Ortho Review

Introduction
o History of orthodontics
Pierre Fauchard (1723) Father of Dentistry made first regulating appliance
(Bandeau/bandolet expansion arch bar)
Kingsely (1880) published treatise on oral deformities
Joh Nutting Farrar (1888) publishes treats on irregularities of the teeth and their
correction)
Edward Angle (1899): father of modern orthodontics, classification of
malocculsions and founded first school in 1900
o Who needs orthodontics
Psychosocial problems
Oral function problems
Injury or dental disease
o Evolutionary trends
More prevalence of malocclusions now
As society is more urbanized, more malocclusions
o Prevalence of malocclusion types in U.S (NHANEs III)
Overjet
Ideal is 1-2 mm of overjet (42%)
Many are mild class II (3-4 mm) (39%)
Class II is more common than class III
o Moderate class II (10%) vs mild class III (5%)
Overbite
0-2 mm is considered ideal (50%)
3-4 mm is moderate overbite (35%)
Most people have overbites rather than open bites
o Severe deep bite (15%)
Angles classifications
~30% of population is class I normal
~55% is class I malocclusion
~15% Class II
<1% Class III
o Evidence of need for orthodontic treatment
35-50% of population is in need of orthodontics
35% general population
55% dentist recommendation
o Indications for orthodontic treatment
Dental esthetics
Facial esthetics
Periodontal considerations (severe crowding of impinging deep bite)
Functional considerations (Irregular contacts, crossbite, open bite, speech)
Restorative considerations (missing teeth, molar uprighting)
 Developmental problems (cleft lip/palate, craniofacial anomalies)
Development of Dentition
o Recognize stages in the development of dentition
Primary dentition
Early mixed (permanent incisors and 1st molars)
6-8 years for females
6-9 years for males (slower)
Late Mixed (loss of deciduous molars and canines)
10-13 years for females
10.5 -13 years for males
Permanent dentition
2nd molars come in, 12-14
o Normal features of primary dentition
Spaced anteriors and primate space (permanents are 2-3 mm wider)
Primate is mesial of canine in Mx, distal of the canine in Md
Shallow overbite and excess overjet
Mx grows faster, causing excess overjet
Flush terminal plane
Flush (71%) becomes class I or Class II
Distal step (10%) Md molar is distal, always becomes class II
Mesial step (19%) Md molar is mesial, Class I or Class III
Vertical inclination of the incisors and ovoid arch form
o General sequence of eruption of the primary and permanent dentitions
Primary
A,B,D,C,E for both arches
Permanent
Mx 1st molar, centrals, laterals, 1st premolar, 2nd premolar, canine, 2nd
molar
Md 1st molar, central, laterals, canines, 1st premolar, 2nd premolar, 2nd
molar
o Dental Age and Eruption dates
4 month rule for Primary
Central 8 months
Lateral 12 months
1st molar 16 months
Canines 20 months
2nd molars 28 months
Permanent teeth
6 years Mn centrals, Mn and Mx 1st molars
7 years Mn laterals, Mx centrals
8 years Mx laterals
9-10 years development of permanent canines and premolars (almost
no roots on premolars in x-rays at 9)
 11 years Mn canines and 1st premolars, Mx 1st premolars
12 years Mn 2nd premolars, Mx 2nd premolars and canines. 2nd molars
also
o Permanent 2nd molars typically erupt around the time of the last
succedaneous tooth
13-15 years development of 3rds, and root development of other
permanent teeth completed (often finished by age 15)
Teeth usually emerge with 2/3 to of the root formed
Root formation completes 2-3 years after tooth reaches occlusion
Major deviation in sequence is more of a concern than a general delay or
acceleration
Permanent teeth on one side usually erupt within 6 months of its counterpart
on the other side
o Pre-emergent vs post-emergent eruption
Pre-emergent
Resorption of overlying bone and roots, and eruption mechanism itself
pushes tooth into created space
Begins soon after root formation begins
Normally rate of eruption is such that apex doesnt move, but crown
does
Unknown mechanism
Post-emergent eruption
Post-emergent spurt: rapid eruption to occlusal surface after gingival
penetration. Slows as teeth occlude
Juvenile occlusal equilibration: eruption matches vertical mandibular
growth during adolescence
o Dont want to place implants too early because of this
Adult occlusal equilibration: after growth has stopped, it matched the
rate of attrition
o Supraerpution in the absence of contacts
o Changes in arch form and length that occur during the transition from the primary to
adult dentition
Arch broadens with eruption of canines
Permanent anterior teeth procline
Arch length decreases
Leeway space: amount of extra space the primary posterior teeth take
up compared to the space the permanent premolars occupy
o Mx 1.5 mm (all from E space)
