ETIOLOGY OF MALOCCLUSION & HABITS

Dr. Biswaroop Mohanty

 Malocclusion is a developmental condition.

Any perversion of normal occlusion of teeth. Malposed teeth are but the symptoms of

errors of growth in the osseous framework of the facial structures.

Grabers Classification
1. 2.

General factors Hereditary. Congenital defects. Cleft palate. Torticollis. Cleidocranial dysostosis Cerebral palsy. Syphilis. Environmental Prenatal - Trauma. - Maternal diet. - Maternal metabolism. - German measles.

3. a.

b. Postnatal
- Birth injuries. - Cerebral palsy. - TMJ injuries.
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4. Predisposing metabolic climate & disease a. Endocrine imbalance. b. Metabolic disturbances. c. Infectious diseases (poliomyelitis). 5. Dietary problems. 6. Abnormal pressure habits & functional aberrations. a. Abnormal suckling. b. Thumb & finger sucking.
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c. d. e. f. g. h. i.

Tongue thrusting & sucking. Lip/nail biting. Abnormal swallowing. Speech defects. Respiratory abnormalities. Tonsils/adenoids. Psychogenic aberrations clenching/bruxism.

7. Posture. 8. Trauma.
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Local factors

1.

Anomalies of number. a. Missing. b. Supernumerary.

Abnormalities in tooth size. Abnormalities in tooth shape. Abnormal labial frenum, mucosal barriers. Premature loss. Prolonged retention. Delayed eruption of permanent teeth. Abnormal eruptive path.

2. 3. 4. 5. 6. 7. 8.

9.
10. 11.

Ankylosis.
Dental caries. Improper dental restorations.
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Hereditary / Genetic factors in malocclusion

Strong influence of heritance of facial features- obvious at a glance. The Hapsburg jaw- prognathic mandible.


1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Heredity also plays an important role in the foll. conditionsCongenital deformities. Facial asymmetries. Macro/micrognathia. Macro/microdontia. Oligodontia & anodontia. Tooth shape variations. Cleft-lip/palate. Frenum diastemas. Deep overbites. Crowding & rotation of teeth. Mandibular retrusion. Mandibular prognathism.
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Congenital defects

CLEFT LIP & CLEFT PALATE.

every 800 live births.

1in

Both

dental & skeletal components affected. common in maxilladamage to profile due to maxillary deficiency.

More

 CEREBRAL

PALSY

Lack of muscular coordination. Intracranial lesion,Birth-injury. Lack of motor controlabnormal muscle function. Upset muscle balance-

malocclusion.
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 TORTICOLLIS (Wry Neck): Foreshortening of sternocleidomastoid. Profound changes in bony morphology of

cranium & face.

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CLEIDOCRANIAL DYSOSTOSIS: Hereditary important cause of malocclusion. Unilateral/bilateral absence of clavicles. Delayed closure of cranial sutures. Maxillary retrusion. Mandibular protrusion. Retarded eruption of permanent teeth Retained deciduous teeth. Multiple impacted supernumerary teeth.
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 CRANIOFACIAL DYSOSTOSIS (Crouzons disease):

Genetic Cranial

disease. & facial deformities.

Hypoplasia
Mandibular

of maxilla.
prognathism. palates & clefts.
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High-arched

MANDIBULOFACIAL

DYSOSTOSIS (Treacher-Collins Syndrome)

Hereditary. Hypoplasia of mandible. Microstomia. High-arched palate with /without cleft. Abnormal positions of

teeth.

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 PIERRE ROBIN SYNDROME:

May/may not be genetic. Characterised by- cleft palate, micrognathia,glossoptosis. Primary defect in the mandible. Respiratory difficulty due to epiglottic obstruction.
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FACIAL

HEMIHYPERTROPHY

Etiology unknown-hormonal imbalance or chromosomal abnormalities. Effects on the dentition-increase in crown size(50%),root size,increased rate of development. Maxilla and mandible enlarged.
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 CONGENITAL SYPHILIS.

Abnormally

shaped & malposed teeth.

Screw-driver
Short

incisors, mulberry molars.

maxilla, high-arched palate.

