Treatment Planning

Planning the Final Interincisal Relationship:

Establishing an ideal inter-incisal relationship is a prime objective in treatment planning.

Class I Incisor Relationship:

 Usually satisfactory, so treatment plans should aim to preserve it.

Class II, Division 1 Incisor Relationship:

 Severity of skeletal discrepancy determines treatment choice.
 Retroclination of maxillary incisors may suffice in underlying Class I skeletal pattern.
 Mild Class II skeletal pattern may require camouflage treatment with fixed appliances.
 Severe cases often need growth modification or surgical treatment.

Class II, Division 2 Incisor Relationship:

 Palatal root torque or proclination of maxillary incisors may achieve desired interincisal relation.
 Severe cases may require proclination of maxillary incisors followed by growth modification or surgery.

Class III Incisor Relationship:

 Forward path of closure (pseudo-Class III) may be corrected by proclination of maxillary incisors.
 Severe cases may require proclination of maxillary incisors and retrodination of mandibular incisors.
 Surgical correction may be necessary in very severe cases.

Planning Space Requirements:

Correction of Crowding: Rotations:

1 mm of arch length (space) required for every mm of Space required for derotating teeth calculated by
crowding. subtracting proximal surface distance from total mesio-
distal width.
Leveling the Curve of Spee: Correction of Proclination:
Excessive curve of Spee requires space for leveling to Retraction of proclined teeth requires space; 2 mm of
prevent unstable proclination. space needed for every 1 mm of reduction in
proclination.
Molar Correction: Space for Anchorage Loss:
Molars should be moved to achieve stable Tooth movements often result in anchorage loss.
intercuspation. Approximately 40% of space is lost in extraction cases
due to mesial movement of posterior teeth.

Methods of Gaining Space:

1. Use of existing spacing 5. Distalization
2. Proximal stripping 6. Uprighting of molars
3. Expansion 7. Derotation of posterior teeth
4. Extraction 8. Proclination of anteriors

Planning Extractions:
Extraction of teeth is integral to orthodontic procedures to address arch length-tooth material discrepancies,
crowding, proclination, and inter-arch relationships.

Class I Skeletal or Dental Pattern: Class II Cases:

Extractions should be done in both upper and lower Upper arch forwardly placed or lower arch set back;
arches to maintain buccal occlusal relationship. extracting only in the upper arch can reduce abnormal
upper protrusion and discourage upper arch forward
development.
Extraction only in maxillary arch may result in Class II
molar and Class I canine relation.
 Lower Arch Crowding or Incomplete Class II Angle's Class III Cases:
Occlusion: Avoid upper arch extractions to prevent retarding
Extractions may be needed in both upper and lower maxillary forward development.
arches to achieve Class I molar and canine relation. Preferably treat by extraction only in lower arch or
extraction in both arches.

Planning Anchorage:
Importance: Minimizing unwanted tooth movements is crucial to treatment success.

Factors Determining Anchorage Demand:

1. Number of teeth being moved: More teeth moved, higher demand on anchorage.
2. Type of teeth: Multi-rooted posteriors demand more anchorage than smaller teeth.
3. Type of tooth movement: Bodily movements strain anchorage more than tipping movements.
4. Duration of treatment: Prolonged treatment strains anchor teeth, leading to greater anchorage loss.

Selection of Appliance:

Growth Potential: Type of Tooth Movement:

Growing patients with skeletal malocclusion benefit Removable appliances suitable for simple tipping
from appliances that modulate growth to solve or movements.
prevent worsening of existing skeletal problems. Fixed orthodontic appliances required for bodily tooth
movements and complicated tooth movements like
rotation, root movements, and axial movements.
Oral Hygiene: Cost:
Fixed appliances pose higher risks of caries, Removable appliances are less expensive than fixed
decalcification, and plaque accumulation compared to appliances due to shorter chairside time and limited
removable appliances, demanding meticulous oral material use.
hygiene maintenance.

Planning Retention:

Stretched Periodontal Ligament: Unstable Occlusion:

Stretched gingival fibers, especially common in rotated Teeth in unstable positions post-orthodontic therapy
teeth, take time to reorganize, necessitating adequate are prone to relapse.
retention for an appropriate period.
Continuation of Growth Pattern:
Post-treatment continuation of the growth pattern that caused skeletal malocclusion leads to resurfacing of
malocclusion.

