1.miu - Orthodontics For Undergtaduate 6th Edition On CD

ORTHODONTICS
FOR
UNDERGRADUATE
Prof. Hussam M. Abdel-Kader Professor of Orthodontics

BDS, BMMSc, HDD, HDD, PhD
6th Edition 2009
Hussam M. Abdel-Kader
Orthodontics for Undergraduate: 2009
PREFACE
The best evidence can inform, but can never replace, individual clinical expertise because it is this expertise which decides whether the evidence applies to the individual patient and, if so, how it should be integrated into a clinical decision Harrison E Jayne 1999 My interest in Orthodontics dates back to my undergraduate study, when I first learned that Orthodontics is art and science. These days belong to around five decades ago, when every thing is some what very simple compared with that of the present days. Now-a-day we are living under the umbrella of globalization, Digital Era and every thing is at our finger tips. Accordingly modern orthodontics of the 21st century, after around one century from the days of Dr. Edward H. Angle, has become a highly sophisticated care service, which can provide excellence treatment of dental malocclusion and facial disharmony, based on the premise that this treatment is given by highly educated, highly qualified, well skilled, and experienced clinicians. On the basis of this concept, the undergraduate orthodontic training program is frequently concentrated on teaching the students how to recognize and prevent the development of dental malocclusions, rather than to enable them to provide treatment. Our main objectives, by the end of the orthodontic course, to have the appropriate knowledge about; growth and development of dentoskeletal complex, diagnosis of dental malocclusion, needs and indications for treatment, what should we refer and at what age. Within the overall course number of hours, the program will be assigned to theoretical orthodontics, to recognize early the deviation from normal dental occlusion, preventive orthodontics and laboratory works to be acquainted with simple removable orthodontic appliances. In the preparation of this hand book, it has been my purpose to provide a simple and practical manual for the undergraduate student. The selection of the materials needed by the undergraduate, presents considerable difficulty mainly because of the limited time in which orthodontics is studied. On the other hand, most will agree that the scope must be sufficient to assure the proper understanding of the subject.
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Step-by-step illustration of the subject, together with my experience during postgraduate study, clinical and academic experience since my graduation on 1966, teaching the subject in the classroom, long experience gained from attending and active participation in international scientific meeting, publication in scientific international and national journals and direct contact with eminent professor in the field, have formed the foundation of the presentation. Finally, I would like to extend my sincere appreciation to all of my professors, colleagues, students and patients; for their continuous encouragement which extended for around five decades, my debt to them is everlasting. Acknowledgement must also be made for the illustrations taken from the book by Professor T.M. Graber.
Prof. Dr. Hussam M. Abdel-Kader

Cairo, Egypt E-mail address: hmkader@hotmail.com Web Site: http://geocities.com/hussamkader
CONTENTS
1. 2. 3. 4. 5. 6. 7. 8. Introduction and aim of orthodontics Orthodontic history Concept of modern orthodontics of the 21st century Growth and development of the craniofacial complex Normal development of dentition and occlusion Normal dental occlusion Forces of occlusion The closed functional system and the development of normal occlusion 9. Movements of the tempromandibular joint 10. Malocclusion 11. Classification of malocclusion 12. Etiology of malocclusion 13. Orthodontic examination 14. Scope of orthodontics: Preventive, interceptive (serial extraction) and corrective 15. Orthodontic tooth movement 16. Extraction in orthodontics 17. Orthodontic appliances 18. Orthodontic-orthopedic appliances; facemask and midpalatal expander 19. Anchorage in orthodontics 20. Myofunctional therapy 21. Adult orthodontics 22. Occlusal equilibration 23. Managements of orthodontic patients at high or moderate risk from infective endocarditis 24. Communication skill and signed consent form 25. Materials used in orthodontics 26. Retention and relapse in orthodontics 27. Biomechanics in orthodontics 28. Adjunctive orthodontic treatment 29. Risk factors in orthodontics 30. Ethics in orthodontics 31. Patients different ages in orthodontics
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32. Infection control in dental practices 33. Egyptians cephalometric measurements average norm 34. Growth prediction 35. Evidence based orthodontics 36. Guideline for research writer 37. Statistics in orthodontics REFERENCES
CHAPTER 1: INTRODUCTION AND AIM OF ORTHODONTICS

INTRODUCTION: Orthodontics is a branch of the science and art of dentistry which deals wit the developmental and positional anomalies of teeth and jaws as they affect oral health in general, physical, psychological, social, esthetic and mental well-being of the person. The main goal of orthodontics is to create and maintain a normal environment for proper physiologic activity of the teeth and investing tissues, the oral soft-tissues and the facial esthetic and masticatory efficiency, in order to ensure as far as possible optimum dentofacial development and function. Now a day; orthodontics is evidence based. Evidence based orthodontics means the integrations between our clinical expertise and systematic research the data base either electronically or physically for the best available evidence. We are now living under the umbrella of the Digital Era, the miracle of internet technology and global informations exchange. The introduction of digital radiography and photography and the computer generation of 3D image of the skeleton and soft-tissue of the craniofacial complex added too much to our continuous challenging specialty, The study of orthodontics could looks from the first glance a very tough study, but in fact it is very simple. It is only need a scientific way of thinking, wide background of other dental specialties, psychology of child and adolescent, how to communicate with others, tissue changes, biomechanics, biocompatibility, dental materials physical properties, and geometry among other related topics. To practice orthodontics, we have to academically study and work under direct supervision of professional teaching professors for at least five years, to see the treatment outcome of some of the assigned orthodontic problems to the candidate. The orthodontic problems could be grouped into classes as in Angle Classification of dental malocclusion. The approach to each problem could vary and very specific to that problem in particular, but we have to be within the general orthodontic concepts and principles. How to work within a team is very important in orthodontics. We are active partner in some important teams such as; orthognathic surgery team, cleft lip and palate team, tempromandibular (TMJ) team etc.
AIM OF ORTHODONTICS: The practice of orthodontics deals directly or indirectly with prevention, alleviation, or elimination of any one or more of the following: 1. Dentofacial abnormalities of genetic, congenital and environmental origin, including those resulting from clefts of lips, alveolar process and plate, trauma and surgical intervention. 2. Shifted or abnormally situated teeth and abnormal jaw relationship. 3. Improvement of facial esthetics. 4. Improvement of masticatory function. 5. Elimination and prevention of periodontal disease. 6. Reduction of susceptibility to dental caries. 7. Helping in correction of tempromandibular joint problems. 8. Elimination of harmful dentofacial habits. 9. Helping in elimination of abnormal mental attitude in relation to dentofacial esthetics. 10. Correction of malposed teeth prior to the construction of removable and/or fixed restoration of missing teeth. 11. Improving teeth alignment and leveling for cases in need of surgical approach; skeletal craniofacial discrepancy cases (orthognathic surgery or distraction osteogenesis surgery) and cleft lip and palate surgery. NB: Distraction osteogenesis means mechanical stretching of bone through osteotomy site, corticotomy site or suture by stretching devices; distractor either intraoral or extraoral distractor.
CHAPTER 2: ORTHODONTIC HISTORY

Orthodontics is derived from the Greek words Odous (straight) Odont (tooth) which mean straight teeth. Now a day the concept completely changed from arranging the teeth to be in good leveling and alignment to arrange the teeth to be in good aesthetic functional long term stable occlusion within healthy stomatognathic system. The irregular position of teeth has been a problem for some individuals since the beginning of time. Attempts to correct this disorder go back to at least 1000 BC. 1850 AD the first texts which systematically described orthodontics appeared. Dr. Norman Kingsley was among the first to use extraoral force to correct protruding teeth. The emphasis of this era was to correct facial proportions via extraction of teeth. Very few people of this time had a complete set of teeth. Little attention was given to how teeth bite together (occlude). 1890's AD Advancements were being made in the replacement of teeth with artificial ones and the development of how these teeth should bite together. Dr. Edward Angle, "The Father of Modern Orthodontics," was one of the first to emphasize occlusion in the natural dentition. His interest in creating proper occlusion in natural teeth created the specialty of Orthodontics. The publication of Angle's Classification of Malocclusion not only subdivided major types of malocclusion, it also included the first clear concept of normal occlusion in the natural dentition. (Highlighted area will take you to 1C) 1900's AD With a concept of normal occlusion established by Angle, Orthodontics began to evolve into the treatment of malocclusion and not just the straightening of teeth. 1930's AD Esthetics associated with malocclusion were reemphasized and extractions to improved facial proportions were reintroduced into Orthodontics. This improvement in esthetic proportions allowed for a more stable occlusal relationship. Within this period the concept of occlusion changed from static occlusion to functional dynamic occlusion in approaching dental malocclusion problems. 1940's AD Cephalometric radiographs were developed which allowed the orthodontist to see how the bones of the face contributed to malocclusion. With this technology, it was discovered that one could alter the growth of bones in growing individuals and prevent malocclusion by redirecting growth.
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1970's AD Surgical techniques developed which allowed oral surgeons to perform surgery on patients who did not have the ability to grow any longer. Now bony causes of malocclusion in adults could be treated. Present time; Orthodontics uses a combination of extraoral forces to align teeth as well as growth modification, surgery and extractions to accomplish three goals: 1. 2. 3. 4. Create the best occlusal relationship Create acceptable facial esthetics Create a stable occlusal result Teeth move based on the mechanical principle from the science called Statics. In order to fully understand the forces involved in creating orthodontic tooth movement, some basic terms must be defined.
CHAPTER 3: CONCEPT OF MODERN ORTHODONTICS OF THE 21st CENTURY

The goal of modern orthodontics of the 21st century: With the 21st century the concept of orthodontic changed and putting the following important points in consideration: 1. Orthodontic practice is running under the umbrella of evidence base orthodontics. The best evidence can inform, but can never replace, individual clinical expertise because it is this expertise which decides whether the evidence applies to the individual patient and, if so, how it should be integrated into a clinical decision Harrison E Jayne 2. We are not either occlusionist or cosmetologists but we are professional orthodontists aiming to establish well balanced aesthetic long term stable functional occlusion within the stomatognathic system. Ackerman et al 3. Creation of the best accepted normal occlusion but not on the expenses of function, long stability and healthy stomatognathic system Ackerman et al 4. Too much concern on creation and establishment of the best balanced functional occlusion, dental and facial aesthetics, long-term stability and maintenance of the treatment outcome (be free from the dogma of detailed ideal occlusion) Proffit 5. Orthodontics changed from the occlusion concept to functional aesthetic concept Ackerman et al 6. Respecting patients psychosomatic norm Elisha Richardson, Abdel-Kader 7. We are treating patients subconsciously up to our psychosomatic norm Peck and Peck 8. We are not the sole decision maker; we have to be autonomist and not paternalist Ackerman, Proffit 9. The miracle of internet technology and global information Peck 10. Orthodontics is now a day running with the miracle of Digital Era Peck Proffit summarizes the concept of modern orthodontics in the following statement: In the early 21st century, orthodontics differs from what was done previously in three important ways: 1. There is more emphasis now on dental and facial appearance. This reflects a greater awareness that parents and patients seek treatment largely because of concern about facial appearance, and that psychosocial problems related to appearance can have major effects on an individual's quality of life. The advent of orthognathic surgery has made it possible to correct facial disproportions that previously were not treatable, and the development of computer imaging methods that allow the orthodontist to share facial concerns with patients in a way that was not possible until recently.
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2. Patients now expect and are granted a greater degree of involvement in planning treatment. No longer is it appropriate for the paternalistic doctor to simply tell patients what treatment they should have. Now patients are given the opportunity to participate in selecting among treatment options-a process that is facilitated by computer imaging methods; and Orthodontics now is offered much more frequently to older patients as part of a multidisciplinary treatment plan involving other dental and medical specialties. The goal is not necessarily the best possible dental occlusion or facial esthetics but the best chance for long-term maintenance of the dentition. This increased emphasis on treatment coordinated with other dentists has the effect of integrating orthodontics back into the mainstream of dentistry, from which Angles teachings had tended to separate i
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CHAPTER 4: GROWTH AND DEVELOPMENT OP THE CRANIOPACIAL COMPLEX I. BONE GROWTH

Before we study the growth of the various parts of the cranio-facial complex, it is important to have a full appreciation of how bone grows, as bone forms the structural framework of the body. It is a calcified organic tissue rigid enough to support the body and to give points of attachment to the musculature, and yet flexible enough not to be brittle. Types of Bone Formation: The forerunner of all bone is always connective tissue. The terms cartilaginous or endochondral, membranous or intra-membranous, identify the type of connective tissue. 1. Endochondral bone formation: It is laid down within the cartilage which proliferates from the original mesenchyme cells. Osteoblasts develop and provide a network of fibrous matrix which replaces and invade destroyed cartilage. Bone formation proceeds until the only remaining cartilage is that forming the epiphyseal plates at the end of bone shafts. This cartilage plate continues to provide a. framework into which ossification can develop, permitting the increase in length necessary for growth. At maturity the epiphyseal plates disappear. In the case of the craniofacial bones, and in between the individual bony centers, there are areas of growing cartilage which forms SYNCHONDROSIS. These are similar in structure and function to the epiphyseal plate, but differ in that growth occurs on both sides. 2. Intramembranous bone formation: The first step is the development of osteoblasts from a concentration of undifferentiated mesenchymal cells. These specialized cells proliferates a fibrous network which is progressively mineralized by the deposition of calcium salts. As bones grow toward each other, as in the cranium, the osteogenic region between them is composed of connective tissue. This zone is c a l l e d a s S U T U R E . I t i s c o m p o s e d o f f i v e l a y e r s o f t i s s u e : a) cellular osteogenetic layer, associated with each of the bones bounding the suture. b) Fibrous layer, bounding the cellular osteogenetic layer, c) intermediate layer between the adjacent fibrous layers, containing connecting fibres and blood vessels. Obviously, in nature's plan growth of any one part of the s k ul l i s c o o r d i n a t e d w i t h t h a t o f t h e o t h e r p a r t s . T h i s g r o w t h is accomplished in three ways:
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1. Replacement of cartilage - synchondrosis; or replacement of connective tissue - suture. 2. Surface apposition; in this method new bone is laid down beneath a surface periosteum. It is often associated with resorption of the previously formed bone from the other side. The balance between bone deposition and resorption is an important factor in changing the form of individual bony elements of the skull. This process is responsible for the g r o wt h o f c a v i t i e s s u c h a s t h e n a s a l c a vi t y a nd t he p a r a - nasal sinuses. 3. The growth of bone is dependent primarily upon the growth of i t s functional matrix. This idea is the airway and alimentary spaces and associated soft-tissues are what must grow, and the supporting structures do the accommodating.
II. Growth of the craniofacial complex:

