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script number (7) , Title Class I malocclusion , Date 4-3-2014

Class I Malocclusion

Baraa'h AlSalamat

Dr. Emad Maaita

4 / 3 /2014
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script number (7) , Title Class I malocclusion , Date 4-3-2014

CLASS I MALOCCLUSION
SCRIPT NUMBER (7) we clssify malocclusions according to incisal relationship or the incisal classification : Class I , Class II dev. I, Class II dev, II and Class III. definition:
Class I mal occlusion : when the incisal relationship is class I but there are malocclusion features, presence of alignment or occlusal features outside the normal when the anteroposterior incisor relationship is class I. in the photograph the incisal relationship is class I however there is crowding, molar relationship is class II and the over bite is slightly deep. pic slide #2. Prevalence: it is around 60% , it is the most common type of malocclusion.

Skeletal features:
Anterioposterior : - Since the teeth are in class I relation it is more common to the skeletal features to be class I also. - May be mild class II or III , how come to have class I incisal relation and class II or III skeletal? with dentoalveolar compensation so the teeth try to compensate for the underling skeletal disturbances. Vertical and transverse: - Vertically usually is within normal range. it is assisted by lower facial height and
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script number (7) , Title Class I malocclusion , Date 4-3-2014

maxillary mandibular plans angle. - However some cases have some vertical and transverse anomalies.

Soft tissues:
they are the soft tissues surrounding teeth which are lips, tongue and cheek. - Favorable : when they are favorable we expect that teeth in class I otherwise (e.g. lip trap --> class II dev.I) it would be another classification. - soft tissue form activity and activity are usually within normal range.

Growth :
growth features with class I usually is favorable , there is a harmonious growth between the upper and lower jaw, which account for the skeletal and facial balance.

Intra-oral features:
- since we classify the mal occlusion as class I , then incisal relation is class I relationship. - canine and molar relationship is usually class I, but can be class II or III. (in the pic, it is class II) -over jet is usually within average because the incisal relation is Class I , except in case of bimaxillary proclination (uppre and lower incisal both are proclined but in class I skeletal relationship) over jet in this case is slightly increased. - Over bite could be normal , deep , reduced or open bite. - Can be associated with normal bite, cross bite or scissor bite. -Transverse problems can be localized, unilateral or bilateral.

So what are the problems usually associated with Class I malocclusion?

script number (7) , Title Class I malocclusion , Date 4-3-2014

1- Crowding: -It is the most common problem has another name : space deficiency. - It can be in labial or buccal segment or both. - can be as a result of : . genetic factors : disproportion between jaw size and teeth size the jaws may be in normal size but teeth mesiodistal size is big. or the opposite the teeth are in normal size but jaws are small. .Local factor : early loss of primary teeth and space loss. for ex. if you have early loss of primary canines this may result of space loss and crowding anteriorly. or if you have early loss of primary Es then 6s may drift mesially and cause crowding for the erupting 5s. - Can be classified as : Mild , Moderate and severe. acording to the degree of crowding : .Mild : (1-4 mm) .Moderate : (5-8 mm) .Severe : (9 mm or more) -treatment of crowding depends on the severity, so we need to do space analysis. if it is mild we can treat it without extraction. and if the crowding is severe it means we have to do extractions, if it's moderate it is in the border line it can be treated with or without extraction. depending on other factors. Treatment of crowding: as general aim of treatment we need to create space because it is crowding. a. Stripping: -to reduce the width of the teeth, for ex. a lower incisor 7 mm width we can take up to 0.5 mm from the mesial side and 0.5 from the distal side making the total width of the lower incisor 7 - 1 = 6 mm, so as if you are creating 1 mm of space,
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script number (7) , Title Class I malocclusion , Date 4-3-2014

