Chapter 1: Introduction to Orthodontics
Orthodontics: is a branch of dentistry concerned with facial growth, development
of dentition and occlusion and diagnosis, interception and treatment of occlusal
anomalies. Orthos (from Greek) means straight and –odont- means tooth.
Aims & objectives of orthodontic treatment:
Aims of orthodontic treatment (according to William R. Proffit):
1. Improve aesthetic.
2. Improve function.
3. Psychological benefits.
Aims & objectives of orthodontic treatment have been summarized by Jackson as the Jackson’s Triad.
1. Functional Efficiency.
2. Structural Balance.
3. Esthetic Harmony.
Functional Efficiency: Many malocclusions affect normal functioning of the stomatognathic system. The
orthodontic treatment should thus aim to improve the functioning of the orofacial apparatus. Structural
Balance: The oro-facial region consists of the dentoalveolar system, the skeletal tissue and the soft tissue
including musculature. Stable orthodontic treatment is best achieved by maintaining a balance between
these three tissue systems. Esthetic Harmony by far the most common reason for seeking orthodontic care
is to improve the appearance of the teeth & face. Many malocclusions are associated with unsightly
appearance of teeth & can thus affect the individual’s self-image, wellbeing & success in society. Thus, the
orthodontic treatment should aim at improving the esthetics of the individual.
Orthodontics can improve the following:
1- Dental health:
a- Dental caries: Mal-alignment of the teeth may reduce the potential for natural
teeth –cleansing and increase the risk of decay.
b- Periodontal disease: Irregular teeth reduce effective brushing, in addition to
that, crowding may force one or more teeth to be squeezed buccally or lingually
out of their investing bone reducing periodontal support and finally traumatic
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occlusion may lead to increase loss of periodontal support (e.g.: anterior
crossbite).
c- Trauma to anterior teeth: Researches have shown that overjet more than 3
mm had more than double the risk of traumatic injury.
d- Impacted teeth: Impacted (unerupted) tooth may affect normal position and
health of adjacent teeth in addition to the loss of function of the impacted tooth
itself.
2- Function:
a- Masticatory function: Patients with open bites; markedly increased overjet
(Class II) or reversed overjet (Class III) often complain difficulties with eating,
particularly incising food.
b- Speech: Crowding may have little effect on normal speech.
c- Tempro-mandibular joint: There is no clear association between
malocclusion and the TMJ.
3- Psychosocial -wellbeing: Unattractive dento-facial appearance does have a
negative effect on expectations of teachers and employers.
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Scope or range of orthodontic treatment:
1. Alteration in tooth position.
2. Alteration in skeletal pattern.
3. Alteration in soft tissue pattern.
Occlusion: any position or relation in which the upper and lower teeth come
together.
‘Ideal occlusion’ is the term given to a dentition where the teeth are in the optimum
anatomical position, both within the mandibular and maxillary arches
(intramaxillary) and between the arches when the teeth are in occlusion
(intermaxillary).
Fig. Ideal untreated occlusion
Malocclusion: is the term used to describe dental anomalies and occlusal traits that
represent a deviation from the ideal occlusion. In reality, it is rare to have a truly
perfect occlusion, and malocclusion is a spectrum, reflecting variation around the
norm.
Development of Orthodontics
Early orthodontics:
Crowded, irregular, and protruding teeth have been a problem for some individuals
since antiquity, and attempts to correct this disorder go back at least to 1000 BC.
Primitive (and surprisingly well designed) orthodontic appliances have been found
in both Greek and Etruscan materials.
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Edward H. Angle (Fig. below) was the first dental specialist in orthodontics. Whose
influence began to be felt about 1890, Angle’s original interest was in
prosthodontics, and he taught in that department in dental schools in Pennsylvania
and Minnesota in the 1880s. His increasing interest in dental occlusion and in the
treatment necessary to obtain normal occlusion led directly to his development of
orthodontics as a specialty, with himself as the “father of modern orthodontics.