Management of Midline Diastema:

Anterior spacing between maxillary central incisors.
Frequently seen malocclusion, easy to treat but difficult to retain.

Causes:

1. Transient Malocclusion: 2. Tooth Material - Arch Length Discrepancy:

 Often self-correcting.  Arch length exceeds tooth material due to missing
 Seen in deciduous dentition and mixed dentition. teeth, microdontia, macrognathia, or extractions
 Eruption of permanent canines displaces roots of leading to tooth drifting.
lateral incisors mesially, causing midline spacing.
3. Abnormal Frenal Attachment: 4. Pressure Habits:
 Thick labial frenum prevents central incisors from  Thumb sucking, tongue thrusting predispose to
approximating due to fibrous connective tissue. midline diastema, often associated with
proclination and anterior spacing.
 5. Midline Pathology: 6. Iatrogenic Causes:
 Soft tissue or hard tissue pathologies like cysts,  Rapid maxillary expansion leading to
tumors, odontomes. intermaxillary suture opening.
 - Presence of unerupted mesiodens between central
incisor roots.

Management Approach:
 Treatment modality depends on the cause and severity of diastema.
 Conservative approaches for transient malocclusions, addressing habits, or pathological causes.
 Surgical intervention for abnormal frenal attachment or midline pathology.
 Orthodontic treatment for tooth material-arch length discrepancy, often involving space management and
alignment.

Diagnostic Approach:
1. Blanch Test:
 Diagnostic for fleshy labial frenum.
 Pulling upper lip outwards to observe blanching of tissue in incisive papilla region.

2. Radiographic Evaluation:
 Notching in inter-dental alveolar bone indicates thick fleshy frenum.
 Midline radiographs aid in diagnosing midline pathology causing spacing.

3. Model Analysis:
 Determines tooth material-arch length discrepancies.

Treatment of Midline Diastema:

1. Removal of Cause
 Eliminate habits using fixed or removable habit breakers.
 Extract unerupted mesiodens.
 Perform frenectomy for thick fleshy frenum.
 Treat any underlying midline pathology.
2. Active Treatment
 Utilizes removable or fixed appliances.
Removable Appliances Fixed Appliances
 Finger springs or split labial bows to close midline  Incorporate elastics or springs for rapid correction.
spacing.  Elastics stretched between central incisors or using
 Finger springs placed distal to central incisors. elastic thread/chain.
 Split labial bows extend to distal aspect of  Closed coil spring or M-shaped springs activated
opposite central incisor. by closing helices.
3. Retention
 Long-term retention crucial.
 Lingual bonded retainers recommended.
 Other options include banded retainers, Hawley's retainers, etc.
Cosmetic Restorations Prosthesis/Crown
 Esthetic composite resins used for adult patients.  Peg-shaped laterals or teeth with anomalies require
 Gradual composite build-up on mesial surface and prosthetic rehabilitation.
stripping of distal surface for natural shape and  Missing teeth replaced with fixed or removable
size. prosthesis.

Crowding
 Common manifestation of Class I malocclusion.
 Results from disproportion between tooth size and arch length.
 Can be caused by various factors leading to tooth misalignment.

Etiology:
1. Arch Length-Tooth Material Discrepancies: 4. Abnormalities in Tooth Size and Shape:
 2. Supernumerary or Extra Teeth 5. Premature Tooth Loss:
3. Retention of Deciduous Teeth

Diagnosis:
 Clinical examination to determine extent and location of crowding.
 Model analysis for arch length-tooth material discrepancy.
 Identify possible causes for crowding.

Treatment:
1. Gaining Space:
 Calculate amount of crowding and determine methods to gain space (proximal stripping, expansion, extraction,
etc.).
2. Removable Appliances:
 Incorporate coil springs, canine retractors, or labial bows to move teeth to non-crowded positions.
3. Fixed Appliances:
 Use multilooped archwires or resilient nickel-titanium wires for effective correction of crowding.