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ECTODERMAL DYSPLASIA:

Hereditary. Hypohidrosis, hypotrichosis & hypodontia. Anodontia/oligodontia- deciduous &

permanent teeth. Truncated or cone-shaped. Reduction in vertical dimension. Cleft-may/may not be present. Jaw growth not impaired.
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Environment
PRE-NATAL Intrauterine moulding:

Pressure against rapidly growing areas

leads to distortion
Arm pressed against the face-maxillary

deficiency
Head flexed against the chest-

mandibular deficiency.
Decreased amniotic fluid-small

mandible-cleft palate results due to upward displacement of tongue.

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 Teratogens Chemicals and drugs consumed at low doses,causes malformation of dentofacial structures.

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 German measles(Rubella)
When occurs in the I trimester of pregnancy

causes a number of developmental defects. Cleft lip/palate,enamel hypoplasia,delayed eruption of teeth.

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 POST-NATAL Birth injuries

Trauma to mandible Most mandibular deformities-due to congenital anomalies-but thought to be due to birth trauma. Forceps delivery TMJ damage.
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 Fractures of the jaw Mandible more common than the maxilla. Condylar neck is vulnerable. 75% of these fractures normal growth

occurs. Asymmetric growth due to injury to the soft tissue matrix scarring restricts the growth.

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PREDISPOSING METABOLIC CLIMATE AND DISEASE.

Endocrine imbalance. Hypopituitarism: Dwarf Delayed eruption of permanent teeth and delayed shedding of primary teeth. Crowding due to smaller arch size. Mandibular growth more affected than maxilla.

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Hyperpituitarism:

Gigantism-large teeth and jaws. Acromegaly-occurs after growth and ossification

is complete. Lips thick,tongue enlarged,shows scalloping. Accelerated condylar growth-large mandible. Teeth tipped buccally due to large tongue.

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 Hypothyroidism:

Delayed

eruption.

Abnormal
Retained

resorption pattern.

deciduous teeth. teeth-deflected from eruption path.

Malposed Gingival

disturbances.

Hyperthyroidism: Early

shedding and eruption of alveolar bone.

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Atrophy

Nutritional Deficiency.
Disturbances in the developmental timetable. Rickets,scurvy and beri-beri can produce severe malocclusions. Premature loss of teeth /Prolonged retention. Abnormal eruptive path. Poor tissue health Poor absorption-hormonal /enzymatic deficiency. Decreased fluoride intake-loss of teeth due to caries-malocclusion.
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Abnormal Habits
All habits are learned patterns of muscle

contraction of a very complex nature. Habits such as normal lip action and mastication-stimulants for normal growth, Undesirable habits malocclusion.

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 Duration not the only determinant but

frequency & intensity affect the end result. The trident of habit factors.

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 Deleterious habitual patterns of muscles behavior produce:

1. Perverted osseous growth.

2. Tooth malpositions.
3. Disturbed breathing. 4. Difficulty in speech. 5. Upset balance of facial musculature. 6. Psychological problems.
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Thumb/Finger sucking
One of the most important factors in producing and maintaining malocclusion. Begins at birth and outgrown by 3-4 years.

Finger sucking from birth to 4 years: Suckling mechanism most important exchange with the outside world. Through suckling child obtains- nutrients, feelings of euphoria, sense of security and feeling of warmth.
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Digit Sucking & Malocclusion.

Large percentage of children practicing digit sucking but little

correlation with malocclusion.

Sucking habits in primary dentition little or no long term effects. Habits persist beyond the time that the permanent teeth erupt -

malocclusion occurs.
Characterized by flared & spaced maxillary incisors, lingually

positioned lower incisors, anterior open bite, narrow upper arch.

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Tongue Thrusting

Often associated with thumb sucking. Tongue thrust is forward placement of the

tongue between the anterior teeth & against the lower lip during swallowing- Schneider (1982). lightly closed, the tongue held against the palate behind the anterior teeth.
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Normal swallow the teeth are in occlusion, lips

Tongue Posture & Tongue Size

TONGUE POSTURE:
Tongue thrust swallowing

short duration to have impact on tooth position. forward resting for long duration effects tooth position.

If posture of tongue is

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 TONGUE SIZE:
Macroglossia can lead to proclination of

anteriors & anterior openbite.

Aglossia/Microglossia can lead to crowding and lingual inclination of teeth.

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 Skeletal openbite Steep mandibular plane. Increased anterior facial height. Tongue thrusting results due to lack of

anterior seal.

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Respiratory Pattern
Respiratory needs Primary determinants of the jaw & tongue.
Breathing through the mouth alters

equilibrium of the jaws & teeth. Lowering of the mandible & tongue & extension of the head is seen.