Angle’s classification of malocclusion in the 1890s was an important step in the
development of orthodontics because it not only subdivided major types of
malocclusion but also included the first clear and simple definition of normal
occlusion in the natural dentition. Angle’s postulate was that the upper first molars
were the key to occlusion and that the upper and lower molars should be related so
that the mesiobuccal cusp of the upper molar occludes in the buccal groove of the
lower molar. If the teeth were arranged on a smoothly curving line of occlusion (Fig.
below) and this molar relationship existed, then normal occlusion would result.
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Angle then described three classes of malocclusion, based on the occlusal
relationships of the first molars:
• Class I: Normal relationship of the molars, but line of occlusion incorrect because
of malposed teeth, rotations, or other causes.
• Class II: Lower molar distally positioned relative to upper molar, line of occlusion
not specified.
• Class III: Lower molar mesially positioned relative to upper molar, line of
occlusion not specified.
Note that the Angle classification has four classes: normal occlusion, Class I
malocclusion, Class II malocclusion, and Class III malocclusion (Fig. 1.3). Normal
occlusion and Class I malocclusion share the same molar relationship but differ in
the arrangement of the teeth relative to the line of occlusion. The line of occlusion
may or may not be correct in Class II and Class III malocclusion.
Note: Angle’s classification, which is still widely popular, only can serve as a
framework, as it does not take into account many other important relationships in
the anteroposterior (e.g. overjet, canine relationship), transverse (e.g.
buccolingual crossbites), or vertical (e.g. overbite) planes of space. It also does
not identify intra-arch problems, such as crowding, spacing, rotations, missing or
impacted teeth.
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Modern orthodontics (The Soft Tissue Paradigm):
The soft tissue paradigm states that the goals and limitations of modern orthodontic
treatment are determined by the soft tissues of the face, not by the teeth and bones.
This reorientation of orthodontics away from the Angle paradigm that dominated the
20th century is most easily understood by comparing treatment goals, diagnostic
emphasis, and treatment approach in the two paradigms as in the table below:
It must be kept in mind that orthodontics is shaped by biological, psychosocial, and
cultural determinants. For that reason, when defining the goals of orthodontic
treatment, one has to consider not only morphologic and functional factors, but a
wide range of psychosocial and bioethical issues as well.
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Note: When there is missing of the first permanent molar or there is drifting
as a result of an early loss of deciduous molars so we shift to another
classification which is canine classification, and if there is no canine or
impacted canine or severely malposed canine so we shift to another
classification which is incisor classification.
Canine classification:
Class I: It is a normal canine relation, when the tip of the upper canines located in
the embrasure area between lower canine and first premolar (or the mesial slope of
the upper canine coincide with the distal slop of lower canine) in occlusion.
Class II: Abnormal canine relation in which the lower canine will be more backward
from normal canine relation in occlusion.
Class III: Abnormal canine relation, when the lower canine will be more forward
than from normal canine relation.
Incisor classification
The incisor relationship does not always match the buccal segment relationship.
Since much of orthodontic treatment is focused on the correction of incisor
malrelationships, it is helpful to have a classification of incisor relationships. The
terms used are the same but this is not Angle's classification, although it is a
derivation. In clinical practice the incisor classification is usually found to be more
useful than Angle's classification.
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Incisor classification:
Class I: The lower incisor edges occlude with or lie immediately below the cingulum
plateau (middle part of the palatal surface) of the upper central incisors.
Class II: The lower incisor edges lie posterior to the cingulum plateau of the upper
incisors.
Note: Class II can be subdivided into:
Class II Division 1: A Class II malocclusion with proclined maxillary incisors,
resulting in an increased overjet with normal or mostly deep bite.
Class II malocclusion, Division 2: A Class II malocclusion typically with the
maxillary central incisors tipped palatally, a short anterior lower face height, an
excessive overbite and normal or decreasing overjet.
Three types of Class II Division 2 malocclusion can be distinguished, based on
differences in the spatial conditions in the maxillary dental arch:
Type A: The four maxillary permanent incisors are tipped palatally, without the
occurrence of crowding.
Type B: The maxillary central incisors are tipped palatally and the maxillary
laterals are tipped labially.
Type C: The four maxillary permanent incisors are tipped palatally, with the
canines labially positioned.