Rotations
 Tooth movements around their long axes.
 Two types: Mesio-lingual or Disto-buccal rotation, and Disto-lingual or Mesio-buccal rotation.

Treatment:
1. Space Management:
 Provision for space is crucial for treating anterior tooth rotations.
2. Removable Appliances:
 Mild rotations can be treated with a removable appliance incorporating a double cantilever spring and a labial
bow.
3. Fixed Appliances:
 Use rotation wedges, resilient archwires like nickel titanium, elastic threads, or derotation springs for effective
treatment.
4. Retention:
 Long-term retention is essential due to high risk of relapse.
 Precision or circumferential supracrestal fibrotomy may be needed to prevent relapse by incising gingival
fibres.

Management of Class II Malocclusion

Class II Malocclusion:
 Mandibular arch is distal to the maxilla.
 Characterized by Class II molar relationship.
 Two main forms: Class II, division 1 and division 2.

Class II, Division 1 Malocclusion:

Features:
1. Class II molar relationship. 6. Lack of anterior lip seal.
 Can vary from end-on molar to full Class II.  Restoration essential for maintaining corrected
2. Proclined maxillary anterior teeth. position.
 Increased overjet. 7. Abnormal muscle activity.
3. Convex profile.  Constricted upper arch, predisposing to posterior
4. Lower anterior teeth fail to contact upper anteriors. crossbite.
 Increased overbite and curve of Spee.  Hyperactive mentalis activity common.
5. Short hypotonic upper lip. 8. May have proclined lower anteriors.
 Lip trap phenomenon.  Natural compensation to reduce overjet.
Skeletal Features:
Class II malocclusion may have abnormal skeletal relationships:
1. Maxillary protrusion.
2. Mandibular retrusion.
3. Combination of maxillary protrusion and mandibular retrusion.

Etiology of Class II Malocclusion:

1. Prenatal Factors:
a) Hereditary: Genes determine jaw size, position, and relationship.
b) Teratogenesis: Certain drugs during pregnancy can lead to abnormal development.
c) Irradiation: Exposure to radiation during pregnancy can alter development.
d) Intrauterine Fetal Posture: Abnormal posture may affect mandibular growth.

2. Natal Factors:
a) Trauma during Delivery: Improper forceps application can cause condylar region trauma.
b) TMJ Complications: Ankylosis or fibrosis due to trauma can lead to mandibular underdevelopment.

3. Postnatal Factors:
a) Traumatic Injury: Injuries to the jaw or TMJ.
b) Irradiation Therapy: Long-term therapy affecting skeletal cranio-facial region.
c) Infectious Conditions: Conditions like rheumatoid arthritis can affect mandibular growth.
d) Abnormal Function: Oral respiration, abnormal swallowing, and habits like thumb sucking can hinder
muscle activity.

Treatment Objectives:
 Relieve crowding and irregularity.
 Establish stable incisor and molar relationship.

Approaches to Treatment:
1. Growth Modification: 2. Camouflage:
 Correct maxillary prognathism or mandibular  Extraction of teeth and orthodontic tooth
deficiency using myofunctional appliances. movement to mask underlying skeletal
 Face bow with headgear restricts further maxillary discrepancies.
growth.  Repositioning teeth for optimal occlusion post-
 Appliances like Herbst appliance or Jasper Jumper growth.
for fixed functional correction.
3. Surgical Correction:
 Maxillary setback or mandibular advancement in severe cases of skeletal malrelationship.
 Undertaken after growth completion.

2. Camouflage:
 In patients beyond growth, growth modification procedures are not feasible, so orthodontic tooth movement is
employed to camouflage underlying skeletal discrepancies.
 This often involves extracting certain teeth and moving the remaining teeth into the space created.
 Extraction allows for achieving correct molar and incisor relationships despite the underlying skeletal
discrepancy not being addressed directly.
 It implies that major skeletal changes are not possible after growth cessation, and the orthodontist aims for the
best possible occlusion within the limitations of skeletal jaw relations.
 Repositioning of the teeth can significantly impact facial aesthetics.
 Space requirements in the upper and lower arches vary but generally aim to reduce overjet, overbite, correct
minor local irregularities of teeth, and stabilize molar relationships.