1. Growth of the cranial bases: For our purposes the anterior cranial base extends from the Nasion to the Sella Turcica. The Nasion is a point formed by the external junction of the for mal bone a nd the two nasal bones. The frontal bone is entirely formed from intramembranous bone. The posterior cranial base is the area between the Sella Turcica and any of several posterior points. The basion is the anterior rim of the Foramen Magnum. The Opisthion is the posterior r i m of the Foramen Magnum. The Bolton point is the deepest point in the notch behind the Occipital condyles. There are different growth rates for different parts of the cranial base: 1. That part of the anterior cranial base growth from Nasion to foramen Caecum represents the thickness of the frontal bone. This area has general skeletal growth. That is, it increases throughout the growth period until third molars have erupted and/or the spheno-occipital synchondrosis has fused. The distance from foramen Caecum to Sella Turcica includes the l e n g t h o f t h e c r i b r i f o r m p l a t e o f t h e E t h m o i d . T h i s a r e a has a neural growth. Thus is grows rapidly, but stops growing early after eruption of the first permanent molars. 2. The spheno-occipital synchondrosis is included within the posterior cranial base from Sella Turcica to Basion. This dimension increased 9.3mm from the time of eruption of the first permanent molars until the eruption of the third molars and fusion in the spheno-occipital synchondrosis. Thus, this area also has generalized skeletal growth. The distance from the anterior to the posterior margin of the foramen magnum does not increase beyond the time of eruption of the first permanent molars. Certainly the term neural growth is apropos for the passageway of spinal cord.
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From the above; the growth of the cranial base, generalized skeletal growth and neural growth alternate. The spheno-occipital synchondrosis, influencing the antero-posterior growth of the cranial base, and its situation behind the maxilla affect simultaneously the anteroposterior growth of the maxilla. 2. Growth of the cranial vault: The cranial vault enlarges by growth of the flat bones of the skull: The frontal, the parietals and the squamous parts of the temporal bones and occipital bone. These bones formed directly from membranous tissue are the first to show evidence of ossification at about the sixth week of pregnancy. The area of these bones enlarges by growth at the sutures, probably initiated at first by growth of the brain. This alternates with an active apposition-resorption mechanism. The sutural growth of the cranial vault is influenced by the brain growth (internal functional matrix) at an early stage, and later by growth and migration of muscle attachments (external functional matrix) after mastication and active muscle function commences. The thickness of the frontal bone increases with the development of the frontal sinuses (functional matrix), particularly in the adolescent male. 3. Growth of the maxilla: The maxillary complex is joined to the cranial base, hence, the crania] base naturally influences the development of this region. The position of the maxilla in space and with respect to the cranium its growth is dependent on growth at the spheno-occipital and spheno/ethmoidal sutures. Sutural connective tissue proliferations, ossification, and surface apposition are the mechanism for maxillary growth. The maxilla is halted to the cranium by the; I) frontomaxillary suture, 2) zygomaticomaxillary suture, 3) zygomaticotemporal suture, 4) pterygopalatine suture, 5) zygoma t i c o fr o n t a l s u t u r e a nd 6) fr ont ona s al s ut ur e . The s e s ut ur e s are all oblique and mere or Jess parallel to each other. Thus, growth ha these areas would serve to move the maxilla downward and forward (or the cranium upward and backward). The increase of height of the maxillary complex is by the continued apposition of the alveolar bone on the free borders of the alveolar process as the teeth erupt. By the alternate process of bone deposition and modeling resorption, the orbital and nasal floor and the palatine vault move downward in a parallel fashion. T h e i n c r e a s e o f w i d t h o f t h e m a x i l l a r y c o m p l e x i s b y : 1) sutural growth: median palatine suture, ethmoid suture, lacrimal suture, zygomatic suture and nasal suture. 2) Appositional g r o w t h o n t h e l a t e r a l w a l l s o f t h e ma x i l l a i t s e l f . T h e e a r l y closure of the premaxillary suture limits the width of the palate in this area.
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4. Growth of the mandible: At birth the two rami of the mandible are quite short and the condyles have developed relatively l i t t l e . There is a separation of the right end left bodies of the mandible at the midline, or symphysis, by a thin line of fibro-cartilage and connective tissue, which is replaced by bone between 4 months of age and t h e end of the first year. During the first year of life appositional growth is especially active at the alveolar border, at the distal and superior surfaces of the ramus, at the mandibular condyle, along the lower border of the mandible and on i t s lateral surfaces. After the first year of life, the condyle a ssumes i t s role as the primary growth center and contributes to the downward and forward growth of the mandible. Heavy appositional growth occurs on the posterior border of the ramus, alveolar border and the coronoid process. Resorption occurs along the anterior border of the ramus, lengthening the alveolar border and maintaining the anteroposterior dimension of the ramus. The body of the mandible maintains a rather constant relationship to the ramus throughout life. The increases of length of the mandible is by; growth of the condyle and apposition of bone on the posterior border of the ramus. The increase of height of the mandible is by, the condyle plus alveolar growth. The increase in width of the mandible is by; growth at the posterior border of the ramus, additive growth at the coronoid notch, coronoid process and condyle increases the superior inter-ramus dimension, and by the continued growth of the alveolar bone, upward and outward on an expanding arc, with the developing dentition.
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CHAPTER 5: NORMAL DEVELOPMENT OF DENTITION AND OCCLUSION

This can be divided into the following developmental periods: 1. Predental stage; from birth to the eruption of the first deciduous tooth. 2. Deciduous dentition stage; from the eruption of the first deciduous tooth and complete eruption of all deciduous teeth to the eruption of the first permanent molars. 3. Mixed dentition stage; from the eruption of the first permanent molars to the complete shedding of all deciduous teeth and eruption of their permanent successors. 4. Permanent dentition stage; after the eruption of all the permanent teeth. 1. The Predental stage: At birth, the maxillary and mandibular arches are covered by 20 segmented elevations corresponding to the unerupted deciduous teeth, and are called Gum Pads. The segments for the second deciduous molars are poorly defined until the age of 5 months. The groove marks the distal margin of the canine segment continues on the buccal surface of the ridge and is called the Lateral Sulcus. The gum pads of the maxillary arch are separated on its palatal side from the hard palate by a continuous horizontal groove called the Dental Groove. The upper arch is horse-show shaped and the vault of the palate is very shallow, while the lower arch is U-shaped and the gum pad anteriorly is slightly everted labially. At this stage it is difficult to establish the occlusion. The maxillary gum pads usually project slightly over the mandibular ones, anteriorly as well as buccally, in a relationship resembling that which exists when the teeth are actually in occlusion. The mandible is normally in distal relationship to the maxilla at birth, b u t i t m a k e s u p m o s t o f t h e d i f f e r e n c e i n t h e c o u r s e o f t h e first three to four months. There is l i t t l e or no anteroposterior movement of the mandible at birth, and become evident with the eruption of the deciduous incisors and the lateral movements with the eruption of the first deciduous molars. The gum pads are not in contact at any point when the mandible is in the rest position. There is usually a space in the anterior intermaxillary gum pad region, when the posterior segments are in approximation. The absence of this space interfe r e s with the forward growth of the ma ndible which is in a distal position at birth. Jaw relationship: During the first years the infant does not seem to have a definite centric occlusal relationship or rest position of the mandible. There is a limited anteroposterior hinge-like movement of the
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mandible but no lateral movement. 2. The deciduous dentition stage: Calcification of the deciduous teeth begins early in the fourth month of intra-uterine life, and by three years of age the roots of all the deciduous teeth are completed. At birth 1/4 to 1/2 of the crowns are formed. Eruption of the deciduous teeth b e g i n s u s u a l l y a t 6 t o 7 mo n t h s a n d c o mp l e t e d b e t w e e n 2 y e a r s to 3 years of age. Sequence of eruption: mandibular central incisor (6-7 months), maxillary central incisor (8 months) lateral incisors (9 months), first molars (15 months), canines (18 months) and second molars (30 months). By about 2 1/2 years the deciduous dentition is usually complete and in full function, the jaw of the child contain the calcifying crowns of all the permanent teeth with the exception of the permanent 3rd molars. Spacing of the deciduous teeth; the deciduous teeth are usually spaced, the spaces in the incisor region are present to allow for the difference in size between the deciduous incisors and their permanent successors. Two distinct spaces can be observed one between the mandibular deciduous canine and the first deciduous molar and the other between the maxillary lateral deciduous incisor and the deciduous canine, these two spaces are termed Primate Space. Incisor relationship: with the eruption of incisor teeth, the upper incisor overlap the lower incisor teeth (deep overbite), and characterized by slight overjet. This deep overbite is reduced by t h e e r u p t i o n o f t h e d e c i d u o u s mo l a r s . A t t h e a g e o f a b o u t 5 years, the occlusal surfaces of the primary teeth wear to the extent that the incisor relationship ends with an edge-to-edge bite. This edge-to-edge bite occurs among people whose diet includes coarse rough food. The removal of cusped interferences permits the mandible, which is growing more at this age than the maxilla, to assume a forward position more easily. Occlusal relationship: two types of occlusion considered normal, one in which the canine and the posterior teeth to it are in a cusp-to-cusp relationship, and the other with cusped relationship resemble that in the permanent dentition, the maxillary canine occludes distal to the mandibular canine and mesial to the deciduous first molar, and the maxillary first molar occludes between the distoclusal aspect of the first deciduous molar and the mesioclusal aspect of the second deciduous molar in the mandible. The distal surfaces of the upper-and lower second deciduous molars may end of the same vertical plane, mesial step or distal step, this is determined by the mesiodistal length of the crowns themselves. These occlusal relationships remain unchanged during development and the arches are comparatively constant from 3 1/2 years until beginning of eruption of the permanent teeth. Arch length or arch circumference: this is the distance from the distal surface of the second deciduous molar along side the
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arch to the distal surface of the second deciduous molar on the other side. It diminishes with age from 3 to 6 years due to mesial migration of second deciduous molars, interproximal attrition and interproximal cavities. 3. The mixed dentition stage: Formation; except the cusps of the first permanent molars which are calcified before birth, the permanent dentition is calcified after birth. Eruption of the permanent teeth: 1. A t 6 y e a r s ; t he c l i ni c a l d e nt a l p a t t e r n a t t h e o n s e t o f t h e mixed dentition is seen, with the 20 deciduous teeth augmented by the 1 st permanent molars. 2. At 7 years; the permanent mandibular central and lateral incisors and maxillary central incisors have erupted. 3. At 8 years; the permanent maxillary lateral incisors have erupted. 4. At 9 1/2 years; the maxillary 1st premolars are erupting. 5. At 10 1/2 years; all 1st prernolars and the maxillary 2nd premolars have begun to erupt. 6. At II years; all of the deciduous teeth with the exception of the 2 nd mandibular deciduous molars, have been shed. 7. A t 1 2 st e a r s ; a l l o f t h e d e c i d u ou s t e e t h ha v e b e e n sh e d . y T h e 1 permanent molars, canines and premolars undergo adjustment to normal adult occlusion. Sequence of eruption: The most common sequence of eruption of the permanent teeth in the maxillary arch: 6-1-2-4-5-3 and in the mandibular arch 6-1-2-3-4-5, for maintaining the length of the arch during the mixed dentition stage. The sequence for both arches: L6,U6,L1,U1,L2,U2,L4,L3,U4,U5,U3,L5, with the exception of the maxillary second premolars, the mandibular permanent teeth erupt ahead of the maxillary teeth. Occlusal adjustment: There are two different mechanisms of normal occlusal adjustment as the deciduous dentition enters the mixed dentition until the permanent dentition is established: 1. When the distal surface of thedmaxillary 2 n d deciduous molars is distal to that of the lower 2 n deciduous molar, the permanent 1st molars suit directly into proper occlusion without altering, the position or the deciduous teeth. 2. When the distal surfaces of both the upper and lower 2nd deciduous are on the same vertical plane(flash terminal plane), normal permanent 1 st molar occlusion is affected by an early mesial shift of the deciduous molars closing the primate space distal to the mandibular deciduous canines. Or late mesial shifts of the mandibular permanent 1 st molars after n dshedding of the 2 nd deciduous molars a n d e r u p t i o n o f t h e 2 p r e m o l a r s . T h i s i s
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due to the difference between the sum of the mesiodistal dimensions of the deciduous canines and molars, and that of their permanent successors. The mesiodistal dimension of the deciduous is greater than that of the permanent, by about 0 . 9 t o 1 . 3 m m i n t h e m a x i l l a a n d f r o m 1 . 7 t o 3 . 1 m m . i n the mandible. This difference is known as Lee Way Apace, and is of much important for the normal occlusal adjustment of the permanent 1 st molars.
The permanent maxillary incisors usually erupted fanning out and with median diastema, due to pressure on their roots from the developing permanent canines, this is known as the Ugly-Duckling stage. The incisor position usually improved with the eruption of the permanent canines. The permanent mandibular incisors may show crowding at the time of their eruption and the permanent lateral incisors may overlap the deciduous canines. This crowded condition can be overcome by the space "Leeway space" thus provided in addition to the usual increase in the intercanine width, which is active during the eruption of the permanent incisors and canines. This increase is about 2 1/2 to 3 1/2 mm. from the age of 6 to 8 years, after the age of 10 years there is little, if any change in the mandibular intercanine width.
4. Permanent dentition stage:
At 14 years: The 2nd permanent molars are erupting. Thus space for these teeth is created principally by the forward migration of the anterior two third of the facial mass and partially by the backward growth of the posterior third of the face. The 2nd permanent molars usually erupt shortly after the 2nd premolars and the mandibular before the maxillary one. At 18 years: Room for the 3rd permanent molars is now available and they like their forerunners in the permanent molar series, wiggled their way toward the occlusal plane, erupting into the oral cavity to complete the permanent dentition.
Tooth development
1. Assessment as described by Demirjian et al 1973 Eight stages of calcification, A to H, were described by Demirjian et al for each tooth: Stage A: Crypt present. Stage B: Initial calcification. Stage C: Enamel formation has been completed at the occlusal surface and dentine formation has commenced. The pulp chamber is curved, and no pulp horns are visible. Stage D: Crown formation has been completed to the level of the amelocemental junction. Root formation has commenced. The pulp horns are beginning to differentiate, but the walls of the pulp
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chamber remain curved. Stage E: The root length remains shorter than the crown height. The walls of the pulp chamber are straight, and the pulp horns have become more differentiated than in the previous stage. In molars the radicular bifurcation has commenced to calcify. Stage F: The walls of the pulp chamber now form an isosceles triangle, and the root length is equal to or greater than the crown height. In molars the bifurcation has developed sufficiently to give the roots a distinct form. Stage G: The walls of the root canal are now parallel, but the apical end is partially open. In molars only the distal root is rated. Stage H: The root apex is completely closed (distal root in molars). The periodontal membrane surrounding the root and apex is uniform in width throughout. 2. Dental calcification stages as described by Nolla 1960 Eleven stages of calcification, 0 to 10, were described by Nolla for each tooth: Stage 0: Crypt absent Stage 1: Crypt present Stage 2: Initial calcification Stage 3: Crown one-third complete Stage 4: Crown two-third complete Stage 5: Crown almost complete Stage 6: Crown complete Stage 7: Root one-third complete Stage 8: Root two-third complete Stage 9: Root almost complete, apex open Stage 10: Root apex complete
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CHAPTER 6: NORMAL DENTAL OCCLUSION

Dental occlusion in the individual is in a state of constant change, especially during childhood. Normal occlusion is the usual or accepted relationship for species of the teeth in the same jaw and those in the opposing jaw when the teeth are approximated in terminal occlusion and the mandibular condyles are in centric position in the glenoid fossa.
Characteristics of normal occlusion:
1. Common occlusal plane for both arches. 2. Correct axial inclination of the teeth. 3. Normal relationship of the dental arches to each other and to the face and cranium. 4. Normal overjet and overbite
Six Keys to normal occlusion: Key 1: Molar relationship. a) The distal surface of the distal marginal ridge of the upper first permanent molar contacts and occludes with the mesial surface of the mesial marginal ridge of the lower second molar. b) The mesio-buccal cusp of the upper first permanent molar fails within the groove between the mesial and middle cusps of the lower first permanent molar. c) The mesio-lingual cusp of the upper first molar seats in the central fossa of the lower first molar. Key 2: Crown angulation (the mesio-distal tipping). In normally occluded teeth, the gingival portion of the long axis of each crown is distal to the occlusal portion of t h a t a x i s . T h e d e g r e e o f t i p v a r i e s w i t h e a c h t o o t h type. Key 3: Crown inclination (labio-lingual or bucco-lingual torque). Crown inclinations: the angle between a line 90 degree to the occlusal plane, and a line tangent to the middle of the labial or buccal clinical crown. a) Anterior crowns of the central and lateral incisors. In the upper incisors, the occlusal portion of the crown's labial surface is labial to the gingival portion. In all other crowns, the occlusal portion of the labial or buccal surface is lingual to the gingival portion. b) Upper posterior crowns, canines through molars. The lingual crown inclination is slightly more pronounced in the molars than in cuspids and bicuspids. c) Lower posterior crowns, cuspids through molars: The lingual inclination progressively increases. Key 4: Rotations: Teeth should be free of undesirable rotation. If rotated, a
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Key 6: Curve of spee. Is an imaginary curve, in the horizontal dimension, passing through the condyle and buccal cusps of the teeth ending at the incisal edge of the mandibular central incisors. It is measured from the most prominent cusp of the lower second molar to the incisal edge of the most prominent central incisor. A flat curve of spee is the most respective to normal occlusion and not deeper than 1.5mm.
molar or bicuspid occupies more space than normally. A rotated incisor can occupy less space than normal. Key 5: Tight contacts. In the absence of such abnormalities as genuine tooth size discrepancies, contact points should be tight.
The six keys of normal occlusion by Andrews LF (1972)