o Mn 2.5 mm (0.5 mm from D, and 2.0 mm from E)
o Difference between early and late mesial shift
Early mesial migration of the erupting mandibular permanent molar using up
primate space, usually occurs around age 6
Late mesial migration of the erupting mandibular permanent molar using up
the leeway space, occurs around 11 when 2nd molar is lost
 o Changes in molar relationship as you transition from primary to permanent
Flush terminal plane as mandibular molar erupts, mesial shifting leads to the
mandibular molar moving mesial into the normal class I relationship
Mesial step already resembles class I, can only end up class III with significant
mandibular growth
Distal step requires a lot of mandibular growth for it to shift far enough into a
class I
o Variations of normal
Incisor liability: transitional crowding caused by larger mandibular incisors
coming in before the mandible has grown enough
Can spontaneously resolve from expansion at canines, proclination of
incisors, and leeway space from primary dentition
Diastema
Transitional 1-3 mm diastema is common, usually resolves with the
eruption of the canines
Delay treatment until after canines come in
Ugly duckling phase: midline diastema and distally angled incisors
Teeth straighten and space closes with eruption of canine
Growth/Development I
o Overall concepts of growth/growth pattern
Infants
Jaws are proportionally small in infant.
Infants eyes are wide-set relative to the face
Ears appear low
Young childs forehead is upright and bulbous,
Changes
Vertical facial growth tends to outpace transverse growth
o Sinuses have a large vertical growth and some lateral expansion
Childs mandible is more V-shaped, while adults becomes U-shaped
Maxilla grows quicker than the mandible
o Maxilla arch is convex in children, but concave in adults
2/3 of growth is complete by age 10-12
Patterns
Cephalocaudal gradient: structures further from the brain tend to grow
more, and later than those that are closer
Mandible follows general body growth rate, while maxilla is a little
earlier
Females hit their spurt earlier than males, but males grow 2 years longer
o Distinguish between normal variations of growth and the effects of abnormal or
pathologic process
Patients outside 2 SD (97%) may warrant further study
o Methods of assessment of physical growth
Hand-wrist radiograph and atlas
Cervical Vertebral maturation
 Measurements
Craniometry (dry/dead skulls)
Anthropometry (soft tissue studies)
Cephalometrics (radiology)
Experiments
Vital staining
o Understand distance growth curve and velocity growth curve. Variability in growth
between male and female
Distance continually increases, velocity is the integral of distance and plots the
slope. Biggest velocity jump is puberty
Females hit their spurt earlier, but they stop 2 years earlier than males
Growth/Development II
o Principles of growth (drift vs displacement)
Drift: modeling on one side and remodeling on the other so that the bone
moves in one direction
Primary displacement: one end has modeling while the other is fixed, leading to
the bone that is modeling to elongate
Secondary displacement: one end has modeling while the other is fixed, and this
causes elongation that pushes another bone into a different location
o Know growth at the different components of the craniofacial complex
Cranial vault
Formation: entirely intramembranous bones
Controlling factors: brain development
Cortical drift causes frontal bone to protrude to keep up with maxilla,
causing frontal sinus and frontal prominence to increase (supraorbital
ridge)
Cranial Base (basioccipital, sphenoid, and ethmoid bones)
Formation: endochondral ossification to bone (mostly done by age 7)
o Spheno-occipital synchondrosis closes at 14
o Spheno-ethmoid syndchondrosis closes at age 6
o Intersphenoid synchondrosis closes at birth
Controlling factors: brain development, olfactory development
A-P and downward growth leads to displacement of the Mx and Md
downward and forward
Nasomaxillary complex
Formation: intramembranous bone formation
Controlling factors: airway/sinus and naso-cartilage
All 3 types of growth
o Secondary displacement (from cranial base) forward and
downward
o Primary displacement in the posterior that pushes the maxilla
forward
o Cortical drift increases vertical dimensions of sinuses
 Transverse growth (V) principle: both maxilla and mandible grow in a
V-shaped pattern over time
o Maxilla is due to mid-palatal suture growth up to age 6, then
mostly surface remodeling and alveolar bone development
Mandible
Formation: primarily intramembranous, but a little endochondral
(condyle) and periosteal (surface) activity
Controlling factors unknown
Body of the mandible growing backwards is the main growth. Pushes
mandible down and out.