Patient Criteria for Camouflage:

1. Patient is too old for successful growth modification using myofunctional appliances.
2. Mild to moderate skeletal Class II malocclusion.
3. Reasonably well-aligned teeth with available extraction space for retraction.
4. Good vertical facial proportions without deep or open bites.

Extraction Strategy:
1. Upper first premolars are most frequently extracted.
2. Extraction may be unilateral or bilateral depending on the specific needs of each case.
3. Upper and/or lower premolars may be extracted based on the severity of malocclusion and space requirements.
4. Second premolars may be extracted in cases where minimal anchorage is needed.

Additional Techniques:
1. Distal driving of maxillary molars may be employed in mild Class II malocclusions before eruption of second
molars.
2. Surgical correction is considered for severe skeletal malrelationship after growth completion, involving
maxillary setback or mandibular advancement surgeries.

Class II, Division 2 Malocclusion:

 Characterized by a Class II molar relationship with retroclined upper central incisors overlapped by the lateral
incisors.
 Variations may include retroclined canines.
 Retroclination of upper incisors compensates for the Class II skeletal pattern to reduce overjet.

Features of Class II, Division 2:

1. Molars in disto-occlusion. 1. Broad square face.
2. Retroclined central incisors, occasionally other 2. Backward path of closure.
anteriors. 3. Deep mentolabial sulcus.
3. Deep overbite. 4. Absence of abnormal muscle activity.
4. Pleasing straight profile.

Treatment Objectives:
1. Relief of gingival trauma. 3. Relief of crowding and local irregularities.
2. Correction of incisor relationship. 4. Correction of buccal segment relationship.

Extraction and Correction:

 Like Class II, Division 1, extraction is employed to address the buccal segment relationship.
 Deep anterior overbite and retroclination are treated by reducing incisal overbite and altering incisal
inclination.
 Reduction of overbite can be achieved using anterior bite planes or fixed appliances with anchor bends or
reverse curves of Spee.
 Torquing springs may be used to adjust incisor inclination.

Role of Functional Appliances:

 During the mixed dentition period, proclination of maxillary incisors can be done to convert Class II, Division
2 into a malocclusion resembling Class II, Division 1.
 Functional appliances, as used for Class II, Division 1 malocclusion, can then be employed.

Management of Class III Malocclusion

Class III Malocclusion Overview:
 Represents a condition where the mandible is in a mesial relation to the upper arch.
 Class III molar relationship defined by the mesio-buccal cusp of the upper first molar occluding between the
mandibular first and second molars.

Features of Class III Malocclusion:

1. Class III molar relationship. 5. Concave profile due to prominent chin.
2. Incisors may be in edge-to-edge or anterior 6. Vertical growers may exhibit increased inter-
crossbite relationship. maxillary height and anterior open bite.
3. Upper arch often narrow and short, lower arch 7. Deep overbite may occur.
 broad, leading to posterior crossbites. 8. Pseudo Class III malocclusion: occlusal
4. Upper teeth may be crowded due to narrow upper prematurities result in habitual forward positioning
arch; mandibular arch often spaced. of the mandible, with a forward path of closure.

Skeletal Features of Class III Malocclusion:

 Often associated with underlying skeletal malrelations.
 Commonly seen skeletal features include:
1. Short or retrognathic maxilla.
2. Long or prognathic mandible.
3. Combination of the above features.

Treatment Considerations:
 Treatment of Class III malocclusion may be challenging due to its skeletal component.
 Orthodontic treatment may involve dental compensation to improve occlusion and appearance.
 Surgical intervention may be necessary in severe cases to correct underlying skeletal discrepancies.
 Treatment aims to achieve functional occlusion, improve facial aesthetics, and address any associated issues
such as crowding or open bite.

Etiology:
 Class III malocclusion with underlying skeletal imbalance is often inherited, suggesting a strong genetic basis.
 Other causes include habitual forward positioning of the mandible due to occlusal prematurities or enlarged
adenoids.