The following is the characteristics shared by all teeth to be within normal occlusion: Key I. Molar relationship: The distal surface of the distobuccal cusp of the upper first permanent molar made contact and occluded with the mesial surface of the mesiobuccal cusp of the lower second molar. The mesiodistal 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 buccally, and a cusp fossa relationship lingually.) Key II. Crown angulation, the mesiodistal "tip": The term crown angulation refers to angulation (or tip) of the long axis of the crown, not to angulation of the long axis of the entire tooth. As orthodontists, we work specifically with the crowns of teeth and, therefore, crowns should be our communication base or referent, just as they are our clinical base. The gingival portion of the long axis of each crown was distal to the incisal portion, varying with the individual tooth type. The long axis of the crown for all teeth, except molars, is judged to be the mid-developmental ridge, which is the most prominent and centermost vertical portion of the labial or buccal surface of the crown. The long axis of the molar crown is identified by the dominant vertical groove on the buccal surface of the crown. Key III. 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 the entire tooth. The inclination of all the crowns had a consistent scheme: a. Anterior teeth; central and lateral incisors: Upper and lower anterior crown inclination was sufficient to resist overeruption 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 crowns. b. Upper posterior teeth; canines through molars: A lingual crown inclination existed in the upper posterior crowns. It was constant and similar from the canines through the second premolars and was slightly more pronounced in the molars.
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c. Lower posterior teeth; canines through molars: The lingual crown inclination in the lower posterior teeth progressively increased from the canines through the second molars. Key IV. Rotations: The fourth key to normal occlusion is that the teeth should be free of undesirable rotations. An example of the problem: a superimposed molar outline showing how the molar, if rotated, would occupy more space than normal, creating a situation unreceptive to normal occlusion. Key V. Tight contacts: The fifth key is that the contact points should be tight (no spaces). Persons who have genuine tooth-size discrepancies pose special problems, but in the absence of such abnormalities tight contact should exist. Without exception, the contact points on the non-orthodontic normals were tight. (Serious tooth-size discrepancies should be corrected with jackets or crowns, so the orthodontist will not have to close spaces at the expense of good occlusion.) Key VI. Occlusal plane: The planes of occlusion found on the non-orthodontic normal models ranged from flat to slight curves of Spee. Even though not all of the non-orthodontic normals had flat planes of occlusion, I believe that a flat plane should be a treatment goal as a form of overtreatment. There is a natural tendency for the curve of Spee to deepen with time, for the lower jaw's growth downward and forward sometimes is faster and continues longer than that of the upper jaw, and this causes the lower anterior teeth, which are confined by the upper anterior teeth and lips, to be forced back and up, resulting in crowded lower anterior teeth and/or a deeper overbite and deeper curve of Spee. At the molar end of the lower dentition, the molars (especially the third molars) are pushing forward, even after growth has stopped, creating essentially the same results. If the lower anterior teeth can be held until after growth has stopped and the third molar threat has been eliminated by eruption or extraction, then all should remain stable below, assuming that treatment has otherwise been proper. Lower anterior teeth need not be retained after maturity and extraction of the third molars, except in cases where it was not possible to honor the musculature during treatment and those cases in which abnormal environmental or hereditary factors exist. Intercuspation of teeth is best when the plane of occlusion is relatively flat. There is a tendency for the plane of occlusion to deepen after treatment, for the reasons mentioned. It seems only reasonable to treat the plane of occlusion until it is somewhat flat or reverse to allow for this tendency. In most instances one must band the second permanent molars to get an effective foundation for leveling of the lower and upper planes of occlusion. A deep curve of Spee results in a more contained area for the upper teeth, making normal occlusion impossible. Only the upper first premolar is properly intercuspally placed. The remaining upper teeth, anterior and posterior to the first premolar, are progressively in error. A reverse curve of Spee is an extreme form of overtreatment, allowing
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excessive space for each tooth to be intercuspally placed. The six keys to normal occlusion contribute individually and collectively to the total scheme of occlusion and, therefore, are viewed as essential to successful orthodontic treatment.
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CHAPTER 7: FORCES OF OCCLUSION

Teeth position within the jaw in normal occlusion is maintained by certain factors known as the forces of occlusion, which are normally in balance. Imbalance of these forces may affect the normal dental occlusion. The forces of occlusion can be divided into: 1. A forward force, designated as the anterior component force, which become active with the eruption and occlusion of the 1st permanent molars. This force is produced by the relationship of the long axes of the teeth to their occlusal surfaces and is assisted by pressures of the buccinator and masseter muscles. 2. A distal and lingual force, which acts upon the incisors. This force is produced by the orbicularis oris, caninus, zygomaticus quadratus labii superioris and inferiors, the mentalis and buccinator muscles. These forces aid in keeping the canines in their proper position in the arch. 3. An anterior resultant of these two opposite forces guided by the proximal contact areas of the teeth. Each tooth in addition to its function in mastication is an essential key in the dynamic balance of adjacent teeth and denture position. The forces produced by function aid in the forward and lateral growth of the dentition and help to maintain the proximal contact of the teeth. The orbicularis oris and its associated muscles, in conjunction with the buccinator, prevent the dentition from being carried too far forward. The dentition reached an apparently fixed form and position when all of the forces acting upon it are in state of balance. The forces of occlusion may be described as follows: 1. Normal cell metabolism necessary for dentofacial development and growth. 2. Normal muscular pressure of the facial and masticatory muscles. 3. Normal force of the inclined planes in mastication and in occlusion. 4. Normal proximal contact of the teeth in the same arch. 5. Harmony in the size of the arches which permits the teeth to occupy their proper position in the line of occlusion.
6.
Normal atmospheric pressure which is exerted on the dento-facial components during proper respiration.
The normal interaction of these forces assures balanced occlusion and determines the individual positions of the teeth and dentofacial relationship. In function the human dentition exerts a buccal and labial force on the maxillary dental arch and lingual and distal force on the mandibular dentition. In addition, the buccinator and the superior
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constrictor muscle of the nasopharynx surround the dentition and keep the maxillary dental arch against the mandibular dental arch. Function is the activator of the forces of occlusion, and the force of occlusal stress received by the surfaces of the teeth when the muscles of mastication contract are distributed throughout the bones of the face and cranium. As a result of these stresses, bone trabeculae are arranged and thickened into well defined ridges in order to compensate for this, arrangement of the bony trabeculae is known as Trajectories of Force.
TRAJECTORIES OF FORCE
Trajectoral force is that lines of orientation of the bony trabeculae correspond to the pathways of maximal pressure and tension and that bone trabeculae are thicker where the stress is greatest. These tines or trajectories indicate the directions of functional stresses. In the skull (Flgure1) the entire facial skeleton is seen to be enclosed by trajectories which extend fanlike from the median palatine suture across the alveolar process through the maxilla and terminate at the base of the skull. The facial skeleton is thus firmly united with the cranium by a basketlike formation or lines of stress. These lines do not halt at the sutures of the individual bones but continue across the various facial bones as if the sutures did not exist. In the mandible, trajectories are essentially parallel. A line of stress extends from condyles to condyle and passes across the symphysis along the compact lower border of the mandible. Immediately above it are additional parallel lines of stress which arise in the ramus on each side and run through the spongiosa. At the incisors, the lines of stress do not run horizontally but extend obliquely downward from the crest of the alveolar process and converge at the
symphysis in the constricted part of the body of the mandible below the alveolar process.
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In the maxilla: The maxillary bones consist of thin plates of bone supported by strong bony thickenings "Buttresses" which brace and stiffen the facial frame. The buttresses consist of three columns of bone on each side of the face and run through the upper component of the skull. The buttresses are classified into: 1. Anteriorly, the fronto-nasal buttress; for the transmission of pressure fro the region of the incisors, canine and partly from the pre-molar teeth, especially the 1st premolars. The lines of stress run Figure 1: Skull and mandible, showing cranially along the side of Benninghoff lines of stress or the piriform aperture and the trajectories. crest of the nasal bones to the frontal bone. 2. Laterally, the powerful malar-zygomatic buttress transmits stress from the buccal group of teeth. The malar bone and zygomatic arch also receive the stress of the masseter muscle. There is a CP separation of the lines of stress in the malar area as follows: through the zygomatic arch to the base of the skull; upward to the frontal bone along the lateral orbital border, and by a third a nd w e a k e r p a t h a l o n g t h e l o w e r o r b i t al ma r g i n t o t h e u p p e r part of the fronto-nasal buttress. 3. Posteriorly, the pterygoid buttress forms a posterior elongation or curved support which passes around the choanae of the nasal cavity to the strong middle portion of the base of the skull.
4. Auxiliary buttresses are the hard palate, the walls of the orbits, the zygomatic arches, the palatal bones and the lesser wings of the
sphenoid. In the mandible: 1. The mylohyoid ridge and its extension upward and backward to the condyle. 2. In the region of the mental foramen, a thickening of bone passes backwards and upwards to the coronoid process along its anterior border. 3. The thickened inferior border of the mandible.
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CHAPTER 8: THE CLOSED FUNCTIONAL SYSTEM AND DEVELOPMENT OF NORMAL OCCLUSION

Mastication is carried on by a force-linked, closed functional system of; muscles, jawbones, tempromandibular articulation, other bones of the skull and teeth. There is a feedback mechanism in mandibular function in which force exerted by the mandible is fed back again to the jawbones and muscle of mastication, from their back again to the teeth. Since the teeth are a part of a closed force-linked, functional system their position are limited to certain area within this system. This area is termed the area of functional tolerance. Teeth within this area will remain stable because they are situated so that they conform to the trajectorial forces generated in function. The area of functional tolerance is governed by: 1. Size, form and relationship of the basal arches. 2. Lip cheek and tongue morphology and behavior.
1. THE BASAL ARCHES:
While the alveolar processes support the teeth, through which the pressure is received, they are not the stress-concentrating units of jaw structure. Such areas are located at the more or less constricted portions of the jaws subjacent to the alveolar process in the mandible and superjacent to the alveolar process in the maxilla. These areas are called the Basal arch or basal bone of Salzmann (Figures 2 and 3). In the maxilla, the basal arch does not cover an area as extensive as that covered by the mandibular basal arch. Its borders are continuous with the outer and inner cortical plates superjacent to the alveolar process at the level of the hard palate. In the mandible, the heaviest part of the basal arch lies under the tooth-bearing area in the body of the mandible, where it occupies an almost rectangular cross section between the outer and the inner cortical plates and contains spongy, medullary bone. The relationship and size of the basal arches determine the pattern and form of the dental arches. When the basal arches are large enough and in proper relationship to one another in the anteroposterior and lateral direction: the teeth attain a normal occlusion. Therefore: a) Disproportion between the sizes of the dental arches and basal arches manifest itself in, spacing or crowding of teeth. b) Malrelationship of the basal arches to each other or to the cranium results in malrelationship of the dental arches.
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Figure 2: The basal arches of the maxilla and mandible, and the distribution of the buttresses.
Figure 3: Relationship of the maxillary and mandibular basal arches in the adult, with teeth in normal occlusion.
2. Lip, CHEEK AND TONUGE MORPHOLOGV AND
BEHAVIOUR
The teeth and supporting structures are constantly under the influence of the contiguous musculature. The integrity of the dental arches and the relations of the teeth to each other within each arch and with opposing members are the result of stabilizing and active functional duties of the muscles. The lip, cheek and tongue team up to maintain this relationship (Figure 4).
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Buccinator muscle Figure 4: The molding pressure on the central arch exerted by the contiguous musculature, and the buccinator mechanism.
Cheek and the buccinator mechanism:

The external restraining force of the cheek has been called the buccinator mechanism. Starting with the decussating fibers of the orbicularis oris muscle, joining right and left fibers in the lips, the buccinator mechanism runs laterally and posteriorly around the corner of the mouth, joining other fibers of the buccinator muscle which insert into the pterygomandibular raphe just behind the dentition. At this point it intermingles with fibers of the superior constrictor muscle and continues posteriorly and medially to anchor at the origin of the superior constrictor muscles, the pharyngeal tubercle of the occipital bone. The buccinator mechanism resists and balanced the very powerful force of the tongue.
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Lip morphology and behavior:
Anatomy The Orbicularis oris is not a simple sphincter muscle like the Orbicularis oculi; it consists of numerous strata of muscular fibers surrounding the orifice of the mouth but having different direction. It consists partly of fibers derived from the other facial muscles which are inserted into the lips, and partly of fibers proper to the lips. Of the former, a considerable number are derived from the Buccinator and form the deeper stratum of the Orbicularis. Some of the Buccinator fibersnamely, those near the middle of the muscledecussate at the angle of the mouth, those arising from the maxilla passing to the lower lip, and those from the mandible to the upper lip. The uppermost and lowermost fibers of the Buccinator pass across the lips from side to side without decussation. Superficial to this stratum is a second, formed on either side by the Caninus and Triangularis, which cross each other at the angle of the mouth; those from the Caninus passing to the lower lip, and those from the Triangularis to the upper lip, along which they run, to be inserted into the skin near the median line. 1- Normal lip; competent lips: a. The lips are sealed together, without active contraction of the orofacial muscle and the mandible in the physiologic rest position. b. The lips habitually apart without dental interference, consciously ox subconsciously, and the mandible in the physiologic rest position e.g. cases of mouth breathing. c. The lips are habitually apart due to dental interference, and the mandible in the physiologic rest position, as in cases of excessive overjet. The lips are considered secondarily incompetent or potentially competent. 2- Abnormal lip; incompetent lips: With the mandible in the physiologic rest position, the lips are parted, and in order to approximate them, there will be an active muscle contraction. This may be due to: - Short lips.
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- Increased distance between the anterior nasal spine and gnathion - Skeletal Class II or III patterns. i.e.: Incompetent t i p is essentially due to, disproportion between soft-tissue and its bony framework. a. The lips are apart. b. The lips are held subconsciously together, by active contraction of the muscles. This may result in crowding or retroclining of incisor teeth.
Tongue morphology and behavior:

Tongue size, position and function are important consideration for normal dental occlusion. 1. Tongue size; its effect on the dentition is shown dramatically in two cases: a) Congenital aglossia or microglossia and the resultant collapse of the dental arch b) Macroglossia and the resultant broad arch and spacing of teeth. 2. Tongue position: tongue thrust may be a natural consequence of the forward displacement of the base of the tongue in the presence of enlarged tonsils and adenoids. 3. Tongue function; the pressure of the tongue during function is greater in the lateral and anterior areas of the palate than in the central area. The pressure during conscious swallowing is approximately double that of spontaneous swallowing.
Dynamics of Swallowing
1. Infant type of swallowing; a. Breast feeding: The lips are closed around the areolar tissue of the breast; the tongue protrudes to the extremity of the lower lip and forms a spoon like enclosure around the nipple which lies against the palate. The mandible supports the l i p and tongue above it and supplies part of tongue pressure against the nipple. The tongue is lowered, producing a vacuum around the nipple while the mandible moves back. The milk from the nipple is directed continuously to the pharynx by an automatic peristaltic like movement of the tongue and mylohyoid muscles. b. Bottle feeding: The upper lip protrudes over the lower l i p and envelops the nipple, while the lower lip supports it. The lips are sealed around the nipple, but should take no active share in pumping the milk into the pharynx. This should be accomplished by the tongue and the jaw muscle. c. Spoon feeding: The mouth is opened, the tongue is protruded to receive the spoon, and the lips are sealed around t h e e d g e s t o d r a w f o o d f r o m t h e s p o o n i n t o t h e o r a l cavity. The lips and the cheeks are actively employed to k e e p t h e f o o d i n t h e mo u t h . Wh e n s w a l l o wi n g b e g i n s , t h e t i n o f t h e t o n g u e i s p r e s s e d u p w a r d a n d f o r w a r d against the hard palate and the inner surface of the upper alveolar process. A peristaltic wave of contraction occurs, and the body of the tongue
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squeezes the food backward. During normal infant swallowing, the orbicularis and buccinator muscles contract to seal the walls of the oral cavity a n d t o p r e v e n t t h e f o o d f r o m b e i n g t h r u s t o u t o f t h e mouth, and to restrain the forward movement of the tongue during the swallowing act. The maxillary and mandibular gum pads are separated. When the teeth erupted, the child learns to keep the food within the oral cavity. The lips and cheek keep the alveolar buccal sulcus free of food. The lips may or may not be closed in swallowing, which is accomplished by bracing the tongue against the linguogingival margin of the maxillary incisor teeth. 2. Adult type of swallowing: a. Swallowing fluids: The jaws are brought firmly together. The buccinator muscle contracts and the tip of the tongue rest against the palate just behind the incisive papilla. The mylohyoid muscles contracts, raising the floor of the mouth and compressing the tongue. The lateral and forward bulging of the tongue is prevented by the teeth so that the posterior part of the tongue bulged backward into the oral pharynx driving its contents into the laryngeal part of the pharynx. b. Swallowing solids: Protrusion of the tongue by contraction of the transverse intrinsic muscles, bringing the t i p of the tongue in contact with the lower lip. The tongue is then retracted to carry the food backward in a mass and the movements of mastication carry it to the posterior part of the oral cavity. Contraction of the mylohyoi d muscles brings the tongue against the roof of the mouth and completes the passage of the bolus of food into the pharynx. The teeth are in light occlusion, the lips are tightly closed together and the t i p of the tongue touches the lingual interdental papillae of the maxillary arch. c. Idle swallowing: It is unassociated with food or drink, but is performed reflex or voluntarily every few minutes during the day and at intervals at night for the swallowing of saliva. The teeth are normally brought together, and the whole process is the same as adult type of swallowing. During normal adult type of swallowing, the tongue within the mouth cavity proper exerts pressure on the dental arches and palate, and thus maintains the normal balance with the pressure of lips and cheek muscles. 4. Atypical or infantile or tongue-thrust type of swallowing: It is the persistence of the infant type of swallowing during the adult life. The teeth are not held in full occlusion. The thrust of the tongue during the swallowing act brings it through the separated teeth until it comes into contact with the cheeks and lips. The dorsum of the tongue drops away from the palatal vault. Instead of the lips creating a firm seal with each others, the upper lip remains relatively functionless while the mentalis muscle exert a strong forward and upward thrust of the lower lip.
N.B. It is obvious that an act repeated so frequently as swallowing, a relatively
inactive person swallows over 1200 times a day, may have a profound effect on the maxilla, mandible and dental occlusion particularly if there is an abnormal swallowing pattern.
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CHAPTER 9: MOVEMENTS OF THE TEMROMANDIBULAR JOINT

Introduction: The two movements that occur at this joint are anterior gliding and a hinge-like rotation. When the mandible is depressed during opening of the mouth, the head of the mandible and articular disc move anteriorly on the articular surface until the head lies inferior to the articular tubercle. As this anterior gliding occurs, the head of the mandible rotates on the inferior surface of the articular disc. This permits simple chewing or grinding movements over a small range. Movements that are seen in this joint are: depression, elevation, protrusion, retraction and grinding.
Muscles acting on the Tempromandibular Joint: Movements of the tempromandibular joint are chiefly from the action of the muscles of mastication. The temporalis, masseter, and medial pterygoid muscles produce biting movements. The lateral pterygoid muscles protrude the mandible with the help from the medial pterygoid muscles and retruded largely by the posterior fibres of the temporalis muscle. Gravity is sufficient to depress the mandible, but if there is resistance, the lateral pterygoid, suprahyoid and infrahyoid, mylohyoid and anterior digastric muscles are activated.
Actions Depression mouth)
Muscles (Open Lateral pterygoid Suprahyoid Infrahyoid (Close Temporalis Masseter Medial pterygoid
Elevation mouth)
Protrusion (Protrude Masseter (superficial chin) fibres) Lateral pterygoid Medial pterygoid
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Retrusion (Retrude chin)
Temporalis Masseter (deep fibres)
Side-to-side movements (grinding and chewing)
Temporalis on same side Pterygoid muscles opposite side Masseter
of
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CHAPTER 10: MALOCCLUSION

A condition where there is a deviation from the usual or accepted normal relationship. A dental malocclusion exists when the individual teeth within one or both jaws are abnormally related to each other. This condition may be limited to a couple of teeth or it may involve the majority of teeth present-Dental malocclusion may be associated with one or more of the following conditions: 1. Malpositions of individual teeth in arches and jaws which are them selves normally related to one another. 2. Malrelation of the dental arches, upon bony bases of normal relation. 3. Skeletal pattern unfavourable for the development of normal occlusion.
1. Malpositions of Individual teeth:

There are different positions of malocclusion of the individual teeth, e.g. tilted, bodily displaced or rotated teeth. These are designated according to the direction and nature of the malocclusion. Tilting, means that the crown is in abnormal position while the root in its normal position, bodily displacement means that the tooth as a unit (crown and root) is in abnormal position on the other hand rotation means that the tooth moved along its long axis. 1. Labial inclination or proclination: Labial or buccal inclination of a tooth or teeth. 2. Labial or buccal displacement: Bodily displacement of teeth in labial or buccal direction. 3. Lingual inclination or retroclination: the crown of tooth or teeth tilted in lingual direction. 4. Lingual displacement: Refers to bodily displacement of a tooth or teeth towards the tongue. 5. Mesial inclination: Means that a tooth is tilted towards the midline. 6. Mesial displacement: Bodily displacement of a tooth towards the midline. 7. Distal inclination: A tooth which is tilted in a direction away from the midline, 8. Distal displacement: Bodily displacement of a tooth away from the midline. 9. Infraocclusion: Means that a tooth or teeth, not reached the line of occlusion.
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10. Supraocclusion: Means that a tooth or teeth passed the line of occlusion (over eruption). 11. Mesio-lingual rotation: the tooth is rotated so that its mesial aspect is towards the tongue. 12. Disto-lingual rotation: the tooth is rotated so that its distal aspect is towards the tongue. 13. Transposition: Refers to a tooth that erupted in abnormal numerical order e.g.; canine between central and lateral incisor teeth. 14. Imbrication: Refers to irregular arrangement of teeth due to lack of space. The suffix version is simply added to a word to indicate the direction of deviation from the normal position e.g. mesioversion, labioversion, torsiversion etc.
2. Mal relation of the dental arches:

Described the deviation of the dental arches from the normal relationship to one another: in the anteroposterior, lateral and vertical directions. Anteroposterior direction: 1. Anterior segment: a) Excessive overjet b) Edge-to-edge bite c) Anterior crossbite 2. Post-normal occlusion: In the centric occlusion, the lower dental arch, appear to l i e too far distally in relation to the upper dental arch. 3. Pre-normal occlusion: In the centric occlusion, the lower dental arch, appear to l i e in forward relation to the upper arch. 4. Postural pre-normal occlusion (bite of accommodation): The lower dental arch is postured forwards in relation to the upper dental arch (pre-normal occlusion), while the condyles are outside their normal position within the glenoid fossae. It is a habitual position of the mandible due to loss of the posterior teeth, and the use of anterior teeth. Lateral direction: Cross bite of the lateral teeth segments. It may be unilateral or bilateral cross bite. 1. The buccal cusps of the maxillary buccal teeth occlude within the central fossae of the mandibular teeth. 2. The upper dental arch is completely contained within the lower dental arch. 3. Or the lower dental arch is completely contained within the upper dental arch.
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These cases are due discrepancy between the upper and lower dental arches and/or basal bone. Vertical direction: 1. Deep overbite: May be due to: a) Over-eruption of the lower incisor teeth, due to abnormal axial inclination of the upper and/or lower incisor teeth, and loss of contact between the lower and upper incisor. The lower dental arch is characterized by an exaggerated curve of spee. b) Abnormal relationship of the dental arches. c) True over closure or close-bite; due to lack of eruptive power of the posterior teeth to reach their normal occlusion, with an increase in the free way space. So when the teeth occlude, it appears in a position of overdue lire. 2. Openbite: It is a lack of occlusion of a tooth or teeth, while the remaining teeth are in occlusion, it may be anterior or posterior open bite. This may be due to: a) Lack of normal development of the dento-alveolar structures, due to local interference between the upper and lower arches e.g. abnormal habits (thumb sucking or tongue thrust). b) Abnormal skeletal pattern, with high Frankfort mandibular plane angle. c) In cases of cleft palate due to lack of normal development of the maxillary dento-alveolar structures. d) In rickets; there is a degree of anterior openbite, which is suggested to be due to, malformed mandibular body resulting from the effect hyperirritable muscles (depressor muscles acting against the elevator muscles), on relatively soft bone.
3. Skeletal pattern:
Commonly applied to describe the relationship of the basal arches (basal bone), in the anteroposterior direction, and the teeth are in centric occlusion- Skeletal pattern can be classified as: Skeletal Class 1: Normal anteroposterior relation of the mandibular basal arch to the maxillary basal arch. This condition is favorable for the development of normal dental occlusion. The profile of the patient is Orthognathic. Skeletal Class 2: The mandibular basal arch is postnormal to the maxillary basal arch, either due to maxillary protrusion, mandibular retrusion or both. The profile of the patient is Retrognathic. Skeletal Class 3: The mandibular basal arch is prenormal to the
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maxillary basal arch, either due to maxillary retrusion, mandibular protrusion or both. The profile of the patient is Prognathic.
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CHAPTER 11: CLASSIFICATION OF DENTAL MALOCCLUSION

Classification is the description of dentofacial deviations according to a common characteristic, or norm. It is necessary to classify dental malocclusion according to the type of morphologic deviation present in order to establish a plan of treatment. A classification system, is grouping a different cases of malocclusion, each group are characterized by certain specific and fundamental clinical features. 1. Primary Classification: a) Cephalic anomalies: Deformities of the osseous components of the head in general which affect dental occlusion and dentofacial development. It includes the following: 1) Microcephalus, usually accompanied by a receding chin. 2) Macrocephalus, usually accompanied by spacing of teeth, mandibular prognathism. 3) Osteogenic, hyperostosis of the maxilla accompanied by over growth in width and depth of the mandible and retardation of the dentition. b) Dysgnathic anomalies: A term suggested by Lischer to denote gross developmental abnormalities of the teeth, dental arches, alveolar processes, jaws and other oral structures. It includes the following: 1) Macroglossia, abnormal frenum labii. 2) Facial clefts cleft plate and cleft lip. 3) Total or partial agnathia, total or partial absence of the maxilla or mandible or micrognathia. 4) Tumors of the jaws and diseases of the periodontium. 5) Severe changes in the form, structure and relationship of the jaws and teeth which may or may not be associated with systemic diseases. c) Eugnathic anomalies: A term suggested by Lischer used to denote anomalies of the teeth alone which influence occlusion with malformation of alveolar processes but without deformity of the jaws and facial features. It includes the following: Disturbance in degree of tooth development, impaction, retardation or incompletion of eruption. Position of tooth or teeth in relation to the line of occlusion, or to any of the three planes of space e.g. linguoversion, labioversion, mesioversion, infraversion etc.
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2. Classification by body type (BERGER): He used Kretschmer's somatic types as an adjunct in classifying arch forms. a. Asthenic or leptosomatic, long and slender: A tall, thin person with narrow shoulders, slim arms and hands, the face is high and narrow, the mandible is underdeveloped and the bridge of the nose overdeveloped in length. b. Pyknic, short and squat: The person is characterized by comparatively short in stature with a short neck and compact trunk. The face is broad and less high than the leptosomatic type. c. Athletic, muscular type: A person with strongly developed muscles, broad shoulders, a fully developed chest. The skeleton is well developed. The mandible is square and fully developed. The types do not always occur in their pure state and that one type may show features of any of the other two. It is in the types of mixed features that facial disharmony and malocclusion are more prone to occur. 3. Classification according to the etiology (BENNETT): The malocclusion is classified according to their etiologic factors: a. Class I: Abnormal position of one or more teeth due to local etiological factors. b. Class II: Abnormal development of the upper and/or lower arch due to developmental defects of the bone. c. Class III: Malrelationship of the upper and lower arches to each other, and between the upper and/or lower arch to the face due to developmental defects of the bone. 4. Classification according to dental arch relationship:
Angles Classification of Dental Malocclusion

Angle considered the upper permanent first molars as a fixed point in the skull, which he called the keys to occlusion. Angle believed that the 1st permanent molars were the key to occlusion because they: 1. Are the largest teeth. 2. Are the firmest in their attachment. 3. Have a key location in the arches. 4. Help determine the dental and skeletal vertical proportions due to the lengths of their crowns.
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5. 6. 7. 8.
Occupy normal position in the arches far more often than any other teeth because they are the first permanent teeth and are less restrained in taking their position. More or less control the positions of other permanent teeth anterior and posterior to them. Have the most consistent timing of eruption of all the permanent teeth. Determine the inter-arch relationship of all other teeth upon their eruption and "locking" with the mandibular first molars.
Angle based his classification of malocclusion on the normal mesiodistal relations of the permanent canines and of the mesiobuccul cusps of the upper 1 st molars in relation to the mandibular canines and 1st molars (Figure 5).
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Class I Malocclusion; severe crowding
Class II Malocclusion
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Class III Malocclusion
Figure 5: Angle's Classification