this is done for every single tooth. - so it is minimize the width of the teeth mesiodistally. - used usually in Mild cases , and in Moderate cases if most other factors are favorable toward non extraction but may not be enough since it is (5-9 mm) crowding. stripping can give 3 mm maximum space, so we need other methods beside striping if we are treating a moderate case. b. Distallization: - Means moving the tooth distally, usually molars and usually the upper molars. usually it is difficult to distallize lower molars except if you don't have 7s and 8s, because we have the ascending ramous. where as in the maxilla there is the maxillary tuberosity which can occupy teeth. - applying force directed distally to move teeth distally and create space, for ex. by using H.G. (head gear: growth modification appliance to increase the growth of the maxilla ,to prevent anchorage or un wanted teeth movement, to distallize molars in order to create space). - Used in Mild to Moderate cases of crowding. c. Expansion: -Transverse dimension: widen the arch and usually the upper arch moving bone in young patients or teeth. but in the lower by moving teeth only. used in Mild to Moderate cases. -Anterioposterior dimension: we mean proclination of teeth in upper and lower arches, which increases the arch perimeter then provide space. as a rule "proclination of lower incisors by 1 mm we create space in the arch by 2 mm on right the other on left side" d. Extraction: - usually used in severe cases and in moderate cases. usually we extract 1st or 2nd premolars, unless there is another indication for another extraction. but also we can extract 1st molars>> if we have the 1st molar is grossly carious and the premolars are sound teeth.
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script number (7) , Title Class I malocclusion , Date 4-3-2014

another problem of malocclusion associated with class I is : 2- Spacing : -the opposite of crowding when you have space excess or extra space, it can be because of a genetic factor; small teeth and nor mal size jaws, or large jaw and normal sized teeth. -Can be localized (Diastema) or generalized. - Causes of diastema: a. supernumerary teeth, mesiodence is the most common one. b. frenal attachment, high frenal attachment prevents normal attachment of teeth. c.Tooth size discrepancy, ex. small upper lateral incisors d. Tooth-jaw discerpancy. -Generalized spacing: as a result of Tooth-jaw discerpancy. Treatment of Diastema: first you need to eliminate the cause: - if the cause is high frenal attachment you need to do frenectomy and fixed appliances. - Extraction of supernumerary tooth and fixed appliance. - if the teeth are small especially the upper lateral incisors we can do build up and close the spaces. - Fixed appliance. Treatment of Generalized spacing: -fixed appliance and permanent retainer - removable appliance if the case is indicated for removable appliance (Robert's retractor : the upper incisors are proclined, spaced, over jet increased, over bite reduced and canines in class I relation.)
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script number (7) , Title Class I malocclusion , Date 4-3-2014

3- Deep bite: the upper incisors cover the whole labial surface of the lower incisors. the Treatment of deep bite : -Removable appliance (Anterior bite plane) -Fixed appliance : intrude incisors or extrude posterior teeth to reduce the over bite. - in some severe cases especially in adults may need orthognathic surgery. 4- Open bite: can be : - Dental AOB : if the open bite localized ateriorly, usually it is a result of thump sucking, asymmetric open. -Skeletal AOB : if the anterior open bite is extending posteriorly to the molars. it means that the Maxillary mandibular plane angle is high. Treatment of AOB depends on if it is dental or skeletal: - if due to thump sucking then we need to stop the habit at early age using (habit breaker) -if it is skeletal we can use high pull head gear, as if you are preventing the posterior part of maxilla from growing down while allowing the anterior part to grow down so as if you are inducing rotation of the maxillary plane. - functional appliance: for vertical problems using (Frankel IV appliance). - fixed appliances. - if the case is skeletal and severe and in adults we can do orthognathic surgery.

script number (7) , Title Class I malocclusion , Date 4-3-2014

5- Cross bite: -it can be unilateral or bilateral. - it can be localized due to crowding so the treatment is as we treat crowding case. or generalized. - the important point here if you have unilateral cross bite and it is generalized for ex. all the right side, then you need to check if there is mandibular displacement (when the patient closes his mouth and there is premature contact, he will have mandibular displacement to achieve maximum inter cuspation and to eliminate the interferences). In 75% of unilateral cross bite, usually there is mandibular displacement which means that the ICP is not constant with RCP (retruded contact position). Treatment of cross bite: Expansion with Removable appliance, Quad Helix, Raped palatal expansion or using fixed appliance. in severe cases surgery. 6- Bimaxillary proclination: Features of Bimaxillary Proclination: -upper and lower incisors are proclined. -usually well aligned teeth or spaced it is very rare to see crowding in bimaxillary proclination. -usually reduced over bite . -slightly increased over jet, although the incisal relation is class I. -reduced inter maxillary angle, (angle between lower incisor and upper incisor the