Alveolus grows up to keep teeth in contacts
o Soft-tissue changes with time
Lips
Tends to increase in vertical dimension in the adolescent years
Lip thickness reaches maximum during adolescence
Nose
Nasal bone is completed around 10, so most growth is soft tissue and
cartilage after this
Grows downward and forward
Class I patients straighter, Class II curve downward

o 3 planes of space
Width completed first, around age 12 before the growth spurt
Length jaws continue to grow through puberty (14-15)
Height/vertical growth continues through early adulthood
o Growth centers vs growth sites
Growth site: location where growth occurs
Growth center: location at which independent genetically controlled growth is
initiated (epiphyseal plates, nasal septum cartilage, and possibly the condyle)
cant be affected by environmental factors
all growth centers are sites, but not all growth sites are centers
Bone Biology
o Bone types
Flat bones: formed by intramembranous (direct) bone formation
Skull, mandible, and scapula
Long bones: bones formed by endochondral (indirect) bone formation
femur, tibia, and radius
o Bone components/cell types
Components
60-70% inorganic (hydroxyapatite)
20-40% organic (mostly type I collagen)
5-9% Water
3% lipids
Cells
 Osteoblasts: secretion of a complex mixture of bone matrix proteins
(osteoid)
o Local regulation of osteoclastic differentiation and bone
resorption
Osteocytes: serve as a mechanoreceptor that communicate through
caniculi
Osteoclasts: bone lining cells responsible for bone resorption
o Bone cell communication/regulation
Bone resorption
Macrophage colony stimulating factor (M-CSF) stimulates cells to grow
and proliferate into pre-osteoclastic cells
RANKL binds to RANK receptors and stimulate maturation of pre-
osteoclast cells to osteoclasts
o RANKL comes from osteocytes
TNF- and IL-1 induce osteoclast formation as well
Bone formation
Osteoclasts present is essential (# of osteoclasts present controls the
number of osteoblasts)
IGF-1 and TGF- from osteoclasts induce bone formation
o Control factors (cell mediators/drugs)
Activation-Resorption-Formation (ARF) cycle
Activation damage bone leads to osteocytes releasing M-CSF and
RANKL to initiate resorption from osteoclasts
Resorption osteoclasts mature and do their thang
Reversal osteoclasts are turned off and recruit osteoblasts to the site
Formation osteoblasts are turned on and make osteoid
Termination osteoid begins to calcify and mature
Gonadal steroids
Androgens increase bone formation
Estrogens increase bone formation
Corticosteroids induce osteoporosis
Osteoporosis
Bisphosphonates inhibit bone resorption by osteoclasts
o Nitrogen containing affects ruffled border
o Non-nitrogen containing incorporate into ATP and are
metabolized by osteoclasts, killing them
Denosumab fully human monoclonal antibody against RANKL
Wnt induce osteoblastogenesis and suppress osteoclastogenesis
o Good for glucocorticoid induced osteoporosis
o Wnt antagonist for osteopetrosis
Biology of tooth movement
o Know the difference between physiological and orthodontic tooth movement
Physiologic normal process, very slow (take years), primarily a PDL
phenomenon, and not associated with inflammation or pain
 Eruption of teeth
Mesial drift
Soft tissue imbalance (tongue thrust)
OTM mechanically induced, occurs rapidly (weeks to months), primarily a PDL
phenomenon, often associated with some inflammation/pain
Light prolonged pressures (50-350 grams)
Tooth moves
Bone around tooth remodels
Sutures can also be induced (500-750 grams)
o Understand the difference between frontal and undermining resorption
Frontal resorption
PDL is compressed so that the blood supply is limited but not
interrupted.