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 Effects of mouth-breathing:
Increase in facial height. Supraeruption of posterior teeth.

Rotation of mandible downwards &

backwards. Open bite anteriorly. Increase in overjet. Pressures from stretched cheeks narrow maxillary arch.-Posterior crossbite . &class II malocclusion.

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Causes leading to mouth breathing: 1. Chronic respiratory obstruction. 2. Mechanical obstruction. 3. Size of the nostril. 4. Pharyngeal tonsils or adenoids (adenoid facies). Greater effort required to breath through the nose tortuous nasal passages. Partial blockage of the nose leads to resistance of airflow person shifts to mouth breathing.

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Lip-Sucking & Lip-Biting

May be seen on its own or associated with thumb

sucking. Mandibular lip mostly involved. Results in labioversion of maxillary teeth. Open bite & linguoversion of mandibular incisors.
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Nail-Biting
Seen in high strung & nervous children.
Symptom of social & psychologic

maladjustment. Often mentioned to cause malposition but rarely does.

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Clenching & Bruxism

Very obscure in relation to malocclusion.
Is rhythmic contraction of the masticatory

muscle side to side grinding & gnashing of teeth during sleep. Wearing down of teeth occurs damages the occlusion.

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 Can occur due to nervous tension or when

there is existing malocclusion deep bite or single high contact due to restorations or malpositions.
Vicious circle one leading to another.

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Posture
Frequently suggested that poor posture can

lead to malocclusion. Stooping with chin on the chest- mandibular retrusion. Child resting head on hand or sleeping on arm or fist- possible development of malocclusion. May accentuate existing malocclusion.

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Appliances Leading to Malocclusion

Milwaukee Brace Given in the

treatment of scoliosis. Holds the head in extended position. Constant pressure on the mandible causes malocclusion.
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Accident or Trauma
Undiscovered traumatic experiencessignificant in malocclusion.
Eruptive abnormalities.

Abnormal resorption.
Loss of vitality.

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Local factors
Anomalies in number of teeth. Supernumerary & missing teeth.

Additions or deletions of teeth causes a disturbance within the arch & the opposing arch. Supernumerary teeth. Closely resembles the teeth / group of teeth to which it belongs molars, premolars or anteriors. .
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 Etiology
Splitting of the permanent tooth bud. Hereditary tendency.

Commonly found in the maxilla.

Commonest mesiodens between maxillary

central incisors. Can be conical in shape, singly or in pairs, inverted or fused.

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 Maxillary 4th molar second most common.

Causes malocclusion deflection or non-eruption

of the permanent teeth. Cause malposition of adjacent teeth. Careful removal of these teeth required,

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 Complications : Delayed eruption- drifting of teeth, arch length decrease Displaced, rotated teeth 82% displaced labially Diastema Dilacerations/ malformation of teeth Crowding Cyst formation dentigerous cyst Eruption into nasal cavity Resorption of adjacent roots
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 1. 2. 1.

Management : Early surgical removal Reduces risk of mid line deviation Reduces cross bite decreases mal occlusion Delayed extraction If doesnt interfere with eruption of adjacent teeth 2. Observation recommended 3. Can lead to displacement of permanent tooth buds 4. Child tolerates extractions better at an older age
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2. Missing teeth

More frequent than supernumerary. Frequent in permanent than deciduous.

False/induced anodontia result of extraction of teeth.

True partial anodontia (hypodontia /

oligodontia) congenitally missing one or more teeth (hereditary).

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 Commonly missing teeth. Maxillary & mandibular third molars. Maxillary lateral incisor. Mandibular 2nd premolar. Maxillary incisors. Maxillary 2nd premolars.
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 Malocclusions due to absence of teeth. Spacing. Drifting of teeth. Abnormal eruption permanent canines

erupt mesially if maxillary lateral incisors are missing. If permanent tooth is lost one must decide its space has to be maintained or can be used for orthodontic therapy.

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Anomalies of tooth size

Discrepancies in size makes normal alignment & occlusion impossible.

Size largely determined by heredity. Microdontia-

1.

Teeth smaller than normal.

Generalized microdontia leads to spacing. Seen in pituitary dwarfism.

Single tooth microdontia more common.

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 Commonly affected Maxillary lateral incisors. 3rd molars. Mandibular 2nd premolar.