Treatment Rationale:
 Early recognition and treatment of Class III malocclusion are crucial due to several reasons:
1. Early interception can reduce the severity of the developing malocclusion by modulating abnormal skeletal
patterns.
2. Anterior crossbites in Class III malocclusion can retard maxillary growth by locking the maxilla within the
mandible.
3. Occlusal forces on mandibular incisors in crossbite encourage further forward growth of the mandible,
worsening the condition.

Interception during Growth:

 Growth modulation procedures aim to intercept developing skeletal malocclusion:
a. Frankel III or myofunctional appliances for Class III due to maxillary skeletal retrusion.
b. Reverse activator for mandibular prognathism.
c. Reverse headgear (or face mask) for severe Class III due to maxillary retrusion.

Frankel III Chin cup therapy

To intercept a class III malocclusion due to maxillary For class III malocclusion with protrusive mandible
skeletal retrusion and normal maxilla
Can also be used as a retainer after maxillary Two types; occipital pull chin cup and vertical pull
protraction using a facemask chin cup (in those with steep mandibular plane angle,
excessive anterior facial height)
Causes the backward repositioning of the mandible,
redirection and remodelling of mandibular growth

Treatment of Anterior Crossbite:

 Mild cases treated with lower anterior inclined planes or removable appliances with expansion screws.

Treatment of Posterior Crossbite:

 Accompanying posterior crossbites can be treated with rapid maxillary expansion.

Role of Extractions:
 Lower arch length deficiency and anterior crossbite may be addressed by extracting lower first premolars
followed by mechanotherapy.
 Class III intermaxillary elastics retract lower anteriors.
 In cases of deficiency in both arches, first premolars are extracted in both upper and lower arches (lower 4,
upper 5).

Treatment of Severe Class III after Growth:

 Surgical and corrective procedures are employed.
 Maxillary deficiency treated by Le Fort I osteotomy for maxillary advancement.
 Mandibular prognathism treated by mandibular setback procedures.

Treatment of Pseudo Class III:

 Removal of occlusal prematurity improves pseudo Class III malocclusion.

Management of Open Bite

Overview of Malocclusion:
 Malocclusion can manifest in three planes of space: sagittal, transverse, and vertical.
 Open bite is a malocclusion occurring in the vertical plane, characterized by the absence of vertical overlap
between maxillary and mandibular dentition.
 Open bites can manifest anteriorly or posteriorly, termed anterior open bite and posterior open bite respectively.
 Diagnosis, treatment, and retention of open bite malocclusion pose challenges to clinicians due to multifactorial
etiology.

Anterior Open Bite:

 Characterized by lack of vertical overlap between upper and lower anterior teeth.
 Aesthetically unattractive, particularly noticeable during speech when the tongue presses between teeth and
lips.

Classification of Anterior Open Bite:

a) Skeletal anterior open bite.
b) Dental anterior open bite.

Etiology of Anterior Open Bite:

 Multifactorial etiology involving both hereditary and non-hereditary factors.
 Potential causes include:
i. Prolonged thumb-sucking habits, influenced by posture, intensity, and frequency, may contribute to open
bite.
ii. Tongue thrusting implicated in some cases.
iii. Nasopharyngeal airway obstruction and mouth breathing play significant roles.
iv. Inherited factors like increased tongue size and abnormal skeletal growth patterns of the maxilla and
mandible may contribute.

Features of Skeletal Anterior Open Bite:

1. Increased lower anterior facial height. 7. Divergent cephalometric planes.
2. Decreased upper anterior facial height. 8. Steep anterior cranial base.
3. Increased anterior and decreased posterior facial 9. Cephalometric examination may reveal a
height. downward and forward rotation of the mandible.
4. A steep mandibular plane angle. Some patients may exhibit an upward tipping of
5. Small mandibular body and ramus. the maxillary skeletal base and vertical maxillary
6. Short upper lip with excessive maxillary incisor increase.
exposure.
Features of Dental Anterior Open Bite:
1. Proclined upper anterior teeth.
2. Lack of vertical overlap between upper and lower anterior teeth, resulting in a space between them.
3. Narrow maxillary arch possibly due to lowered tongue posture from a habit.