Osteoclasts derived from PDL blood vessels
Bone resorption of lamina dura occurs on the frontal surface
Relatively painless, most cells survive
Undermining resorption
PDL is compressed so the blood supply is completely cut off, leading to
hyalinization of the PDL
Osteoclasts are derived from the marrow spaces and resorb the back
side of the lamina dura
Takes longer to get going
Necrosis occurs, leading to pain and inflammation
o Know the threshold for tooth movement (duration of force application)
4-6 hours to initiate cellular response in PDL
Generally you want to use an appliance 8-12 hours/day
2-5 days to initiate bone remodeling
Plateau phase: 2-14 days before lamina dura is resorbed and the tooth remains
relatively non-mobile
After plateau phase, you want to keep adjusting the pressure so that it stays
continuous
o Know the tissue changes that are commonly seen during OTM
Enamel no effect
Cementum localized perforations repaired with cementum
Dentin resorption occurs in areas of cementum perforation, filled up with
cementum
Pulp modest and transient inflammation
PDL described above
Bone alveolar bone is remodeled in areas of compression, and modelled in
areas of tension
Orthodontic root resorption- occurs in all teeth, but more common in maxillary
anteriors
o Know the theories and principles behind tooth movement
 Frost theory (mechanostat): strain threshold/fluid flow with
osteocytes/canaliculi leads to the initiation of osteoclastic resorption
Piezoelectric theory (bio-electric): electrical signals are normally sent in
streaming potentials, and bending the alveolar bone sends these signals that
help maintain the bone or tell if it needs to be remodeled
Pressure-tension theory PDL compression decreases O2 levels in the PDL, and
tension causes increase in O2 levels. These signals dictate bone remodeling
o Understand the effect of certain drugs on OTM
Prostaglandins increases OTM
Vitamin D3- increase OTM
Long term NSAIDs is expected to decrease OTM (reduces inflammation)
Acetaminophen doesnt
Other medications that can depress OTM
Bisphosphonates
Prostaglandin inhibitors
Tricyclic antidepressants
Antimalarial drugs
Tetracyclines
Pt Exam and Records
o List the components of an orthodontic clinical record
Interview
CC
Treatment expectations
Physical growth evaluation
Social and behavior evaluations
Clinical exam
Oral health
Jaw and occlusion (function)
Esthetics
o Macro-esthetics at the level of the face/head
Facial and lateral profiles
o Mini-esthetics at the level of the arches
Malocclusions
Midlines
Smile arc
o Micro-esthetics at the level of individual teeth
Tooth proportions
Embrasures
Tooth shade
Diagnostic records
Photographs
Study casts
Radiographs
o Lateral cephalograms
 o Frontal cephalograms (if asymmetry)
o Panographs
o Peri-apicals, occlusals, bite-wings
o CBCT sometimes
o Describe the production of orthodontic diagnostic records
o Evaluate diagnostic data and produce a problem list
Casts
Crowding/spacing
Mixed dentition analyses
Tooth size discrepancies
Curve of Spee
Profile analysis
A-P jaw discrepancy
Vertical jaw discrepancy
Facial proportions and mandibular plane angle
Incisor position/inclinations and lip posture
Frontal analysis
Facial type, proportions, and symmetry
Trichion (forehead), glabella (supraorbital ridge), subnasale (bottom of
nose), menton (bottom of chin)
Assess both at rest and animation (smiling)
o Understand how a prioritized problem list is developed from data related to the patient
Generally should address the patients chief complaint
Includes both pathological, functional, and developmental problems
When possibly, quantify/classify severity
Only list 2-5
o Variations in terminology associated with the diagnosis
Class I, orthognathic, straight-convex (Nasion to ANS to menton angle),
mesiofacial
Mesiofacial: middle ground, more round/ovoid
Class II, retrognathic, convex, dolichofacial
Dolichofacial: long face
Class III, prognathic, concave, brachyfacial
Brachyfaical: flatter, more square faced
Classifications of Malocclusions
o Describe characteristics of normal occlusion
