

1.

Anomalies of number a) Supernumerary teeth. b) Missing teeth (congenital absence or loss due to trauma, caries, etc.) 2. Anomalies of tooth size. 3. Anomalies of tooth shape. 4. Abnormal labial frenum.

5.
6.

Premature loss
Prolonged retention

7.
8. 9.

Delayed eruption of permanent teeth

Abnormal eruptive path Ankylosis

10. Dental caries

11. Improper dental restorations

1) Anomalies of number

A) Supernumerary teeth: Supernumerary teeth is a teeth, which is various in size , shape and location when compared to the normal teeth. B) Supplemental teeth : Supplemental teeth is a teeth ,which is closely resembles the particular group of teeth. This is most commonly seen in premolar region and lateral incisor region.

Supernumerary teeth result from disturbances during the initiation and proliferation stages of dental development. Supernumerary teeth occur most commonly in the maxilla.. The most commonly seen supernumerary teeth is mesiodens. Mesiodens is a small tooth with a cone shaped crown and short root.

Supernumerary teeth

It is seen between the two maxillary central incisors. The presence of teeth obviously has great potential to disturb normal occlusal development. The frequency of other supernumerary teeth are paramolars and distomolars. Multiple supernumerary teeth are seen in cleidocranial dysplasia.

B) Congenitally Missing Teeth

Congenital absence of teeth results from disturbances during the intial stages of tooth formation . Anodontia Total absence of teeth Oligodontia - Absence of many but not all the teeth. Oligodontia showed a tendency for delayed tooth formation

Ectodermal dysplasia
Ectodermal dysplasia is characterized by soft , smooth , thin and dry skin with partial or complete absence of sweat glands. The sebaceous glands and hair follicles are absence. The bridge of the nose are depressed. This also manifested with anodontia or Oligodontia.

Frequency of absence(Missing)

Maxillary and Mandibular third molars Maxillary lateral incisors Mandibular second premolar Mandibular incisors Maxillary second premolar Congenitally missing teeth can lead to spacing between teeth and aberrant swallowing pattern.

Congenitally Missing Lateral Incisors

2)Anomalies of Tooth Size :

A tooth size is determined by heredity . Anomalies of Tooth Size

Microdontia

Macrodontia

True generalized microdontia is usually associated with pituitary dwarfism. True generalized macrodontia is usually associated with pituitary gigantism. The most commonly localized microdontia involves the maxillary lateral incisors (peglaterals).

Microdontia

Macrodontia

3)Anomalies of Tooth Shape :

Intimately related to tooth size is tooth shape. Abnormal shaped teeth predispose to malocclusion. Presence of maxillary-Peg lateral incisors spacing will often occur in the maxillary anterior segment.

Abnormally large cingulum on the maxillary incisor (Talons cusp) or heavy marginal ridge can force the teeth labially and prevent the establishment of a normal overbite-overjet relationship. Mandibular second premolar also shows great variation in shape & size. It may have an extra lingual cusp , which usually serve to increase the mesiodistal dimension of the tooth.

Anomalies of shape can also occur as a result of

amelogenesis imperfecta, hypoplasia, gemination, dens in dente, odontomas , fusion and congenital syphilitic aberration such as Hutchinsons incisors and mulberry molars.

4) Abnormal Labial Frenum

Abnormalities of the maxillary labial frenum are associated with a midline diastema . At birth frenum is attached to the alveolar ridge with fibers running into the incisive papilla. The teeth erupts and as alveolar bone is deposited, the frenum attachment migrates superiorly with the alveolar ridge

Abnormal Labial Frenum

Fibers may persist between the maxillary central incisors and in the V shaped intermaxillary suture , attaching to the outer layer of the periosteum and connective tissue of the suture. Faust in Weber ,noted that diastema may be due to other factors, the possible causative factors : Microdontia, Macrognathia,Super numerary teeth,Peg laterals,Missing lateral incisors ,Habits as thumb sucking, tongue thrusting & midline pathologies

5)Premature loss of Deciduous teeth

Deciduous teeth are the space savers for the permanent teeth. They also maintaining the opposing teeth at the proper occlusal level.

Deciduous cuspids are frequently shed pre-maturely and nature provide more space to align the permanent incisor teeth that have already erupted. Pre mature removal of posterior deciduous teeth because of caries Malocclusion unless space maintainers are placed.

6)Prolonged retention of deciduous teeth

Whatever the reason for the prolonged retention of deciduous teeth, they have a significant impact on the dentition. Whichever deciduous teeth may be retained beyond the usual eruption age of their permanent successor is capable of causing buccal / labial or Palatal / Lingual deflection. Impacted in the maxillary arch might lead to the permanent tooth erupting is a cross bite,which might be difficult to treat at a later stage

Impacted Permanent teeth are more difficult to correct orthodontically, by surgical exposure most commonly impacted tooth is the maxillary canine(3rd molars not in consideration) the reasonIts the last anterior tooth to erupt.

Space occupied by the deciduous canine is lesser than the mesiodistal width of the permanent canines.
It has longer path of eruption

7 )Delayed eruption of permanent teeth

Reasons: 1.Early loss of adjacent primary teeth with a consequential flaring or spacing between erupted teeth may lead to decreased space availability for eruption of the succedaneous teeth. 2. Early loss of primary tooth leading to mucosal thickening over the succedaneous tooth . 3. Early loss of the primary tooth might cause excessive bone deposition over the succedaneous tooth.

4. Due to hereditary in certain children teeth erupt much later than established norms. 5.Presence of supernumerary tooth can block the erupting permanent tooth. 6. Presence of odontomas or other cysts and tumors might prevent the permanent tooth from erupting. 7. Presence of deciduous root fragment that are not resorbed can block these erupting tooth or may deflect it preventing its eruption in an ideal location. 8. Presence of ankylosed deciduous teeth,these might not get resorbed causing a delay in the eruption of the permanent tooth

9. The succedaneous tooth might be congenitally missing delaying the loss of the primary tooth. 10. In certain endocrine disorders the eruption of permanent teeth might be delayed. Eg: hypothyroidism.

8)Abnormal Eruptive path

1.Tooth bud facing and/or placed or displaced from its ideal location. 2.Presence of a supernumerary tooth may divert a tooth from its eruptive path. 3. Presence of odontomas or a cyst tumour may divert it if not altogether prevent its eruption.

4. Un resorbed or retained deciduous teeth might force a tooth to erupt along a path of least resistance rather than in place of the deciduous tooth. 5. Retained root fragments may deflect an erupting permanent tooth. 6.Arch length deficiencies or excess of tooth material may cause one or more teeth to deviate from their eruptive path.

Ectopic Eruption

Malposition of a permanent tooth bud can lead to eruption in wrong place.This condition is called ectopic eruption.

Most likely to occur in the eruption of maxillary first molars. Ecotopic eruption may generally be considered a manifestation of arch length deficiency.

Ectopic eruption

9)Ankylosis

Ankylosis is the condition which involves the union of the root or part of a root directly to the bone, without the intervening periodontal membrane. Ankylosis or partial ankylosis is encountered relatively frequently during the 6 to 12 year age period.

Ankylosis of teeth is more commonly associated with certain infections, endocrine disorders and congenital disorders. Ex : Cleidocranial dysostosis , but there are rare occurrences. Ankylosis may be due to past history of trauma.

10)Dental caries

Dental caries which leads to the premature loss of a deciduous or permanent tooth subsequent drifting of contiguous teeth ,abnormal axial inclination,over eruption and bone loss.

11)Improper dental restorations

Due to improper dental restoration under contoured proximal restoration can lead to a significant decrease in the arch length especially in the deciduous molars.