Class I Malocclusion: The mandibular dental arch and the body of the mandible are in normal mesiodistal relation co the maxillary arch. The mesiobuccul cusp of the maxillary st permanent 1st molars occlude in the buccal groove of the mandibular 1 molars, and the mesiolingual cusp of the maxillary 1st permanent molars occludes with the occlusal fossa of the mandibular permanent 1st molars, when the jaws are at rest and the teeth are approximated in centric occlusion. Malocclusion in Class I is localized anterior to the first molars, and fall into one of the following: 1) Local abnormalities: * Crowding of incisor teeth. * Labial inclination of upper incisor teeth. * Anterior cross bite. * Posterior cross bite. * Impaction of premolars or canines. * Deep overbite. * Open bite (anterior or posterior). 2) Disproportion in size between the bone (spacing or crowding of teeth). teeth and basal
Class II Malocclusion: The mandibular dental arch and the body of the mandible are in distal relation to the maxillary arch by half the width of a permanent 1st molar or the mesiodistal width of a premolar (one unite). The mesiobuccul cusp of the maxillary permanent 1 st molars occluded in the space between the mesiobuccul cusp of the mandibular permanent 1 st molar and the distal aspect of the buccal cusp of the 2nd premolars. The mesiolingual cusps of the maxillary 1st molars occlude mesial to the mesiolingual cusp of the mandibular 1 s t molars. There are two divisions for Class II: Division 1 and Division 2. Unilateral arrangement is called subdivision i.e. the 1st molars
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relationship is Class I (normal) in one side, and Class II on the other side. Division 1 1) The upper incisor teeth are proclined. 2) Excessive overjet and deep overbite. 3) V-shaped upper arch; Narrow in the canine region and broad between the molars. 4) Short upper lip with failure in the anterior lip seal. 5) The mandible may be deficient and under developed chin. Division 2 1) The upper central incisor teeth showed lingual inclination and may be overlapped by the upper lateral incisor teeth. 2) Deep overbite. 3) Normal upper lip and lip seal with deep mental groove. 4) The mandible is of good size. Class III Malocclusion: The mandibular dental arch and the body of the mandible are in bilateral mesial relationship to the maxillary arch. The mesiobuccul cusp of the maxillary permanent 1 st molar occludes in the interdental space between the distal
aspect of the distal cusps of the mandibular permanent 1st molars and the mesial aspect of the mesial cusps of the mandibular 2nd permanent molars. Typically the teeth are in centric occlusion, and the mandibular condyle is within the glenoid fossa. Class III Subdivision: The molar relationship is Class III on one side and Class I on the other side, i.e. malocclusion is unilateral.
Validity of Angle's Classification

With the introduction of cephalometric radiographs into clinical orthodontics with the thirties of the last century by Broadbent, some points were raised against Angles classification; such as: 1. The 1st permanent molar is not a fixed point in the skull. 2. It is now known that, it is possible to have Class I dental arches on skeletal Class 2. 3. In Class II, the classification does not differentiate between true mandibular retrusion and maxillary protrusion and also in Class III either true maxillary retrusion or mandibular protrusion. 4. It is incomplete, as it shows anomalies in anteroposterior direction only and neglecting any anomalies in the vertical or transverse direction.
Modification of Angle's Classification

A. Lischer's modification: Lischer introduced the following to explain Angle's classification:
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1. Neutrocclusion or Class I. 2. Distocclusion or Class II. 3. Mesiocclusion or Class III. He also designated the following tooth position, and dental arch deviations. 1. Bucco-occlusion, when the dental arch, quadrant, or group of teeth is buccal to normal. 2. Linguo-occlusion, when the dental arch, quadrant, or group of teeth is lingual to normal. 3. Supra-occlusion, abnormally deep overbite of group of teeth, or one dental arch occludes over the opposing arch so that the teeth in the respective jaws overlap abnormally. 4. Infra-occlusion, dental arches, quadrants, or group of teeth are in open bite relationship. B. Dewey's modifications: Dewey divided Angle's Class I into the following types: 1. Bunched or crowded maxillary anterior teeth. The canines may be in axiversion, labioversion or infraversion. Other versions of individual teeth may be present. 2. Maxillary incisors in labioversion. 3. The maxillary incisor teeth are in linguoversion to the mandibular incisor teeth. This type can be mistaken for Class III Angle. 4. The molars, occasionally also the premolars, are in buccoversion or linguoversion, but the incisors and the mines are in normal alignment and the dental arches and body of the mandible are in normal relationship. 5. The molars are in mesioversion due to shifting following loss of teeth in positions anterior to the molars the rest of the teeth are in normal relation. Dewey also added the following modifications to Angle's lass III malocclusion: Type1: The dental arches are well formed and the teeth are in normal alignment in the respective arches when viewed individually. There is an edge-to-edge bite when the attempt is made to approximate the dental arches, as represented by the casts in occlusal relationship. There is an appearance in these cases suggesting that the mandibular dental arch has been moved forward bodily. Type 2: The mandibular incisors are crowded and in lingual relation to the maxillary incisors. Type 3: The maxillary arch is underdeveloped. The maxillary incisors are crowded- The mandibular arch is well developed and the mandibular teeth are in normal alignment.
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Simon's Classification
The Three Planes of Occlusion The following craniometric classification was devised by S i mo n . I t r e l a t e s t he d e n t u r e t o t h e f a c e a n d c r a n i u m i n t h e three planes of space: 1. the Frankfort horizontal, 2. the orbital, 3. the raphe or median sagittal plane. 1. The Frankfort horizontal plane or eye-ear plane is determined by drawing a straight line through the margin of the bony orbit directly under the pupil of the eye, to the upper margins of the auditory meat us. This plane is used to determine deviation in the height of the dental arches and teeth in relation to the face and cranium. 2. The orbital plane is perpendicular to the Frankfort plane, at the margin of the bony orbit directly under the pupil of the eye. This plane is used to determine sagittal deviations in the anteroposterior relation of the dental arches and the axial inclination of the teeth to the face and cranium. 3. The raphe or median sagittal plane is determined by points approximately 1.5cm apart on the median raphe of the palate. The raphe median plane passes through these two points at right angle to the Frankfort horizontal plane. This plane is used to determine deviation in the general form and width of the dental arches and the axial inclination of the teeth in relation to the midline of the palate and the head. In normal arch relationship, according to Simon, the orbital plane passes through the distal axial aspect of the canine. This is known as "the law of the canine". 1. Deviation from the raphe or median sagittal plane: a. Contractions: A part or the entire dental arch is contracted toward the raphe median plane. The abnormality may be alveolar, dental, anterior, posterior, unilateral or bilateral. b. Distractions: A part or the entire dental arch is wider than usual (cross bite) from the raphe median plane. 2. Deviation from the Frankfort horizontal plane: a. Attractions: The distance between the occlusal plane and the Frankfort horizontal is comparatively shorter than normal.
b. Abstractions: The distance between the occlusal plane and the
Frankfort plane is comparatively longer than normal. 3. Deviation from the orbital plane: a. Protractions: The teeth, one or both dental arches and/or jaws are too far forward. Normally the orbital plane passes through the distal incline of the canine. b. Retractions: The teeth, one or both dental arches and/or
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jaws are too far retruded. The orbital plane passes too far anteriorly to the canines. Deviation of the dental arches in relation to the orbital plane according to Simon may occur as follows: 1. 2. 3. 4. 5. 6. 7. Both jaws in normal relation to each other Upper jaw normal, lower jaw mesial Upper jaw normal, lower jaw distal Lower jaw normal, upper jaw mesial Lower jaw normal, upper jaw distal Upper jaw mesial, lower jaw distal Upper jaw distal, lower jaw mesial
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CHAPTER 12: ETIOLOGY OF MALOCCLUSION

Etiology in orthodontics is the study of the actual causes of dentofacial abnormalities. The etiology of malocclusion can be classified into: I. Extrinsic Factors (General) 1. 2. 3. 4. 5. 6. 7. 8. 9. Evolution. Heredity. Congenital. Environment. Predisposing metabolic climate and disease. Dietary problems {nutritional deficiency). Abnormal pressure habits. Posture. Trauma and accidents.
II. Intrinsic Factors (Local) 1. Anomalies of number of teeth. 2. Anomalies of tooth size. 3. Anomalies of tooth shape. 4. Abnormal labial frenum. 5. Premature loss of teeth. 6. Prolonged retention of teeth. 7. Delayed eruption of permanent teeth. 8. Abnormal eruptive path. 9. Ankylosis. 10. Dental caries. 11. Improper dental restoration. 12. Loss of permanent teeth. I. EXTRINSIC FACTORS 1. Evolution: With evolution, the jaws become smaller, reduction in *K number and size of teeth and diminution of jaws projection together with increased vertical height of the face. 2. Heredity: (Certain racial and familial characteristics transmitted to the offspring through the union of the germ cells). Heredity could be considered significant in determining the following: 1) 2) 3) 4) Tooth size, shape and number. Width and length of the arch. Crowding and spacing of teeth. Position and conformation of perioral musculature to tongue size and shape.
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5) 6) 7) 8)
Facial asymmetries. Macrognathia and micrognathia. Mandibular retrusion. Mandibular prognathism.
3. Congenital: The defects occur before birth but are not necessarily transmitted through the union of germ cells. 1) Cleft lip and palate individual has concave profile, retruded maxilla, lingually tipped incisors, tendency toward retrusion of the chin point and an excessive interocclusal clearance. 2) Cerebral palsy; is a paralysis or lack of muscular coordination, due to intracranial lesion as a result of a birth injury. The varying degrees of abnormal muscular function that may occur in mastication, deglutition, respiration and speech upset the muscle balance that is necessary for the establishment and maintenance of a normal occlusion. 3) Cleidocranial dysostosis: a. Maxillary retrusion and possible mandibular protrusion. b. Retarded eruption of the permanent teeth. c. Retained deciduous teeth. d. Supernumerary teeth. e. Roots of the permanent teeth are sometimes short and thin. 4. Environmental: 1) Prenatal influence on malocclusion is very small and the deformity may be temporary. Uterine postures, fibroids of mother, amniotic lesions, maternal diet and metabolism, possible injury or trauma and German measles, have been blamed for malocclusion. 2) Postnatal influence: a. Birth injuries with a high forceps delivery b. Deformation of the upper jaw during delivery. c. Falls that produces condylar fractures. d. Extensive scare tissue from a burn. e. The strong elevating force on the mandible as a result of wearing a plaster neck cast for a long period. 5. Predisposing metabolic climate and disease: l) Endocrine imbalance: No tissue in the body is exempt from some sort of hormonal influence, either in the course of its development a n d g r o w t h o r i n i t s f u n c t i o n a l a c t i v i t i e s . F r o m t h i s point of view, it is very important to study the effect of disturbance in hormone metabolism on occlusion. The pituitary gland: The pituitary is considered the master gland of the body. Hyper-pituitarism: In pituitary dwarfs; the eruption rate and shedding time of teeth are delayed, as is the
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growth of the body in general. The clinical crowns are smaller than normal, while the anatomical crowns are of normal size. The roots of the teeth are shorter than normal. The dental arch is smaller than normal, and cannot accommodate all teeth, so that malocclusion develops. There is retarded osseous development of the mandible than in the maxilla. In pituitary dwarfism the disturbance occurring before puberty. Hyper-pituitarism-Gigantism, occurs before the epiphyses of the long bones are closed. In gigantism, the teeth are proportional to the size of the jaws and the rest of the body. The roots may be longer than normal. Acromegaly, occurs after the epiphyses of the long bone are closed. In acromegaly, the lips are thick and Negroid. The tongue is large, and the teeth in the mandible are usually tipped to the buccal or labial side due to enlarged tongue. The mandible becomes large with the acceleration of condylar growth. The thyroid gland: Hypothyroidism: In congenital hypothyroidism or cretinism, the mandible is underdeveloped and the maxilla is overdeveloped. The tongue is enlarged and may lead to malocclusion. The eruption rates of the teeth are delayed, and the deciduous teeth are retained beyond the normal shedding time. Myxedema; the disease produced by thyroid deficiency in adults or children. In this case the tongue is large and interfering with occlusion. Hyperthyroidism: Alveolar atrophy in advanced cases. In children earlier shedding of the deciduous teeth than normal and accelerated eruption of the permanent teeth. Parathyroid gland: Hyperparathyroidism: Aplasia or hypoplasia of the teeth when hypoparathyroidism developed before the teeth was entirely formed. II) Infectious diseases: Exanthematous fevers are known to upset the development timetable of eruption, resorption, and tooth loss. Specific diseases, such as poliomyelitis (paralytic effect) and muscular dystrophy and cerebral palsy (muscle malfunction) are capable of producing malocclusion. 6. Dietary problems (nutritional deficiency): Disturbances such as rickets, scurvy and beriberi can produce severe malocclusion, as a result of upsetting the dental developmental timetables. The resultant premature loss, prolonged retention, poor tissue health and abnormal eruptive paths mean malocclusion. 7. Abnormal pressure habits:
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l) Thumb sucking: Infants who suck their thumb usually begin to do so after birth, during the first 3 months or in the 1st year of life. The average age at which thumb sucking stopped is between 3 a n d 4 y e a r s o f a g e . T h u m b s u c k i n g m u s t n o t b e c o n t i nued beyond the eruption of the permanent incisor teeth, otherwise malocclusion will result. Young children may develop the sucking habits when hungry or tired, bored, or after being scolded or punished. The sucking habit is influenced by excitement, fatigue, position during sleep and the general health of the child. An infant may tend to suck his fingers or thumb because of the pleasure he derives from it, so longer time, in nutritional sucking leads to less thumb sucking. Thumb sucking from birth to four years of age: For the first 3 years of life, that damage to the occlusion is confined largely to the anterior segment, and usually temporary, provided the child start with normal occlusion. The increased pressure from the buccinator mechanism during sucking habit activates the pterygomandibular raphe just behind the dentition and forcing the maxillary teeth forward. Active thumb sucking after age four: The permanence of the deformation of the occlusion is related to: Duration of the habit beyond four years of age, frequency of the habit during the day and night, and intensity of the habit. The damaging effect of the thumb sucking habit may lead to: Protrusion of the maxillary anterior teeth. Spacing of upper incisor teeth, High palatal vault and narrow dental arches. Retraction of mandibular anterior teeth. Crowding of mandibular incisor teeth. Anterior open bite. Flaccid upper l i p and hyperactive mentalis muscle. Excessive overjet. 2) Tongue thrusting: It is of two types: a. The simple tongue thrust swallow, usually is associated with a history of sucking habit, so the tongue thrust forward through the openbite to maintain an anterior seal with the lips during swallowing. b. The complex tongue thrust, is usually associated with chronic naso-respiratory distress, mouth-breathing, tonsillitis or pharyngitis. Tongue thrusting habit prevents the normal vertical development of the dentoalveolar structures anteriorly, resulting into anterior open bite. 3) Lip sucking and l i p biting: The lower l i p is that the most frequently involved, although the upper l i p may be observed as well. The lower lip sucking and biting habits results in: labio-version of the maxillary anterior teeth, linguoversion of the mandibular anterior teeth and often anterior open bite. 4) Mouth breathing:
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Mouth breathing could develop as a result of partial nasal obstruction due to: Deviated septum. Narrow nasal passages. Inflammatory reaction of nasal mucous membrane. Allergic reaction of nasal mucosa.