2. Macrodontia Teeth larger than normal. Generalized macrodontia rare condition pituitary gigantism. Single tooth macrodontia unknown etiology causes crowding.

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Anomalies of tooth shape: Peg lateral - most common spacing in the maxillary anterior segment.

Maxillary central incisors exaggerated cingulum / heavy marginal ridges prevent normal overbite & overjet. Mandibular premolars with extralingual cusp increases the mesiodistal dimension.
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 Conditions which affect

the tooth shape. 1. Gemination division of a single tooth germ. 2. Fusion union of two normally seperated teeth. Spacing & crowding cause due to the above anomalies difficult to achieve proper midlines, esthetics & occlusion.

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 Concrescence fusion of roots by cementum.

Dilaceration sharp

bend or curve in the root.

Taurodontism bulky crowns with short roots.

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Abnormal Labial Frenum

Cause of spacing between maxillary central incisors. Midline diastema may also be caused by-

1. Abnormal habits. 2. Tooth size discrepancies. 3. Congenitally missing teeth. 4. Mesiodens. 5. Midline cysts. 6. Ugly Duckling Stage.
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Premature Loss of Deciduous Teeth

Deciduous teeth- best space

maintainers. Premature loss- childs own dental development / timetable. Unscheduled loss of 1 or more dental units imbalance in dental timetable.
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Loss of primary incisors: Seldom requires space maintenance. If lost before 4yrs.- regular radiographic exam.
Loss of primary cuspids:

Premature loss of dec. maxillary canines- spacing of permanent incisors, labioversion of canines. Mandibular dec. canine losslingual tipping of 4 mandibular permanent incisors.
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Loss of first primary molars: Will cause mesial movement of second dec. molar & first permanent molar. In mandible- 2nd premolar blocked out.
Loss of second primary molars:
loss- mesial drifting of 1st permanent molar & distal movement of canine.
Early

2nd

premolar blocked out.

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Loss of 2 or more primary molars:

Mesial drifting of 1st permanent molars &

distal drifting of anteriors.

Cross-bite may occur as mandibular position

is changed to achieve occlusion.

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Prolonged Retention & Abnormal Resorption of Deciduous Teeth.

Mechanical

obstruction- leads to deflective path of eruption or impaction of the permanent tooth. Prolonged retentionendocrine history check.
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Radiographic exam. required when there is unusual delay in eruption.

Familial patterns of eruption timings must be assessed.

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Delayed Eruption of Permanent Teeth

Causes: 1. Supernumerary tooth. 2. Mucosal barrier. 3. Premature loss of primary toothbony crypt forms in the line of eruption.

Delayed eruption- drifting of adjacent teeth & space closureblocking out or impaction of permanent tooth.

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Abnormal Eruptive Path

Deflection in path of eruption due to1. Lack of space due to arch-length deficiency. 2. Supernumerary tooth. 3. Presence of a root fragment from primary tooth. 4. Blow to the facedeflection of primary tooth/ tooth bud. 5. Mechanical interference by orthodontic treatment. 6. Cysts.
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In ectopic eruption erupting perm. tooth may resorb root of adjacent toothmanifestation of arch-length deficiency.

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Ankylosis
Maybe due to injury- disruption

of periodontal ligament. Formation of bony bridgereplacement resorption. Commonly seen in mandibular primary second molarSubmerged Tooth. Causes1. Impaction/ abnormal path of eruption of perm. successor. 2. Growth of alveolar bone is affected.

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Dental Caries
Loss of crown substance (several proximal caries) severe arch-length loss.
Supra-eruption, abnormal axial inclination,

tipping of the tooth occurs.

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Improper Dental Restorations

1. Undermined restorations- supra-eruption of

2.
3. 4.

5.

teeth. High restorations- premature contactsmandibular shifts. Under-contoured proximal contacts- space loss. Over-contoured adjacent teeth pushed away-occlusal contacts disrupted- functional prematurities. Severe disruption- cross-bite.
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Gingival & Periodontal Disease.

Causes malocclusion by-

1. PDL breakdown- pathological migration.

2. Tooth loss.

Tumours

Push teeth away as they enlarge. Severe malocclusion when found in articulatory region.
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Conclusion

What we think we know today shatters the errors and blunders of yesterday and is tomorrow discarded as worthless. So we go from larger mistakes to smaller mistakes- so long as we do not lose courage. This is true of all therapy; no method is final. - Frederick Jensen
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