Class I molar relationship
Tip
Crowns mesially tipped/angled
Incisors tip labial and canines/posterior teeth tip lingually
Correct rotations
Curve of Spee should be flat or shallow
Normal apical base relationship
Minimum overjet and overbite (1-2 mm, 2-3 mm)
 Symmetrical dental arches with matching midlines
MIP and CR are close together
o Classify malocclusion according to Angle as well as according to Ackerm and Proffit
Angle
Class I
o Triangular ridge of MB cusp of Mx 1st molar articulates with the
buccal groove of the Md 1st molar
o Boney base supporting the mandibular dentition is directly
beneath that of the maxilla in good anterior-posterior
relationship with the cranium
Class II
o MB groove of the Md 1st molar articulates posterior to the MB
cusp of the maxillary 1st molar
o Relative distal relationship of the mandible relative to the
maxilla. Most often the Md is prognathic
Class III
o MB groove of the Md 1st molar articulates anterior to MB cusp
of the Mx 1st molar
o Relative mesial relationship of the mandible to the maxilla.
More often the maxilla is underdeveloped
Proffit Ackerman
Considerations
o Transverse relationship
o A-P relationship
o Vertical relationship
o Soft-tissue relationship
o Intra-arch dental relationship
Classifications
o Transverse dysplasias
Crossbite
Lateral shifts
Apical base discrepancies
o Sagittal (antero-posterior) dysplasias
Dental
Class I, II, and III dental relationships
Skeletal
Class I, II, or III skeletal relationships
o Vertical dysplasias
Open bite
Deep bite
End-to-end
Excessive gingival display
o Intra-arch discrepancies
Crowding
 Spacing
Anomaly in tooth number
o Trans-sagittal deviation
o Vertico-transverse deviation
o Sagitto-vertical deviation
o Trans-sagittal-vertical deviation
o Understand how to describe malocclusion in all three planes of space (see above)
o Describe the etiology of malocclusion
Pathological
Developmental, hereditary, accidental, or acquired
Cleft lip/palate
Congenitally missing or supernumerary teeth
Ectopic eruption or impaction
Early loss of primary teeth (caries)
Trauma
Habits
Cephalometrics I
o Know the standards of a ceph arrangement
Position
Left side of patient toward the film
Central ray goes through the EAM (ear rods)
5 feet from source to mid-sagittal (head holder)
Have patient in Natural Head position: relaxed, looking into the
distance, and feeling comfortable
Right side is magnified more than the left side
o Understand why cephalograms are used in orthodontics
Compare patients to a normal reference group
Growth analysis and orthodontic changes
Evaluate relationship between 5 major functional components
Skeletal cranium and base
Nasomaxillary regions
Maxillary dento-alveolar
Mandibular region
Mandibular dento-alveolar
Evaluate treatment results and biomechanical outcomes
Assess growth
Diagnostic casts have limitations
o Know what diagnostic information can be obtained from a lateral cephalogram
Generals
Skeletal relationships
Underlying etiology of malocclusions
Growth assessment
o At 6 months nasion-menton dimension doesnt change = done
o Vertebral assessment
 Lateral
A-P dysplasias
Vertical dysplasias
Incisor position and inclination
Balance of soft tissue and facial contours
Frontal
Transverse dysplasias
Asymmetries
Cephalometrics II
o Have an understanding of the definition of various cephalometric landmarks and planes
presented
Landmarks
Anterior nasal spine (ANS)
Articulare: point at the junction of the posterior border of the ramus
and inferior border of the posterior cranial base
Basion: lowest point of anterior rim of the foramen magnum
Gonion: point on the curve of the angle of the mandible bisecting the
angle formed by lines tangential to the posterior ramus and the inferior
border of the mandible
Pogonion: most anterior point on the bony chin
Menton: most inferior point on the bony chin
Gnathion: point in-between pogonion and menton
Porion: most superior point of the EAM
Point A (subspinale): most posterior midline point of the concavity
between ANS and the most inferior point on the alveolar bone