Class III: The lower incisor edges lie anterior to the cingulum plateau of the upper
incisors. The overjet may be either reduced or reversed.
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Classification of deciduous teeth:
Depend on the relation between terminal plane present in the maxillary and
mandibular deciduous posterior teeth.
Terminal plane: The distal proximal surface of the maxillary and mandibular second
deciduous molars (being the distal terminal plane of the deciduous dentition). The
relationship between the maxillary and mandibular terminal planes in the early
mixed dentition is thought to determine, to a degree, the eventual relationship
between the (at the time still unerupted) maxillary and mandibular first permanent
molars.
Distal step: A situation in which the terminal plane of the mandibular second
deciduous molar is situated posteriorly to that of the maxillary second deciduous
molar. This situation is thought to be predisposing to, but not necessarily predictive
of, a Class II relationship of the (at the time, still unerupted) first permanent molars.
Flush terminal plane: An end-to-end relationship between the distal proximal
surfaces of the maxillary and mandibular second deciduous molars, usually leading
to a Class I or Class II relationship between the (at the time, still unerupted)
maxillary and mandibular first permanent molars.
Mesial step: A situation in which the terminal plane of the mandibular second
deciduous molar is situated anteriorly to that of the maxillary second deciduous
molar. Depending on the severity of the mesial step, this relationship is thought to
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predispose to (but is, strictly speaking, not predictive of) either a Class I or a Class
III relationship of the (at the time, still unerupted) maxillary and mandibular first
permanent molars.
Clinical implications and variations: The first permanent molars may erupt into
one of the following occlusal relationships.
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6 keys of normal occlusion:
Andrews analyzed 120 ‘normal’ occlusions to evaluate those features which were
key to a good occlusion. He found six features, which are described below. These
six keys are not a method of classifying occlusion as such, but serve as a goal.
Occasionally, at the end of treatment it is not possible to achieve a good Class I
occlusion.
1: Molar relation: The distal surface of the distobuccal cusps of the upper first
permanent molar made contact and occluded with the mesial surface of the
mesiobuccal cusps of the lower second molar, the mesiobuccal cusp of the upper
first permanent molar fell within the groove between the mesial and middle cusps of
the lower first permanent molar. (The canines and premolars enjoyed a cusp
embrasure relationship).
2: Crown angulation “The mesiodistal tip”, The term angulation refers to
angulation (or tip) of the long axis of the crown not to angulation of the long axis of
the entire tooth. The gingival portion of the long axis of each crown was distal to the
incisal portion varying with the individual tooth type (all tooth crowns are angulated
mesially).
3: Crown inclination (Labiolingual or buccolingual inclination): Crown inclination
refers to the labiolingual or buccolingual inclination of the long axis of the crown
not to the inclination of the long axis of entire tooth. The inclination of all the crowns
has a consistent scheme:
a- Anterior teeth (Central and lateral incisors)
The labial inclination of upper and lower anterior crown is sufficient to resist over
eruption of anterior teeth and sufficient also to allow proper distal positioning of the
contact points of the upper teeth in their relationship to the lower teeth, permitting
proper occlusion of the posterior teeth.
b-Upper posterior teeth (Canines through molars)
A palatal crown inclination existed in the upper posterior crown was a constant and
similar from the canines through the second premolar and was slightly more
pronounced in the molars.
c-Lower posterior teeth (Canines through molars)
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The lingual crown inclination in the lower posterior teeth progressively increases
from the canine through the second molar.
As a summary: incisors are inclined towards the buccal or labial surface.
Buccal segment teeth are inclined lingually. In the lower buccal segments this
is progressive.
4: Rotation: There are no undesirable rotations. Rotated molar and bicuspid occupy
more space than normal while rotated incisors occupies less space than normal
5: Spaces: there were no spaces with tight contact point.
6: Occlusal planes: the plane of occlusion varied from generally flat to a slight
curve of spee (which measured from most prominent cusp of lower second molar to
the lower central incisor), no curve deeper than 1.5 mm is accepted from a stand
point of occlusal stability. Recently the authors believe that the correct crown
diameter represents the seventh key to normal occlusion this key (the seventh
key) had to be present in Andrews non-orthodontic normal study models.