Obstructive adenoids.
An increased free way space, and absence of anterior seal. In cases of air hunger e.g. heart diseases and during exercise.
Mouth breathing habit is characterized by: protrusion of upper anterior teeth narrow and contracted maxillary arch hypertrophy of the lower lip hypotonic upper lip increased overbite crowding anterior teeth 5) Fingernail biting: Absent under age 3 and increased at 6 years of age, followed by a sharp rise at puberty, and decline afte r the age of 16. Clinically nail biters showed crowding, rotation and attrition of the incisal edges of incisor teeth especially the mandibular incisors. 8. Posture: Poor postural conditions can cause malocclusions e.g.: Many steep-shouldered children, with the head hung so that the chin rests on the chest, may result in mandibular retrusion. Equally important, a child's resting his head on his hand for periods of time each day, or sleeping on his arm, fist or pillow each night. Poor posture may accentuate an existing malocclusion. 9. Trauma and accidents a. Traumatic displacement of deciduous incisors may affect the normal eruption of the permanent successors. b. Non-vital deciduous teeth have abnormal resorption patterns, and as a result of an initial accident, they may deflect the permanent successors. c. Blow or trauma is responsible for ankylosis of teeth and the resultant malocclusion. d. Ankylosis of the tempromandibular joint, early in life interferes with jaw growth and normal tooth alignment. II. INTRINSIC OR LOCAL FACTORS 1. Anomalies in number of teeth: a) Supernumerary teeth: It occurs most commonly in the maxilla near the mid-l i n e ,
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p a l a t a l t o t h e ma x i l l a r y i n c i s o r s . T h e s e t e e t h a r e usually conical in shape and occur most often singly but can occur in pairs, and may be used to the right or left central incisor. It may erupt in any area of the mouth and may be well formed that, it is difficult to determine which one is supernumerary. The permanent teeth may not erupt or deflect as a result of supernumerary teeth. b) Missing teeth: Congenitally missing teeth are more frequent than supernumerary teeth; missing teeth are frequent in both jaws. The order of frequency of absence is: a. maxillary lateral incisors, b. mandibular second premolars, c. maxillary and mandibular third molars and d. maxillary second premolars. Congenital absence is more frequent in the permanent than in the deciduous dentition. Partial or total anodontia is seen more rarely. In case of missing maxillary lateral incisor teeth the permanent canines may erupt mesial to the deciduous canines. 2. Anomalies of tooth size: The size of the teeth is largely determined by heredity, there is great variation in teeth size even with the same individual. There is a greater tendency for crowding with large teeth than with smaller teeth. Anomalies of size are relatively frequent in the mandibular premolar area, and maxillary lateral incisor (peg lateral). 3. Anomalies of tooth shape: Intimately related to tooth size is tooth shape. The most frequent departure from normal is the (peg lateral). Spacing of the maxillary anterior segment, often occur in this cases. The presence of an exaggerated cingulum or heavy marginal ridges can force the involved teeth labially and prevent the establishment of a normal overjet and overbite. The maxillary central incisors vary a great deal in shape; also the mandibular second premolar shows a great variation in shape and size. Other anomalies of shape occasionally occur as a result of development defects e.g.: amelogenesis imperfect, hypoplasia, gemination, dens in dente, odontomas, fusions and congenital syphilitic aberrations such as Hutchinson's incisors and Mulberry molars. 4. Abnormal labial frenum: At birth the frenum is attached to the alveolar ridge, with fibers actually running into the lingual interdental papilla. As the teeth erupt and as alveolar bone is
deposited, the frenum attachment migrates superiorly with respect to the alveolar ridge. Fibres may persist between the maxillary central incisors and in the "V" shaped intermaxillary suture. This attachment may well interfere with the normal developmental closure of the spacing, resulting into median diastema.
Other causes of maxillary median diastema: 1. Physiological spacing of permanent central incisors (ugly Duckling
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3. 4. 5. 6. 7.
2.
stage) which end with the eruption of permanent lateral incisors and canines. Familial pattern. Abnormal small size of teeth in large jaws. Lateral incisor, missing or Peg shaped. Mesiodens. Mai posed lateral incisors. Median cyst.
5. Premature loss of deciduous teeth: The deciduous teeth serve as space savers for the permanent teeth, and also assist in maintaining the opposing teeth at the proper occlusal level as well as for mastication. The unscheduled loss of one or more dental units may throw off the delicate timetable and prevent nature from achieving a normal healthy occlusion. a) Maxillary deciduous incisors: usually not followed by impaction of permanent incisors. Such interferences may be attributed to inherent lack of growth, presence of supernumerary teeth and other causes. b) Mandibular deciduous incisors: Followed by crowding" of the permanent incisors, with a corresponding crowding in the maxillary incisor region and deep overbite. c) Deciduous canines: followed by interference with eruption of the permanent canines. d) 1st deciduous molars: Rarely followed by impaction of the 1st premolars because of the comparatively early eruption of it and it is of smaller size than its deciduous predecessor. Furthermore, the 2nd deciduous molar does not shift mesially. e) 2nd deciduous molars; May result in a marked forward shifting of the permanent 1st molar and the eruption out of alignment of the 2nd premolars. Space loss is not greater in the maxilla than in the mandible in the deciduous dentition. However, in the permanent dentition space loss is greater in the mandible than in the maxilla, where space closure requires a longer time. If the 2 nd deciduous molars are extracted before the eruption of the 1st permanent molars, then the 1st permanent molars will tend to erupt forward with less rotation or tilting. Prenormal occlusion, false Class III or pseudo-mesio-occlusion may be the result of premature loss of both the upper and lower 2nd deciduous molars, as the child will protrude the mandible to bring the lower posterior part in contact with the upper, to achieve a bite of comfort. This can be distinguished from true Class HI by: a. The mandible can assume a normal mesiodistal relationship by manual retrusion of the mandible. b. The condyles are in forward position outside the glenoid fossa with the teeth in occlusion. c. The pulling action of the muscles to retrude the mandible to its normal position may cause lingual inclination of the upper incisor teeth and labial inclination of the lower incisor teeth.
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The main effects of premature loss of the 2nd deciduous molars are: a. Forward shift and mesial tilting of the lower permanent 1st molar and forward shift and mesial rotation of the upper 1st permanent molar, with impact ion of the 2nd premolars. b. Collapse of the lower anterior teeth, and the center line may be shifted towards the side of extraction if it is unilateral loss. There will be an increase in over bite and also imbrications and crowding of the upper incisor teeth due to loss of support by the lower arch. 6. Prolonged retention of teeth: Causes: a. Incomplete or unequal resorption of the roots. b. Ankylosis of the deciduous teeth. c. Missing permanent teeth. d. Abnormal path of eruption of the permanent teeth, e. Endocrine disturbances e.g. hypothyroidism. f. Cleidocranial dysostosis. g. Nutritional disturbance. The prolonged retention of deciduous teeth usually results in deflection of the permanent successors, with disturbances of occlusion of all or some of the teeth in the arch. 7. Delayed eruption of permanent teeth: Causes: a. Ectopic position of tooth. b. Distance of tooth from its place of eruption. c. Malformation of the tooth itself. d. Presence of supernumerary teeth. e. Trauma of tooth germ. f. Infection of tooth germ. g. Displacement of tooth germ or tooth by a neoplasm. h. Ankylosis of the tooth with the jaw bone. i. Systemic diseases such as dietary, metabolic and endocrine disturbances. Retardation of eruption can cause disturbances in the arrangement of the teeth due to shifting of erupted teeth producing lack of space for oncoming teeth. 8. Abnormal eruptive path: Causes: a. Severe crowding and totally inadequate space to accommodate all the teeth, b. The presence of a supernumerary teeth, retained deciduous tooth, root fragment. c. Trauma to the deciduous teeth, it may turn the developing successor in an abnormal direction. d. Mechanical interference by orthodontic treatment. e. Coronal cysts. f. Ectopic eruption.
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g. Idiopathic origin. 9. Ankylosis: It is relatively frequent during the 6 to 12 year age period. Ankylosis is probably due to injury of some sort, resulting in joining the lamina dura and cementum. Clinically, the ankylosed tooth appears submerged due to the eruption of the other teeth. Early recognition and extraction of the ankylosed tooth Is important to ovoid malocclusion. Permanent teeth may also be ankylosed. Endocrine and congenital diseases like Cleidocranial dysostosis, accidents or trauma are also possible factors, although ankylosis often occurs with no apparent cause. 10. Dental caries: Interproximal caries may result in subsequent drifting of contiguous teeth, abnormal axial inclination. The carious teeth should be repaired to maintain the integrity of the dental arches. 11. Improper dental restoration: The need for anatomic restorations is not limited to the mesiodistal dimension, as poor contacts encourage tooth shift. Also lack of anatomic detail of cusped areas of the restoration can permit elongation of the opposing teeth or create functional prematurity and possible tooth guidance foci for mandibular shifts. 12. Loss of permanent teeth: The removal of any single tooth, the active forces that tend to disarrange the dental arches begin to operate. a. Loss of a central incisor produces mesial shifting of the lateral incisor, and spacing between lateral incisor and canine. b. Loss of lateral incisor produces ducal shifting of the central incisor and mesial shifting of the canine. c. Loss of a canine produces distal shifting of the central and lateral incisors. There is seldom mesial shifting of the premolars, although they may rotate. d. Loss of a 1st premolar usually results in distal shifting of the canine. Spaces between the central incisors or between the central and lateral incisors may appear. Mesial shifting of the teeth posterior to the 1 st premolar, usually accompanied with inclination and rotation. e. Loss of 2 nd premolars induces distal shifting of the 1 st st premolar, producing a space between the canine and 1st premolar and mesial shifting of the molars. The 1 molar may show extreme lingual inclination and loss of occlusal contact. f. Loss of 1st molar produces distal nd shifting of the premolars and mesial shifting of the 2 and 3 rd molars. In the maxilla the premolars shift together. In the mandible the premolars shift singly, which creates space between them and also distal to the canine.
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In time, extraction of the 1st molars in the maxilla produces a flattening or narrowing of the dental arch; in the case of extraction in the mandible the shortening of the arch is also produced in the incisor region, increasing the amount of over bite. nd g. Loss of 2 molar produces mesial inclination and shifting of the 3 rd molar. h. Loss of 3rd molar does not produce distal shifting of the 2nd molar.
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CHAPTER 13: ORTHODONTIC EXAMINATION

The examination must be centered on the child as a whole and not only on the dentofacial malformation. The medical and dental history of the patient and assessment of his developmental growth are important in orthodontic diagnosis. The correlation of chronologic age, skeletal age, dental age and educational age are important factors in orthodontic diagnosis, for determine optimal time for beginning treatment and in prognosis. The patients behavior pattern, having dependent or independent character, their gait, and way of talking and thinking must be noticed and recorded from the first glance. The medical history should be restricted to questions which have a direct bearing on the dental diagnosis and treatment. A clinical examination of the mouth should be made, with the mandible in full occlusion and through various excursions. The midline deviation should be observed with the teeth in full occlusion, at rest position and with the mouth wide open. The dental and gingival tissues should be examined. Speech and functional aspects of the tongue, the position of the lips, the rest position and postural position of the mandible should be noted. Serial examinations are of special value during the mixed dention period, when the deciduous roots may be resorbed abnormally, prematurely lost, or retained beyond their physiologic age for being shed.
DIAGNOSTIC AIDS
I. Case History: A. Medical history: 1) Name, age, sex, date of examination. 2) Place of birth. 3) Full term, premature, or instrument birth. 4) Congenital and heredity factors. 5) Diseases of infancy and childhood 6) Adenoid, tonsils, mouth breathing, respiratory infections. 7) Manner of feeding during infancy-breast or bottle, how long. 8) Habits involving dentofacial development. 9) Gait-normal, shuffling, lameness. 10) Accidents and surgical operations involving dentofacial structures. 11) Speech. 12) Endocrine history, 13) Skeletal age (wrist X-ray). 14) Mental state - progress at school.
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B. Dental history: 1) Teething experiences. 2) Age at eruption of deciduous dentition. 3) Age at beginning of eruption of permanent teeth. 4) Extractions. 5) Periodontal condition. 6) Oral hygiene. 7) History of traumatized teeth. II. Clinical examination: A. Dentofacial examination: 1) Facial-presence of asymmetry. 2) Facial musculature, normal, hypotonic, hypertonic e.g. mentalis, upper-and lower lips. 3) Congenital defects: a. Clefts, abnormal frenum b. Tongue abnormalities of size or shape. 4) Functional impairment, difficulty in swallowing, showing, jaw movements, tongue movements. 5) Speech defects. 6) Abnormalities of dental arches in form, size and position. a. Maxilla only b. Mandible only c. Intermaxillary relationship such as curve of occlusion, overbite, openbite. 7) Classification a. Dental (Angle) b. Skeletal B. Dental examination: 1) Relative size of the teeth: normal, small, and large. Shape of teeth; square, ovoid, tapering. Enamel hypoplasia: grooved, mottled. 2) Anomalies in number of teeth, oligodontia, supernumerary. 3) Anomalies of dental development, state of eruption, retention, premature loss, delayed eruption of permanent teeth. 4) Anomalies of tooth position, rotation, inclination, transversion. 5) Anomalies of groups of teeth, protrusion, retrusion, crossbite. 6) Caries, extraction, nonvital, caries susceptibility, filling. 7) Mucous membranes, pale, pink, congested, swelling, ulcers. 8) Periodontal condition - gingivitis, hypertrophy, infection. 9) Mouth hygiene, good, fair, poor. 10) Vitality of the teeth. 11) Type of dental restorations.
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III.
Functional analysis: Postural resting position and interocclusal clearance. Path of closure from resting position o occlusion. Prematurity, point of initial contact. Clicking or crepitus of the tempromandibular joint (TMJ) during the functional range. 5) Individual tooth mobility when palpated by finger tips during closure. 6) Position of the upper-and lower l i p with respect to upper-and lower incisors during mastication, deglutition, respiration and speech, 7) Tongue position and pressures exerted during functional movement. IV. Orthodontic records A. Dental casts: Should present an exact portray of the details of the anatomy of the teeth, alveolar processes, alveo-buccal folds, palate, attachments of muscles and frenum as well as the relationship of the maxillary to the mandibular arch, and their relationship to the cranium and face. 1) 2) 3) 4) Informations obtained from dental casts: 1) To examine the occlusion from the lingual aspect as well as labio-buccal aspect. 2) To explain the treatment plan and prognosis to the patient and parents. 3) The direction in which teeth are to be moved. 4) The degree of overbite, overjet, rotation, axial relation of teeth, location of median line in reference to the median raphe, intercuspation of teeth and traumatic occlusion. 5) Arch length analysis. 6) The construction of diagnostic set-up. 7) As pre-treatment record. Characteristics of Orthodontic Study models: Orthodontic study models are formed of two main parts; the dentoalveolar part and the base of the cast. The following is full description of the base trimming: 3. Traditional trimming: 1) The sides should be approximately parallel with the deepest part of the sulcus of the upper and lower vestibule. 2) The back should be at a right angle to the median raphe of the palate and the occlusal plane. 3) The top and bottom should be parallel to each other and at right angle to the back and side surfaces. 4) The front of the upper should form equal angles with the side, extended from canine to canine. The tip of the angle should be centered with the median raphe of the palate.
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5) The front of the lower should form a gentle arc from canine to canine, centered on the midline. 6) The back surface should form equal angles with the side surfaces. 7) The teeth should fit in occlusion when the casts are rest on the back, either the right or left sides or surfaces between the back and side surfaces. 8) Upper and lower casts should be about the same height and general proportions should harmonious. 9) The tongue room should be cleaned and finished so the lingual surface of the upper-and lower arch could be examined clearly. 10) The casts should represent clearly the depth of the mucobuccal fold as well as the muscle attachment 11) Finally the orthodontic study model should be finished and polished, may be soaked in a concentrated soap solution, drayed and dusted with talc powder and after that carefully polished with linen. 2. Cephalometric trimming: The study model is trimmed according the certain cephalometric measurements in such a way that it will be good representative of the denture and supporting skeletal bone. This type of trimming is most commonly used in orthognathic surgery. B. Photographs: l) Extraoral (facial) photograph; frontal, right-and left side, lips during rest position, social smile and maximum smile. They are taken with the mandible in the physiologic rest position and lips in repose. They are used to study facial harmony and balance, a permanent record of the face to be compared with the changes that could occurs as a result of orthodontic treatment and/or growth. They are used as well, to study facial types of the patient e.g. baracephalic (broad facial structure and broad dental arch), mesocephalic (average dental arch form) or dolichocephalic (long and narrow face and long and narrow dental arch). 2) Intraoral photographs; a. Teeth in occlusion; right, left and frontal views. b. Occlusal surface (table) of the upper and lower teeth. They are used as a permanent record of the degree of malocclusion and improvement that could be achieved by orthodontic treatment. C.Electromyography: It is used to study muscle activity during function and rest. D. Radiographs: Now a day the introduction of digital dental radiographs into dental practice in general and orthodontics in particular open the door to the get use of the miracle of Digital Era. The exposure time is much less than the conventional radiographs (about 80% less), study of bone density, ease of
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filing, global exchange of experience and consultation, patient and parents ease of communication are some among other benefits of digital radiographs. I. Intraoral radiographs: (Bitewing, Periapical, Occlusal) Informations obtained from the radiographs: 1) Bitewing radiographs: Bitewing radiographs are taken to show the proximal surfaces of the teeth and the crest of the alveolar bone of both the maxilla and the mandible on the same film. While they are used primarily to detect interproximal decay, they can also provide some information on the patient's periodontal status. The height of the interproximal alveolar bone margin relative to the cemento-enamel junction can be observed. Also, deposits of subgingival calculus may be detected. However, the value of bitewing radiographs in the diagnosis of periodontal diseases is limited by the fact that only the coronal sections of the roots of the teeth are observed, and they are limited to the molar-premolar regions. In younger individuals, careful observation of the alveolar bone height around first permanent molars may help detect those individuals at risk of early-onset forms of periodontitis (juvenile periodontitis and rapidly progressive periodontitis). However, radiographs should be used only as a supplement to a careful clinical examination using a periodontal probe around such sites, as up to 30 per cent of bone may be lost before it is evident radiographically. 2) Periapical radiographs: Periapical radiographs are frequently used not only to aid the differential diagnoses of patients' presenting symptoms, but also to screen for otherwise undetected pathological processes of the teeth and surrounding alveolar bone. In the diagnosis of periodontal diseases, periapical radiographs can provide useful information that cannot be obtained through examination of the soft tissues alone. Such information includes: a) Teeth:

Stages of tooth development (Demirjian et al stages or Nolla stages) Morphology and inclination of the roots of the permanent teeth. Pathological oral condition: caries, thickened periodontal membrane, apical infections, root fracture or resorption, retained deciduous roots, cystic lesion etc
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Clinical crown-root ratio: In essence, this term refers to the ratio between the length of the root that is surrounded by bone and the remainder of the tooth. Shape and size of the crown and root: A tooth with a small crown and a long root has a better prognosis than one with a large crown and a short root. A tapered root has less surface area for periodontal attachment than a blunt root. Position of the roots in multirooted teeth: In rnultirooted teeth, roots close together present a poorer prognosis than those which are widely separated. Position of a tooth in relation to adjacent teeth: Open contact points or close proximity of adjacent teeth can be seen in radiographs, and may highlight areas where periodontal problems are occurring. Presence of callculus: Both subgingival and supragingival calculus deposits can be seen on periapical radiographs. Presence of root resorption: internal or external root resorption can be detected. The contours and margins of restorations: The relationship between interproximal overhangs and/or poorly contoured restorations, and loss of periodontal bone can be screened by radiographic examination. Fractures of the root: A tooth with a horizontal or vertical root fracture can present with periodontal symptoms. Foreign bodies and root tips: these may produce or aggravate periodontal lesions and can best be detected in radiographs. Pulpal anatomy and pathology: the shape of the pulpal chamber and root canals can be seen, as well as pulpal pathology.
b) Bone The pattern of bone loss around individual teeth can be determined only through examination of radiographs. Periapical radiographs, using the long cone paralleling technique, provide the most accurate representation of the height of the bone in relation to the CEJ, and to the actual length of the tooth. In the examination of bone features in periapical radiographs as part of periodontal diagnosis, special attention is paid to: Pattern of bone loss: is the bone loss horizontal or vertical? Extent of bone loss: is the bone loss generalized over the dentition or localized to certain teeth? Severity of bone loss: this can be expressed in percentage terms, taking normal bone height to be just below the CEJ, and accounting for the length of the root. Furcation involvement: is there evidence of radiolucencv in furcation areas?
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Lamina dura: The significance of the lamina dura is unclear. Whereas its presence indicates good supporting bone, its absence does not always signify pathology. Periodontal ligaments space: A widening of the periodontal ligament space may indicate that the tooth is subject to occlusal forces or is mobile. It may also be an early sign of pulpal inflammation; therefore a careful clinical examination is necessary to make a diagnosis.
3) Occlusal view radiographs: Occlusal view radiographs, upper or lower, are taken to locate palatal tooth impaction, pathology, sublingual salivary duct stones, midpalatal suture etc To locate the position of impacted teeth (palatal or labial): a) Occlusal view radiographs. b) Parallax technique: two periapical radiographs are taken with the film in the same position each exposure, and the tube is moved about 4 inches in the second exposure. If the impacted tooth moves in the same direction as the tube, then the tooth is impacted palatally and the reverse is true. C) Computed topography (C.T.) radiographs are of significant value in this regards II. Extraoral radiographs: 1) Hand-wrist X-ray (Skeletal age and physiologic age): Growth; growth pattern and prediction are very significant variable in orthodontics. Hand-wrist radiographs help the orthodontists to have as much information as possible about the growth pattern and the degree of accomplishment of that pattern for each patient, as well as, the stages of pubertal growth spurt and the expected percentage of adolescent growth prediction. The developmental stages of certain growth indicators such as; hook of hamates, pisiform, the adductor sesamoid of the first finger, epiphysis and metaphysis of the middle phalanx of the fifth finger, proximal, middle and distal phalanx of the third finger and radius are commonly used in this regards, among other skeletal growth indicators. 2) Panoramic X-ray (Dental age): It gives a panoramic view of the erupted and/or unerupted teeth, , stages of teeth development, supernumerary teeth, missing teeth, alveolar bone, the bone of the mandible and maxilla, TMJ, maxillary sinuses, nasal apertures, as well as, any pathological lesions or anatomical anomalies. Panoramic radiographs provide a general view of the oral structures, and are useful for screening bone loss
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patterns in general. They are not suitable for accurate assessment of the degree of bone loss associated with individual teeth, as there is severe distortion and the outline of the bone margin is often unclear due to superimposition of intervening structures. N.B. Chronological age could be differed significantly from the skeletal age, dental age, physiologic age and psychological age. 3) Cephalometric X-ray: It is a standardized radiographs introduced into orthodontic practice by Broadbent on 1931. This mean that the patient stand in the cephalostat in standard position and the between the patient and the source of X-ray and the X-ray film is constant (distance from x-ray source to patients midsagittal plane is 5 feet or 152.4 cm. and from patients midsagittal plane to film is 12 cm. Enlargement in this case will be slightly bellow 8%. One important problem arise in cephalometrics with patients whose treatment begins in one location may move to another, so cephalometric film positions may not be the same for successive films on the same patient. This creates problems in interpretation when growth and treatment changes are occurring simultaneously, especially if dont have prior information about the magnification error of the previous cephalostat. Lateral and postero-anterior (P/A) views are the most common views taken in orthodontics. Cephalograms are standardized X-ray films taken by the cephalostat. The cephalostat is an apparatus for holding the patients head and the X-ray film in a desired position and relation to each other and to the central ray of the X-ray machine. So that the only variable is the result of growth and/or orthodontic treatment, when periodic cephalometric X-ray films of the same patient are taken. The orbital pointer and ear rods make it possible to adjust the patient's head along the Frankfort horizontal plane (Plane intersect right and left porion and left orbital). The head is adjusted so that the orbital pointer is on the left infraorbital, thus placing the head in the Frankfort horizontal. The teeth should be in centric occlusion and lips in the natural rest position, unless other positions are desired. The cephalometric X-rays are used in orthodontics in treatment planning, follow up of treatment progress, as well as, growth changes. The cephalograms are traced on special tracing
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papers; using combinations of dimensional and angular criteria which employ the various measures of anthropometr i c points and landmarks. Cephalometrics offers the orthodontist with valuable information in the following categories (N.B: cephalometric tracing and analysis now a day are undertaken by computer): 1. Dimensional relationship of the craniofacial components (facial type). 2. Classification of skeletal and dental abnormalities, including jaw and dentition malrelationship. 3. The manifestations of growth and developmental abnormalities responsible for dentofacial anomaly, including those in the cranial base, and facial asymmetry. 4. Aid in treatment planning. 5. Analysis of changes obtained in the hard-and soft- tissue contours. a) By orthodontic treatment. b) By growth. c) By growth and orthodontic treatment. 6. Evaluation of effectiveness of different orthodontic treatment procedures. 7. Effectiveness of retention. 8. Dentofacial growth changes after treatment is completed
Cephalometric Analysis
Background:
Cephalometrics lateral and P/A (postero-anterior) skull radiographs, are special radiographs taken under standardized condition by special X-ray machine, cephalostat, which had been introduced into orthodontics by Broadbent on 1931. The patients are placed in the cephalostat with their head oriented at 90o to the X-Ray beam at a distance of 5ft from the tube. The film is placed at 15 inches distance from the head. This is a standard under which all cephalometric radiographs are taken worldwide; on the other hand, image magnification is within the lowest scale. Now a day by the use of digital radiographs we can correct the magnification to the zero value. It also ensures that radiographs taken at different centers are directly comparable. The film is then traced and various standard landmarks, lines and angles are measured and recorded. This allows; treatment planning, comparison with normal values for a population and assessment of growth and/or effects of treatment. Before tracing we must be sure from the clarity and high resolution of the radiographs and be able to see the soft-tissue out line of the face as well as the tongue and pharynx. All the hard-tissue references points should be clearly visible.
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Tracing techniques 1. Manual tracing and analysis: This should be undertaken in a darkened room. Use good quality tracing paper securely taped to radiograph (along the top edge of the tracing paper, directly to the radiograph - this allows the tracing paper to be lifted to examine the radiograph directly, yet replace it in the same place for tracing). Use a sharp (HB) pencil to outline the following: 1. 2. 3. 4. 5. 6. 7. Soft-tissue profile of face (forehead to chin) Sella Turcica Frontal bone and nasal bone Orbital floor External auditory meatus Maxilla, upper lst molar and upper central incisor Mandible, mandibular symphysis, lowers lst molar and lower central incisor 8. Outline of the mandible up to the condylar head and crinoids process. 9. Cervical vertebral column. 10. Tongue. 11. Nasopharynx and oropharynx. Next Identify and mark the necessary cephalometric points and lines/planes which are recommended for the specified cephalometric analysis: the following are some lines/planes commonly used in cephalometric analysis.
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Hard-tissue tracing and reference points Hard-tissue measurements Reference points: 1. S point (Sella): Mid point of Sella Turcica 2. Bo point (Bolton): It is a point established by the junction of the image of posterior margin of the occipital condyle with that of the occipital bone immediately posterior to it. 3. R point (Registration point): It is the midpoint of a perpendicular from S point to Bolton plane. 4. N point (Nasion): Most anterior point on fronto-nasal suture 5. Or point (Orbitale): Most inferior anterior point on margin of orbit 6. P point (Porion): Upper most point on bony external auditory meatus (Tr: Tragus) 7. ANS point: Anterior Nasal Spine 8. PNS point: Posterior Nasal Spine 9. Go point (Gonion): Most posterior inferior point on angle of mandible 10. Me point (Menton): Lower most point on the mandibular symphysis 11. Pg (Pogonion): Most prominent point of the chin. 12. Gn (Gnathion): midpoint of the lower anterior curvature of the chin, midway between pogonion and menton. 13. A point: Position of deepest concavity on anterior profile of maxilla, representing the most anterior point of the maxillary basal arch. 14. B point: Position of deepest concavity on anterior profile of mandibular symphysis, representing the most anterior point of the mandibular basal arch. 15. U1 point: the incisal edge of the most prominent upper incisor tooth. 16. L1 point: the incisal edge of the most prominent lower incisor tooth. Reference lines: 1. Po - Or (Frankfort Plane): Equivalent to the true horizontal when patient is standing upright. 2. N Bo (Bolton plane): It is a line between Bolton point and nasion. 3. PNS - ANS (Maxillary Plane): Gives inclination of maxilla relative to other lines/planes. 4. Go - Me (Mandibular Plan): Gives inclination of mandible relative to other lines/planes. (Steiner; line between gonion and gnathion, Dowen; line tangent to the lower borders of the symphysis and the ramus) 5. S - N Line: Indicates orientation of anterior cranial base.
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6. N - A Line: Indicates relative position of maxilla to the cranial base 7. N - B Line: Indicates relative position of mandible to the cranial base 8. N Pg line: Facial plane Hard-tissue measurements: Skeletal: 1. MMPA (Maxilla to Mandibular Planes Angle): Gives an inclination of the maxilla relative to the mandible; this in turn indicates the relative proportions of face height and acts as an indicator for future growth direction: 23+/-4o 2. Mandibular plane angle: (Frankfort to mandibular planes angle): 25+/3o 3. Tweed triangle: Triangle formed of mandibular plane, Frankfort plane and the long axis of the mandibular incisor: (95+/-5o) + (25+/-3o) +(60+/-4o) = 180o 4. The angles SNA (82+/-4o), SNB (79+/-4o), ANB (3+/-1) indicates relative position of maxilla/mandible to each other and to the cranial base 5. A B to Occlusal Plane (Wits): -1+/-2 mm 6. Y axis: it is the anterior inferior angle formed between the Frankfort plane and sella gnathion line. It is used as an indicator of growth trend: 61+/-4o 7. Angle of convexity: N-A-Pg angle: 4o (0 to 8o) 8. Facial angle (the inferior inside angle between the Frankfort plane and N-Pg): 87+/-3o 9. S-N-Pg: 80+/-4o 10. Anterior lower facial height (distance in mm from ANS-Me)= 57+/-3% of anterior total facial height (distance in mm from N-Me) 11. Posterior facial height (distance in mm from the S-Go)= 66+/-6% of anterior total facial height (distance in mm from N-Me) 12. A B to N Pg angle: Indicate the relationship of the maxillary and mandibular apical base: Dental: 1. Long axis of the lower incisor to mandibular plane angle: 95+/-5o 2. Long axis of the lower incisor to Frankfort plane angle: 60+/-4o
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3. Long axis of the upper incisor to Frankfort plane angle: 112+/-4o 4. Interincisal angle; Long axis of upper central incisor/lower central incisor (root apex to incisal edge): Allows measurement of the angulation of incisors to maxilla/mandibular planes: 127+/-8o 5. Long axis of the most prominent upper incisor to N A angle: 24+/5o 6. Upper incisor to N A distance (is measured along perpendicular from U1 to N A line): 5+/-4 mm 7. Long axis of the most prominent lower incisor to N B angle: 27+/-4o 8. Lower incisor to N B distance (is measured along perpendicular from L1 to N B line): 6+/-2 mm 9. Overjet: 2.5+/-2.5mm 10. Overbite: 2.5+/-1.5mm N.B.: The linear and angular measurement should be measured to the nearest to 0.1 mm and 0.5 degree accuracy.
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Soft-tissue tracing and reference points Soft-tissue measurements Reference points: 1. N: Soft tissue Nasion (point of intersection between the extension of S N line and soft-tissue profile H angle. By others it is the deepest point on the curvature between the forehead and the nose. 2. Prn: Pronasale: The most anterior point on the tip of the nose. 3. Sn: Subnasale: The junction point between the nose and upper lip. 4. Ss: Stomion Superious: The deepest point on the curvature of the upper lip. 5. Ls: Labrale Superious: The most anterior point on the curvature of the upper lip. 6. Li: Labrale Inferious: The most anterior point on the curvature of the lower lip. 7. Si: Stomion Inferious: The deepest point on the curvature of the lower lip.
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8. Pg: Soft tissue Pogonion: The most anterior on the curvature of the chin. Reference line: 1. H line (Harmony line): Line between Ls and Pg 2. Profile line: Line between Pg and most prominent upper or lower lip. 3. E line (Esthetic line): Line between Prn and Pg 4. S line: Line between Pg and midpoint between Prn and Sn A. Angular measurements: 1. Nasolabial angle (NLA): It is angle between Collumella, Subnasale and Labrale Superius points (Cm-Sn-Ls): 102+/-8o 2. Soft tissue profile angle: It is angle between soft tissue Nasion, Subnasale and soft tissue Pogonion (N-Sn- Pg) 3. Full soft tissue profile angle: It is angle between points soft tissue Nasion, Pronasale and soft tissue Pogonion (N-Prn- Pg) 4. Soft-tissue facial angle: It is the inferior inside angle between the lines S-N and N - Pg : 91+/-7o 5. H-Angle: It is the angle between soft-tissue N- Pg line and H-line (line joining Labrale Superius and soft tissue Pogonion0 (N Pog-Ls Pg): 10+/- 4o 6. Z-Angle: The inferior inside angle between Frankfurt horizontal plane and profile line (i.e. tangent to Pg and most prominent point on upper or lower lip): 71+/-8o B. Linear measurements: 1. Li to H-plane; It is linear distance in mm on the perpendicular from Li to the tangent plane joining Ls to Pg: -1 (02mm) 2. Ls to E-plane: It is linear distance in mm on the perpendicular from Ls to the plane joining Pg and Prn: -3.2+/-1.2mm 3. Li to E-plane; It is linear distance in mm on the perpendicular from Li to the plane joining Pg and Prn: -2.4+/-0.5mm 4. Sn-Me/N-Sn (%): 132.5+/-0.8% 5. Upper lip length: It is the linear distance in mm on the perpendicular from Stomion Superious (Ss) to line tangent to the most inferior point of the upper lip.
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6. Lower lip length; It is the linear distance in mm on the perpendicular from Stomion Inferious (Si) to line tangent to the most superior point of the lower lip. 7. Upper lip thickness: It is the linear distance in mm from Ls to U1. 8. Lower lip thickness: It is the linear distance in mm from Li to L1. 9. Nose prominence: It is measured along perpendicular line from the tip of the nose (Prn) to H line: 8+/-4mm. 10. Upper lip sulcus depth: measured along a perpendicular from Ss to H line: 6+/-2mm 11. Lower lip sulcus depth: along a perpendicular from Si to H line: 6+/-2mm 12. Total chin: It is measured from Pg to Pg: 16+/-2mm N.B.: The linear and angular measurement should be measured to the nearest to 0.1 mm and 0.5 degree accuracy.
Profile analysis
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Facial proportions
Figure 6
These diagrams show lateral cephalometric radiograph; tracing of the soft-and hard-tissue, the relationship of a number of key cephalometric points and lines/planes in relation to the skull, profile analysis and facial proportions. 2. Computerized tracing and analysis: There are many computers soft-wares for cephalometric analyses. The main principle is using digitizer to locate the cephalometric points according the specified computer cephalometric program. The accuracy of locating the points is of vital importance to the validity of the collected measurements, exactly the same as in the manual technique. The computer will not correct any error in locating the specified points. After entering the necessary points the computer programs will give us the choice to select between four or five cephalometric analyses e.g. Ricketts, Steiner etc. Choice between different race could be also available e.g. Caucasian, Black, Asian etc The importance of computer cephalometric analyses could be summarized in the followings: 1. 2. 3. 4. 5. 6. Comparing your case with the standard norm of some races. Superimposition of before, during and after treatment tracing. Changes with growth and treatment can be easily measured. Predicting changes with treatment or growth. Easy communication with patients and their parents. Easy communication with colleague if we are in need of second opinion.
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7. Excellent filing system. Analysis/Interpretation of tracing By comparison of angular measurements with normal values we can interpret the results of our analysis and to give a diagnosis of the case and the proposed treatment plan. Comparison of the findings from the original and final cephalometric radiographs will allow us to assess the outcome of orthodontic treatment or growth. The following are some Caucasian standard cephalometrics values and interpretation of some measurements: 1. Interpretation of SNA, SNB and ANB angles: SNA = 81o (3) SNB = 79o (3) ANB = 3o (2) If SNA or SNB angle is greater or less than the normal, this indicates that the maxilla or the mandible, or both, is either positioned anterior or posterior. This may be due to a difference in jaw growth and size. ANB indicates the relative position of maxilla to mandible, and allows the measurement of the extent of the jaw size/position discrepancy. ANB 2-4o= Class I skeletal pattern ANB > 4o= Class II skeletal pattern ANB < 2o= Class Ill skeletal pattern 2. Interpretation of MMPA: MMPA (max/mand planes angle) 27o (4) MMPA gives an inclination of the maxilla relative to the mandible; this in turn indicates the relative proportions of face height and acts as an indicator for future growth direction. 3. Interpretation of Incisor to maxilla/mandible angles: They give a measurement of the extent of the proclination or retroclination of the incisors 1 - Mx - Upper incisor to Maxilla angle; 109o (6) 1 - Md - Lower incisor to Mandible angle; 93o (6) N.B.: If MMPA is not normal (i.e. greater or less than 27o); the 'normal'
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Ort thodontics for U Undergraduate 2009 e:
lower incisor to Md a angle is calcu ulated as 120o minus MM 0 MPA. he ns metric measurements standard n norms N.B.: Th Egyptian cephalom are prese ented in Cha apter 33. Orthodontic diagnostic records O
Intraora photograp al phs
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Orthodontic study models
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Digital panoramic radiograph
Digital lateral cephalometric radiograph
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Digital P/A cephalometric radiograph
Bitewing radiograph
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Digital P Periapical a bitewin radiograp and ng phs
Assessment of bone density from periapica radiograp and Dig al phs gora program p
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Hand-wrist to study skeletal growth; percentage of predicted adolescent growth and pubertal growth spurt by recorded the developmental stages of the following growth indicators: 1. Adductor sesamoid of the 1st finger, 2. Hook of hamates and pesiform, 3. Proximal, middle and distal phalanx of the 3rd finger, 4. Middle phalanx of the 5th finger and 5. Radius
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Digital radiograph of the middle phalanx of the third finger (MP3-Stages) and the adductor sesamoid of the first finger, taken by radiograph periapical digital sensor
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1 5 4 . 3
2 1 3 8 . 6
Ricketts cephalometric analysis (computer tracing and analysis)
Diagnostic setup (Kesling)
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Medicolegal perspective
1. All orthodontic radiographs must be screened carefully for any significant pathological lesions or anatomical anomalies, as first priority from the medicolegal point of view, before any other orthodontic procedures. Unrecognized carotid artery stenosis could be diagnosed from the panoramic and lateral view cephalometric radiographs. 2. We are living now within the miracle of the Digital Era in which all the orthodontic essential diagnostic records such as; study models, photographs and radiographs could be stored in the computer and get consultation with other orthodontist through the miracle internet technology (global information).
Broken surgical needle in the tonsillar area
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Periapical radiograph (Dens-in-dent)
Occlusal radiograph (impacted supernumerary teeth in the palate)