Point B (supramentale): The most posterior midline point in the
concavity of the mandible between the most superior alveolar bone and
pogonion
Sella (S): geometric center of the pituitary fossa
Plane
Frankfort Horizontal (FH) plane plane through the orbitale and porion
Sella-Nasion (SN) plane through the sella tursica and nasion
Facial plane plane through the nasion and pogonion (anterior of chin)
o Mandible relative to the cranium
Mandibular Plane (MP) plane through menton and gonion (angle of
mandible)
SNA and SNB line from sella to nasion to point A or B
o SNA maxilla. smaller angle = retruded maxilla
o SNB mandible. smaller angle = retruded mandible
ANB general difference between maxillary and mandibular bases
Mandibular plane angle angle between the mandibular plane and the
FH plane
Vertical facial proportions
 o Nasion, Anterior Nasal Spine, and Menton
o N to ANS = upper face (45%)
o ANS to M (55%)
Incisors
o Mx long angle to SN line (102)
o Md long axis to MP (90)
Interincisal Angle angle between the incisors
E plane soft tissue of the nose to soft tissue of the chin
o Lips should be behind this line
Nasolabial angle angle between base of the nose to the soft tissue of
the nose, and the base of the nose to the anterior portion of the lip
o Measures dentoalveolar protrusion
o Understand how your patient relates to a given normal value for the cephalometric
measurements presented (know the different planes and what different measurements
compared to the norm mean)
o Be able to see the big picture when applying cephalometric analyses to patients

Boards Questions

The difference in the total of mesio-distal widths between the primary canine, 1st molar, and 2nd
molar, and the permanent canine, 1st premolar, and 2nd premolar is named:
o Leeway Space
Which are the most commonly impacted teeth? (besides 3rd molars)
o Permanent Mx canines
The most rapid losses in the perimeter of the arch usually are due to
o Mesial tipping and/or rotation of the permanent 1st molar after premature loss of a
primary 2nd molar
Name processes for bone formation and bone growth
o Formation
Endochondral ossification
Intramembranous ossification
o Growth
Apposition
The flat bones of the skull and part of the clavicle are formed by?
o Intramembranous ossification
Bone deposition, responsible for the lengthening of the maxillary arch, takes place in what
maxillary region?
o Tuberosity (posterior)
In a Young child, which structure grows in height and length to accommodate in the developing
dentition
o Alveolar process
Side note: After age 6, the greatest increase in size of the mandible occurs distal
to the 1st molar
Continuous orthodontic forces may cause
o PDL to become crushed
 o Resorption of the cementum
o Resorption of the alveolar bone
Malocclusion is most often:
o Hereditary
o 2nd is bad habits
Class III malocclusion is also referred to as
o Prognathism or underbite (also mesiocclusion)
Which of the following profiles is usually accompanied by a class II malocclusion
o Retrognathic profile
Which type of malocclusion is most often associated with mouth breathing?
o Dental open bite (not skeletal open bite)
What is overbite?
o Vertical overlapping of the maxillary anterior teeth over the mandibular anterior teeth
What is overjet?
o Horizontal projection of the maxillary anterior teeth beyond the mandibular anterior
teeth
What is physiologic occlusion?
o The one that adapts to the stress of function and can be maintained indefinitely (not
necessarily an ideal or class I)
What is pathologic occlusion?
o The one that cannot function without contributing to its own destruction. It can
manifest in a combination of (excessive wear, TMJ, Pulpal changes, PDL damage)
A steep mandibular plane angle correlates with
o Long anterior facial vertical dimensions and anterior open bite malocclusion
Which of the following are uses for cephalometrics in orthodontics?
o Diagnosis
o Analysis of treatment results
o Longitudinal studies of growth
Which of the following would be indicative of maxillary retrognathism?
o An SNA angle lesser than 82