Usual Orthodontic Problems and terms:
1. Incisor irregularity (crowding) usually is expressed as the irregularity index:
the total of the millimeter distances from the contact point on each incisor tooth to
the contact point that it should touch.
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Dental arch with crowding of 2 mm or more (less than 2mm is the acceptable
range) either caused by local factor ex: lack of space for permanent teeth result
from early extraction of deciduous teeth or general factor ex: collapsed maxillary
arch that lead to crowding of the whole arch.
2. Spacing: a space between adjacent teeth is called a diastema. A maxillary
midline diastema is relatively common, especially during the mixed dentition in
childhood, and disappears or decreases in width as the permanent canines erupt.
Note: Spontaneous correction of a childhood diastema is most likely when its
width is less than 2 mm.
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A dental arch with spacing of more than accepted range (2 mm or more), it is either:
a- Localized: Localized in one position like median (midline) Diastema that caused
by abnormal frenal attachment.
b- Generalized: Affect the whole dental arch mostly caused by abnormal soft tissue
function like tongue thrust.
3. Crossbite is an orthodontic problem exists when maxillary tooth/teeth is/are
lingually positioned relative to mandibular tooth/teeth. In the patient below there is
a posterior crossbite (when the maxillary posterior teeth are lingually positioned
relative to the mandibular teeth) and also has a one-tooth anterior crossbite, with
the lateral incisor trapped lingually.
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A crossbite can be dental or skeletal in etiology. The appropriate type of crossbite
can be specified by identifying the teeth or jaws that deviate the most from their ideal
position.
(e.g. when a crossbite is mainly due to a narrow maxillary arch the correct
term is "maxillary posterior lingual crossbite" as opposed to "mandibular
posterior buccal crossbite" which indicates wider mandibular arch).
Classification of crossbite: Based on Location can be summarized in the table
below:
Anterior crossbite: If the one or more of the lower incisors are in front of the upper
incisors, the condition is called reverse overjet or anterior crossbite.
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Posterior crossbite: A crossbite due to buccal displacement of the affected posterior
tooth (or group of teeth) from its (their) ideal position relative to its (their)
antagonist(s).
Subdivided into:
1- Unilateral posterior: Affect only one side of the dental arch, and can be either:
a-True unilateral posterior crossbite: Caused by the asymmetry present in the dental
arch and usually does not associated with deviation of the mandible.
b- False unilateral posterior crossbite: caused by narrowing of the maxilla or
widening of the mandible leading to cusp –cusp relation then the patient tries to get
maximum intercuspation by deviation of the mandible to one side leading to
unilateral crossbite.
2- Bilateral posterior crossbite: Caused by sever maxillary collapse or/ and
mandibular widening, there is no mandibular deviation during closure.
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Based on the Etiologic Factor can be summarized in the table below:
Skeletal crossbite: It is a crossbite with a skeletal basis (constricted maxilla and/or
wide mandible).
Dental crossbite: It is caused by distortion of the dental arch where the jaws are of
normal proportions.
(False): It is a crossbite due to a functional shift of the mandible, it should be treated
early if recognized, because if uncorrected, true crossbite may result by modification
of growth.
Scissors-bite: Situation in which several adjacent posterior teeth overlap
vertically in habitual occlusion with their antagonists, without contact of their
occlusal surfaces. The deviation of the affected teeth from their ideal position could
occur either in maxillary buccal or mandibular lingual direction, where mandibular
dentition is completely contained within the maxillary dentition in habitual
occlusion.
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4. Overjet is a horizontal overlap of the incisors. Normally the incisors are in
contact, with the upper incisors ahead of the lower by only the thickness of their
incisal edges (i.e., Overjet of 2 to 3 mm is the normal relationship). If the lower
incisors are in front of the upper incisors, the condition is called reverse overjet or
anterior crossbite.