Treatment of Anterior Open Bite:

 Removal of the cause: Interception of habits like thumb sucking or tongue thrusting using passive habit-
breaking appliances.
 Myofunctional therapy: Treatment during growth with functional appliances like F.R. IV or modified
activators, incorporating bite blocks to induce intrusive action on posterior teeth.
 Orthodontic therapy: Mild to moderate cases managed with fixed mechanotherapy and box elastics to extrude
upper and lower anterior teeth. This can be combined with a transpalatal arch and high-pull headgear to limit
vertical development. Severe cases may not be suitable for this approach.
 Extractions: In cases of bimaxillary proclination, premolar extractions can be conducted
 Extra-oral traction: High pull headgear and vertical chin pull cup
 Surgical correction: Adults with skeletal open bites often require surgical procedures involving the maxilla and
mandible for effective treatment.

Definition of Posterior Open Bite:

 Posterior open bite is a condition where there is a lack of contact between the posterior teeth when the jaws are
in centric occlusion. It typically affects a segment of the posterior teeth rather than the entire dentition.

Causes of Posterior Open Bite:

 Mechanical interference with eruption:
i. Ankylosis of the tooth to the alveolar bone, which can occur spontaneously or due to trauma.
ii. Obstacles in the path of erupting teeth, such as supernumerary teeth or non-resorbing deciduous tooth
roots.
iii. Pressure from soft tissues (cheek, tongue, finger) between teeth can impede eruption after the tooth
emerges from the bone.
 Failure of the eruptive mechanism:
i. Disturbance of the eruption mechanism itself, leading to insufficient eruption without apparent mechanical
interferences.
ii. Some cases of posterior open bite may not respond to orthodontic treatment due to this cause.

Treatment:
 The primary goal of treatment is to address the underlying cause.
 Control of lateral tongue thrust using lateral tongue spikes can be helpful in intercepting habits contributing to
posterior open bite.
 Once the habit is intercepted, spontaneous improvement may occur.
 Posterior teeth can be forcibly extruded to establish proper occlusion.
 In cases where posterior open bite is due to infraocclusion of ankylosed teeth, treatment involves crowning the
affected teeth to restore normal occlusal levels.

Management of Cross Bite

Definition of Crossbite:
 Abnormal occlusion in the transverse plane.
 Also refers to a reverse overjet of one or more anterior teeth.
 Graber defined crossbite as a condition where one or more teeth may be abnormally malposed buccally,
lingually, or labially concerning the opposing tooth or teeth.

Classification of Crossbite:
Based on location:
a. Anterior crossbite:
1. Single tooth.
2. Segmental.
 b. Posterior crossbite:
1. Unilateral.
2. Bilateral.
Based on the nature of the crossbite:
1. Skeletal crossbite.
2. Dental crossbite.
3. Functional crossbite.

Anterior Crossbite: Posterior Crossbite:

 Malocclusion resulting from the lingual  Abnormal transverse relationship between upper and lower
position of maxillary anterior teeth posterior teeth.
concerning the mandibular anterior teeth.  Mandibular buccal cusps occlude buccal to maxillary buccal
 Can involve a single tooth or an entire cusps instead of in the central fossae.
segment of the arch.  Can be unilateral (affecting one side of the arch) or bilateral
 Prevalent in both permanent and (affecting both sides).
deciduous dentition.  Subtypes include:
i. Buccal non-occlusion: Maxillary posteriors occlude
entirely on the buccal aspect of mandibular posteriors.
ii. Lingual non-occlusion: Maxillary posteriors occlude
entirely on the lingual aspect of mandibular posteriors.

Skeletal Crossbite:
 Associated with a discrepancy in the size of the maxilla and mandible.
 Often inherited or may result from defective embryological development.
 Can manifest in the anterior or posterior region.
Skeletal Anterior Crossbite: Skeletal Posterior Crossbite:
 Result of retarded maxillary growth or a backwardly  Characterized by a narrow upper arch.
positioned maxilla.
 Can also occur due to excessive mandibular growth.

Dental Crossbite:
 Localized conditions where one or more teeth are abnormally related to those of the opposing arch.
 Various factors causing dental anterior crossbite:
i. Lingual eruption path of maxillary anteriors.
ii. Trauma to deciduous dentition causing displacement of tooth buds.
iii. Delayed eruption of deciduous dentition and supernumerary teeth.
iv. Tooth material arch-length discrepancies leading to crowding and lingual positioning of upper teeth.