script number (7) , Title Class I malocclusion , Date 4-3-2014

normal is (133 + - 5) reaching 100 -110 degrees. -incompetent and prominent lips. Treatment of bimaxillary proclination: -Removable appliance if there is enough space. not all cases will not have space, but if there is space we can use Robert's retractor for ex. if it's on the upper jaw, but it is rare to use removable appliance on the lower arch. -if there is no spacing we need to use fixed appliance: .with extraction : if there is no space .without extraction: if there is enough space. Problems of treatment of bimaxillary proclination: -stability: usually bimaxillary proclination is induced by a result of soft tissues, when you finish the treatment by retroclination of lower and upper teeth and no spaces left , but after removing of the fixed appliance, tongue did not changed so it will affect the treatment. we can solve this problem by using permanent retention by inducing stability ,in some cases we are forced to do partial glossictomy. -Profile change is un expected, after treatment the facial profile or the lips should move back but how much they move we don't know, because the soft tissue response is un expected. 7- Localized problems: Impacted Canines : Impacted Maxillary Canine: -A canine that is prevented from eruption into its normal functional position by : Bone, tooth or fibrous tissue. -Incidence of impacted maxillary canine around 2% . some times (2-3%)
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script number (7) , Title Class I malocclusion , Date 4-3-2014

- the highest incidence is for the 2nd and 3rd Molars. the first tooth to be impacted is the 3rd molar then the maxillary canine. - is it palatal or buccal , in 85% of cases canine impacted palatal, and in 15% it is buccal. - unilateral or bilateral impaction , usually it is more unilateral by 4 times more than bilateral. -Females suffer more than males. F:M 70% : 30% Etiology of maxillary canine impaction: = Multifactorial: no specific cause : -long path of eruption, development of the canine starts around the infraorbital foramen so it takes long time and long way to erupt. -Earlier development than adjacent lateral incisor. guidance theory , the lateral incisor should act like a guide for the erupting canine if this guide is lost then there is a high chance to the canine to be impacted. -Genetic theory -Retained primary canines. interceptive treatment is indicated (extraction of primary canines at the age of 10 -13 years) - the rule is : the Maxillary canine should be palpable in the buccal sulcus by 10 years old. Case#1: so if the patient is over 10 years and has no palpable canine from the buccal side in this case you should palpate the primary canine if it is mobile you do nothing , but if it is firm then extraction of the primary canine is indicated. Case #2: you palpate the buccal sulcus and you couldn't feel the bulge of the canine, then palpate on the palatal side, then take X-ray , you find the canine on the RG but you don't know where is it located. then you need to make the parallax technique (2 periapicals at def. angles , or OPG and occlosal) SLOB. Treatment of impacted Canine :

script number (7) , Title Class I malocclusion , Date 4-3-2014

- No treatment , review with RG every 6 months. if no problem is associated, it is nessesary to do follow many complication may happen (dentigerous cyst around the canine, root resorption of adjacent teeth , although it is rare Ameloplastoma may happen) any widening in the dental follicle should ring the bell. -Interceptive treatment extraction of the Cs with insurance that the permanent canines should erupt spontaneously. -Surgical extraction, if the patient does not want to do ortho treatment for two years. -Surgical exposure and orthodontic alignment, expose the canine surgically then align the canine orthodontically. -Auto transplantation, to open surgically over the canine to extract the canine without damaging the root , then re implant the canine in its place by preparing a socket , after 2 weeks of auto transplantation you should do RCT. otherwise it will get resorbed. Orthodontic alignment: Surgical exposure : -closed exposure : open a palatal flap and expose the canine by removing bone if necessary , add an attachment to the tooth for ex. gold chain then close the flap. -open exposure : palatal flap is raised then a window is made in the flap, and the surgical pack is places to keep the canine exposed. to prevent overgrowth of soft tissue. after period of time the canine will continuo eruption and the soft tissue around will get healed , with time we should apply a gold chain and bring the canine with the line of the arch. , , ," , , , ". Done by :
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