Fig.: Incisal overjet: (a) The ideal overjet relationship, (b) Edge to edge incisal position, (c) Reversed overjet
5. Overbite is defined as the vertical overlap of the incisors. Normally, the lower
incisal edges contact the lingual surface of the upper incisors at or above the
cingulum (i.e., normally there is a 2- to 4-mm overbite). In open bite, there is no
vertical overlap, and the vertical separation of the incisors is measured to quantify
its severity. While in deep bite there is vertical overlap more than the normal and
the extra vertical overlap of the incisors is measured to quantify the severity of the
deep bite.
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*Open bite (Negative overbite): Inherited, developmental or acquired
malocclusion, whereby no vertical overlap exists between maxillary and mandibular
anterior teeth (anterior open bite), or no vertical contact is exhibited between
maxillary and mandibular posterior teeth (posterior open bite). Subdivided to:
1- Dental open bite: A localized open bite that involves only a few teeth due to a
digit sucking habit or other local factors.
2- Skeletal open bite: Caused by divergence of the skeletal mandibular or / and
maxillary planes leading to increased facial height as in case of posterior rotational
growth of the mandible.
*Deep bite (Excessive overbite): Type of malocclusion in which the vertical
overlap of the anterior teeth is increased beyond the ideal relationship (more than
the normal range which is 2-4 mm); it is frequently associated with decreased
vertical facial dimensions,
subdivided into;
1- None traumatic deep bite: In which the deep bite still associated with teeth–
teeth relation.
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2- Traumatic deep bite: in which the deep bite associated with the Impingement of
the mandibular incisors in the mucosa palatal to the maxillary incisors commonly is
seen in malocclusions with extremely deep bite as in sever Class II malocclusion.
3-Bi-traumatic deep bite: usually seen in some Class II, Division 2 malocclusions
with minimal overjet, the retroclined maxillary incisors may impinge in the
keratinized tissue labial to the mandibular incisors, causing gingival recession at the
same time there is a trauma to palatal mucosa caused by lower incisors.
6. Midline shift: is the lack of coincidence between the upper and lower dental
midline.
7. Gummy smile: also known as excessive gingival display is a smile that shows
an excessive amount of gum under the upper lip. Normal amount of gingival display
during posed smile is 1mm-2mm.
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8. Lip incompetence: is an inability to maintain a lips together, closed mouth
posture at rest and showing strain in the muscles around the face when a lip seal is
attempted.
9. Bimaxillary protrusion refers to a protrusive dentoalveolar position of
maxillary and mandibular dental arches that produces a convex facial profile.
10. Impacted tooth is a tooth that, for some reason, has been blocked from
breaking through the gum. Sometimes a tooth may be only partially impacted,
meaning it has started to break through. Oftentimes, impacted teeth cause no obvious
symptoms and are only discovered during a routine X-ray at the dentist's office.
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11. Infraposition (Infraocclusion): A situation in which a tooth or group of
teeth is positioned below the occlusal plane; commonly due to a deleterious habit or
to ankyloses.
12. Overeruption (Supraeruption, Supraposition, Supraocclusion): The situation
whereby an unopposed or non-occluding tooth extends beyond the occlusal plane.
13. Dental retrusion: Posterior position of a tooth or group of teeth but keeping
their long axis with normal inclination.
14. Dental retroclination: Posterior positioning of a tooth or group of teeth but
their long axis is tipped labio-lingually. [Note: A tooth can be retrusive without being
retroclined, if it is positioned too far posteriorly but has a normal inclination.
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15. Dental proclination: Anterior positioning of a tooth or group of teeth but
their long axis is tipped labially.
16. Dental protrusion: Anterior positioning of a tooth or group of teeth but
keeping their long axis with normal inclination.
17. Rotation of teeth: A type of malocclusion in which there is a rotation of a
tooth about its long axis, most evident when viewing the tooth from an occlusal
perspective mostly, caused by crowding and sub divided into:
1- Mild (less than 90°): Can be treated easily by removable orthodontic appliance
using couple force system
2- Sever (more than 90°): Must be treated by Fixed orthodontic appliance only
18. Displacement of tooth: Abnormal position of the tooth (crown and root) in
the dental arch.