Functional Crossbite:
 Presence of occlusal interferences leading to mandibular deviation during jaw closure.
 Can present as a unilateral posterior crossbite.
 Habitual forward positioning of the mandible (pseudo Class III) may result in an anterior crossbite.
 Involves acquired muscular reflex pattern during mandibular closure.

Etiology of Crossbite:
1. Persistence of a deciduous tooth causing palatal 5. Narrow upper arch due to decreased growth
deflection of its erupting successor, leading to a stimulation in the mid-palatal suture.
single tooth anterior crossbite. 6. Collapse of the maxillary arch, as seen in
2. Crowding and abnormal displacement of teeth due congenital defects like cleft palate.
to arch length-tooth material discrepancies. 7. Sagittal discrepancies of the jaws, such as a
3. Habits like thumb sucking and mouth breathing forward-positioned mandible resulting in occlusion
can lower tongue position, leading to a narrowing of a wider part of the mandibular arch with a
of the upper arch and posterior crossbite. narrower part of the maxillary arch.
4. 4. Retarded development of maxilla in sagittal and 8. 8. Unilateral hypo or hyperplastic growth of any of
transverse directions. the jaws can cause crossbite.

Treatment of Anterior Crossbite:

1. Use of Tongue Blade:
 Successful for developing single tooth anterior crossbites.
 Tongue blade resembles a flat wooden stick placed inside the mouth contacting the palatal aspect of the tooth in
crossbite.
 Patient rotates the oral part of the blade upwards and forwards for 1-2 hours daily for about 2 weeks.
 Most effective when recognized early by the dentist.

2. Catlen's Appliance or Lower Anterior Inclined Plane:

 Inclined planes on lower anterior teeth treat maxillary teeth in crossbite.
 Made of acrylic or cast metal with a 45-degree angulation to force maxillary teeth in crossbite to a more labial
position.
 Indicated when adequate space exists in the arch for alignment of maxillary teeth.
 Disadvantages include speech problems, dietary restrictions, risk of anterior open bite, and frequent
recementation.

3. Use of Double Cantilever Spring (Z Spring):

 Treats anterior crossbites involving one or two maxillary teeth.
 Used along with a posterior bite plane in cases of deep overbite.
 Indicated when there's sufficient space for labialization of teeth in crossbite.

4. Treatment of Skeletal Anterior Crossbite During Growth Period:

 Utilize protraction face mask (reverse head gear) to normalize skeletal crossbite by orotracting the maxilla.
 Chin cap intercepts excessive mandibular growth causing skeletal anterior crossbites.

5. Fixed Appliances for Treatment of Anterior Crossbite:

 Dental anterior crossbite involving one or two teeth treated with fixed appliances using multi-looped archwires.

Treatment of Posterior Crossbite:

1. Crossbite Elastics:
 Used for single-tooth crossbite involving molars.
 Elastics stretched between maxillary palatal surface and mandibular buccal surface.
 Worn day and night.
 Treatment not to exceed six weeks to prevent tooth extrusion.

2. Coffin Spring:
 Consists of an omega-shaped wire embedded in an acrylic plate.
 Placed in the mio-palatal region for dento-alveolar expansion.
 Can induce skeletal changes in young patients.

3. Quad Helix:
 Spring with four helices capable of dento-alveolar expansion in the molar and premolar region.
 Can induce skeletal expansion in younger patients.

4. Rapid Maxillary Expansion:

 Treatment for bilateral skeletal crossbite characterized by deep palate, nasal obstruction, and narrow maxilla.
 Involves splitting the mid-palatal suture using appliances with screws activated at regular intervals.

5. Removable Plates:
 Treats bilateral crossbites using removable appliances with jack screws.
 Appliance consists of a split acrylic plate, jack screw, and Adam's clasps on posterior teeth.
 Desired effect achieved by sectioning the plate into smaller and larger segments connected by jack screws.

6. Fixed Appliances:
 Treats unilateral crossbites using fixed appliances.
 Asymmetrically expands the arches to correct the crossbite.