19. Overlapping of teeth: Abnormal position of the crown of the tooth in the
dental arch while there is normal position of root in the jaw.
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Who Needs Orthodontic Treatment?
Protruding, irregular, or maloccluded teeth can cause three types of problems for
the patient:
(1) Social discrimination because of facial appearance:
A number of studies in recent years have confirmed what is intuitively obvious: that
severe malocclusion is likely to be a social handicap. The usual caricature of an
individual who is none too bright includes protruding upper incisors.
A witch not only rides a broom; she has a prominent lower jaw that would produce
a Class III malocclusion.
Well-aligned teeth and a pleasing smile carry positive status at all social levels and
ages, whereas irregular or protruding teeth carry negative status. Appearance can
and does make a difference in teachers’ expectations and therefore in student
progress in school, in employability, and in competition for a mate. This places the
concept of “handicapping malocclusion” in a larger and more important context. If
the way you interact with other individuals is affected constantly by your teeth, your
dental handicap is far from trivial.
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(2) Problems with oral function, including difficulties in jaw movement (muscle
incoordination or pain), temporomandibular dysfunction (TMD), and problems with
mastication, swallowing, or speech.
(3) Greater susceptibility to trauma, periodontal disease, or tooth decay.
Malocclusion, particularly protruding maxillary incisors, can increase the likelihood
of an injury to the teeth. There is about one chance in three that a child with an
untreated Class II malocclusion will experience trauma to the upper incisors, but
most of the time the result is only minor chips in the enamel.
For that both psychosocial and functional handicap patients can produce significant need for
orthodontic treatment.
Branches of Orthodontics
The general field of orthodontics can be divided into the following three categories
based on the nature and time of intervention:
• Preventive orthodontics
• Interceptive orthodontics
• Corrective orthodontics.
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preventive orthodontics includes actions undertaken prior to the onset of a
malocclusion, so as to prevent the anticipated development of a malocclusion. They
include the care of deciduous dentition with restoration of carious lesions that might
change the arch length, monitoring of eruption and shedding timetable of teeth, early
recognition and elimination of oral habits that might interfere with the normal
development of the teeth and jaws; removal of retained deciduous teeth and
supernumeraries which may impede eruption of permanent teeth , maintenance of
space following premature loss of deciduous teeth to allow proper eruption of their
successors, removal of low labial frenum attachment in upper arch which lead to
diastema and management of nasal obstruction.
Interceptive orthodontics implies that when the action is taken, an abnormal
situation (malocclusion) already exists. Certain interceptive procedures are
undertaken during the early manifestation of malocclusion to lessen the severity of
malocclusion and sometimes to eliminate the cause. Interceptive procedures include
serial extraction, correction of developing anterior crossbite, control of abnormal
oral habits, removal supernumeraries and ankylosed teeth and elimination of bony
or tissue barriers to erupting teeth.
Corrective Orthodontics like interceptive orthodontics, is also undertaken after
the manifestation of a malocclusion. It employs certain technical procedures to
reduce or correct the malocclusion and to eliminate the possible sequelae of
malocclusion. Corrective orthodontic procedures may require removable or fixed
mechanotherapy, functional or orthopedic appliances, or in some cases an
orthognathic/ surgical approach.
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Timing of Orthodontic Intervention Appropriate
Timing of orthodontic treatment is essential to accomplish the desired treatment
outcome and its long-term stability. Timing of orthodontic intervention is related to
the stage of dentition.
1. Deciduous Dentition
2. Early Mixed Dentition
3. Late Mixed Dentition/Early Permanent Dentition
4. Late Treatment
Risks of orthodontic treatment
Orthodontic treatment is not without risk. The risks associated with treatment can
arise as a direct consequence of placing an appliance or be secondary to the treatment
itself.
Risks from appliances
The principle risks arise from the use of orthodontic appliances and these can
affect the teeth, periodontium and soft tissues.
1. Enamel demineralization
2. Enamel fracture
3. Root resorption
4. Pain and damage to the pulp
5. Gingivitis
6. Alveolar bone loss
7. Oral ulceration
8. Allergic reaction
9. Temporomandibular joint dysfunction
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