Management of Deep bite

Deep Bite:
 Maxillary arch larger than mandibular arch.
 Overlapping of mandibular teeth by maxillary anteriors.
 Horizontal overlap termed overjet, vertical overlap termed overbite.
 Excessive vertical overlap termed deep bite.
 Common malocclusion with potential health implications for masticatory apparatus and dental units.

Definition and Types:

 Graber's definition: Excessive overbite where vertical measurement between maxillary and mandibular incisal
margins is excessive in habitual occlusion.
 Types:
i. Incomplete Overbite: Lower incisors fail to occlude with upper incisors or palate.
ii. Complete Overbite: Lower incisors contact palatal surface of upper incisors or palate.
Classification:
Skeletal Deep Bite: Dental Deep Bite:
 Genetic origin.  Absence of skeletal complicating features.
 Upward and forward rotation of mandible.  Causes:
 Further worsened by downward and forward i. Over-eruption of anteriors.
inclination of maxilla. ii. Infra-occlusion of molars.
 Features:  Deep Bite due to Over-Eruption of Anteriors:
i. Horizontal growth pattern. i. Associated with Class II malocclusion.
ii. Reduced anterior facial height. ii. Increased overjet leads to over-eruption of
iii. Reduced inter-occlusal clearance. lower incisors meeting palatal mucosa.
iv. Cephalometric examination reveals parallel iii. Exhibits excessive curve of Spee.
horizontal planes. iv. Inter-occlusal clearance usually normal.
 Deep Bite due to Infra-Occlusion of Molars:
i. Presence of lateral tongue posture or thrust
may prevent molars from erupting.
ii. Premature loss of posterior teeth can also
cause infra-occlusion.
iii. Characterized by partially erupted molars and
large inter-occlusal clearance.

Factors to be Considered in Treatment of Deep Bite:

1. Modalities of Correction: 4. Inter-occlusal Space:
 Deep bites corrected by:  Average inter-occlusal space: 2-4 mm in premolar
i. Intrusion of anterior teeth. region.
ii. Extrusion of posterior teeth.  Increased inter-occlusal space indicates:
 Posterior teeth not fully erupted.
2. Lip Relationship:  Deep bite can be treated by extrusion of posterior
 Short upper lip or gummy smile: teeth.
 Indication for intrusion of anteriors.  Caution: Avoid reducing normal inter-occlusal
 Normal upper lip with 2-3 mm of maxillary incisal clearance by extrusion of molars.
edge exposed:  Reduction can lead to fatigue of masticatory
 Ideal for extrusion of molars. muscles, predisposing to relapse.
 Normal inter-occlusal clearance:
3. Vertical Facial Relationship:  Indication for intrusion of incisors rather than
 Extrusion of posterior teeth can lead to: extrusion of molars.
 Downward and backward rotation of
mandible.
 Increase in anterior facial height.
 Beneficial in treating skeletal deep bites with
excessive horizontal growth and upward rotation
of mandible.

Treatment of Deep Bite:

1. Removable Appliances: 3. Fixed Appliance Therapy:
Anterior Bite Plane: Intrusion of Anteriors:
 Most common for deep bite treatment. Anchorage Bends:
 Modified Hawley's appliance with flat acrylic  Given mesial to molar tubes on arch wire.
ledge behind upper anteriors.  Anterior part of arch wire lies gingival to bracket
 Mandibular incisors contact the bite plane, slot.
disoccluding posteriors for eruption.  Gingivally directed intrusive force exerted on
 Adam's clasps on molars for retention. incisors, reducing deep bite.
 Labial bow to counter forward force on upper Arch Wires with Reverse Curve of Spee:
anteriors.  Wires curved opposite to curve of Spee.
 Gradually increase height of bite plane as posterior
 Anterior segment curves gingivally into bracket
teeth erupt.
slot, exerting intrusive force on incisors.
Utility Arches:
2. Myofunctional Appliances:
 Bent to bypass buccal segment and engage
 Used for cases with deep bite due to infra- incisors.
occlusion of molars.
 Can perform various tooth movements including
 Activator designed to allow extrusion of affected intrusion of incisors.
teeth.
 Activated by giving a V bend in buccal segment to
produce intrusive force on anteriors.