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Lateral view cephalometric radiograph (severe underdevelopment of the upper face)
Figure 19: Panoramic radiograph (mixed dentition stage)
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Figure 20: Panoramic radiograph (large periapical dental cyst extended from the 2nd premolar to the 2nd molar)
Figure 23: Unrecognized carotid artery stenosis, calcifications is located inferior to mandibular angle, tip of the hyoid bone, superior to thyroid cartilage and could be at the level of CV3, CV4 or CV5 vertebrae, in our case at the level of CV3
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Figure 24: Hypertrophied adenoids (nasopharyngeal tonsil); a soft-tissue mass located on the superior posterior aspect of the nasopharynx, completely block the nasopharyngeal air way
Digital radiography has the following valuable differences from the conventional radiography
1. no dark room processing of the films 2. It provides a highest quality images with an exposure time five times less than the conventional method. 3. Less patients X-ray exposure 4. Much faster and easier orthodontic-patient-parent communication 5. Study of investing bone density changes with orthodontic tooth movement 6. An archived may be easily generated 7. Communication and consultation with other clinicians is much easier.
Technical problems with radiographs
Variations in x-ray technique that produce distortion, coupled

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with the projection of a three-dimensional object onto a two-dimensional plane, limit the diagnostic value of the radiograph. The bone level, the pattern of bone destruction, the radiodensity and trabecular pattern of the interdental bone, all are modified by altering the exposure and development time, the type of film and the x-ray angulation. These features must be considered when trying to compare pre- and post-treatment radiographs. The long cone paralleling technique is recommended for all periapical radiographs taken for periodontal diagnostic reasons, as it produces the most realistic image of the alveolar bone.
The bisection of the angle technique increases the angle of projection and makes the bone margin appear closer to the crown; the level of the facial bone is distorted more than the lingual. Shifting the cone mesially or distally without disturbing the horizontal plane projects the x-rays obliquely and changes the image of the interdental bone, and may distort the extent of furcation involvement. For these reasons, it is strongly recommended that you use beam aligning holders for taking long-cone parallel technique radiographs. (RINN aligning devices are available through DENTSPLY). This technique also allows for more standardized comparisons of radiographs over time even if taken by different operators. Recording of radiographic findings It is important to note the findings of your radiographic examination in the patient's treatment record, and to mount and store the radiographs for future reference. Notations in the treatment record should indicate:

The date the radiographs were taken The type of radiographs taken The reason for taking the radiographs Diagnostic information gained from examination of radiographs Further diagnostic tests that may need to follow up any pertinent radiographic findings.
E. Photo-occlusion analysis: It is the study of occlusal force distribution allover the occlusal table of the teeth. It is of prime importance to locate the area of traumatic occlusion and the
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improvement achieved by orthodontic treatment of dental malocclusion. Photo-occlusion analyzer whatever manual or computerized; is commonly used in this regards. In manual photo-occlusion analysis the patient occludes forcibly on especial plastic wafer, and the cusp prints are interpreted, occlusal force distribution and magnitude, by the photo-analyzer using special light scale. In the computerized the patient occludes on special sensor connected to computer, and by special software we can have the distribution and magnitude of the occlusal force. F. Basal metabolic rate and other endocrine tests: Endocrine upsets may produce, or at least be partly responsible for dental malocclusion. Of special value is the basal metabolic rate test (B.M.R.), or blood sedimentation rate, blood cholesterol level and blood sugar analysis. A negative B.M.R. may be the first indication of a thyroid disturbance. G. Arch length analysis: 1. Nance analysis: The following method was established by Nance for determining relative mesiodistal widths of the deciduous and permanent teeth in the mixed dentition. a. Measure with a pair of dividers the mesiodistal width of the two deciduous molars and deciduous canine, or the amount of space which these teeth occupy in the dental arch. b. Using the dividers, measure the greatest mesiodistal width of the premolars and permanent canines as shown in the roentgenogram. c. Compare the length obtained from (a) with that of (b), the difference between the two dimensions is the Leeway space. Nance then obtained the following measurement from the mandibular cast in the mixed dentition: i. The outside measurement or perimeter of st arch from the the mesiobuccul surface of the permanent 1 molars by adapting a 0.010 in. brass ligature wire so that it touches the middle third of the teeth. ii. Using the dividers, obtain the measurement from the mesiolingual surface of the permanent 1st molar to the apex of the interdental papillae between the mandibular incisors (inside measurement). 2. Ballard and Wylie analysis: It is based on the assumption that there is harmony between t he size of incisor teeth and that of t he canines and premolars. The mandibular incisors width are measured individually and then added to get the total incisors width. Directly opposite that sum on the other side of the scale of Ballard and Wylie's chart, the sum of the unerupted canine and premolars on one side will be seen. 3. Hixon and Oldfather analysis:
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The mesiodistal widths of the lower central and lateral incisors are combined with the X-ray measurement of the unerupted first and second premolars of one side of the arch. The combined widths are entered in their chart, and the predicted size of the unerupted lower canine and pr e molars of the sa me side of the arch are opposite them. 4. Moyers analysis: The combined mesiodistal width of the erupted permanent lower four incisors are used to predict the combined mesiodistal width of the unerupted upper and lower canines and premolars, from Moyers probability chart. He recommends using the 75 % level of probability to protect on the crowded side. 5. Tanaka-Johnson mixed dentition equation: They used the combined mesiodistal width of the erupted permanent lower four incisors to predict the mesiodistal width of the unerupted canine and premolars. The following equation will be used: the mesiodistal width of the mandibular four incisors divided by 2 to which add 11mm+/-1.5 mm and 10.5 mm+/- 1.5 mm , will give the predicted the combined mesiodistal width of the permanent canines and premolars on one side in the maxillary and mandibular arch respectively. H. Mock treatment: Mock surgery: The proposed orthognathic surgical procedure(s) which will be used to correct maxillofacial discrepancies is to be undertaken first on the cephalometric radiographs (series of cephalometric tracing on tracing papers) and series of working models (cephalometric trimming working models are preferable) before performing the operation on the patients. Now a day mock surgery can be done by the use of computer programs facilities and the 3D radiographs and photographs. The computer programs can create 3D model of the hard-and the soft-tissue of the maxillofacial complex. The outcome of the mock surgery will be discussed with the treating team first. After getting approval from all members of the team, the proposed plan will be discussed with the patient and their family to get their approval on a signed consent form. Mock orthodontics: The computer programs facilities adding too much in this respect. We can collect the proposed orthodontic treatment outcome both from different cephalograms and photographs of the patients, as well as, 3D images of the case. This advanced technology gives help for the orthodontists to visualize the problems and to some extent how to solve them. On the other hand, it forms a good communications tool with the patients and their parents. The construction of diagnostic set-up of Keslling could be considered a type of mock orthodontic treatment.
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For how long the orthodontic records are to be saved?

Is a common question running between the orthodontists, and if the policy taken could be differ in the private sector than that taken in the governmental hospital and teaching institutes? As a general role, taken and maintenance of good quality orthodontic records is often critical in refuting allegations of negligence. Children records should be retained until their 24th birth day or 8 years after the last entry, whichever is the longer. On the other hand, it would be wise to arrange to retain radiographic records in some useful form until 27 years of age or 11 years after the last recorded entry10. The minimum time for retention of radiographic records should be 6 years. The computer storage system makes the process of storage of the orthodontic records (radiographs, study models, photographs among other records) a very simple practical system for hospitals and private clinics as well. To have a computer storage system in addition of having internet connection is very beneficial if we would like to have second opinion, to arrange for seminar presentation, study club, teaching for under-and postgraduates and in case of patient transfer to another doctor. If the original orthodontic records have to be given to the patient, for a reason or another, copy of good quality from each record must be retained in the hospital or the clinic filing. These precautions are almost covering the medicolegal requirements in our practice. I would like to end this section by focusing again on Peck statement Digital imaging, and Internet based communication and research have given us diagnostic accuracy and versatility unimaginable just a few years ago. With the miracles of modern electronics and online publishing, information exchange has never been easier between orthodontists separated by thousands of miles. We have become indeed a global community of specialists, sharing the same evidence base, the same patient-centered values, and, yes, the same worrisome vulnerabilities.
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CHAPTER 14: SCOPE OF ORTHODONTICS

Orthodontics is that specific area of dental practice that has its responsibility the study and supervision of the growth and development of the dentition and its related anatomical structure from birth to denial maturity. It includes the following: 1. Preventive orthodontics: It is defined as that phase of orthodontics employed to recognize and eliminate potential irregularities and malpositions in the developing dentofacial complex. It is directed toward improving environmental conditions to permit future normal development. Among these preventive measures are caries control, anatomical dental restorations, space' maintenance, transitory oral habit correction, genetic and congenital anomalies, and supervising the exfoliation of deciduous teeth. A fine line exists between preventive and interceptive orthodontics. 2. Interceptive orthodontics: Although interceptive orthodontics may involve the removal of deciduous teeth that are interfering with eruption of their immediate permanent successors, it does not include the extraction of deciduous teeth in any corrective program leading to the subsequent extraction of permanent teeth. This procedure, commonly known as serial extraction, is an integral part of orthodontic treatment; it has interceptive implications only in its earliest phases, and it has greater limitations than is generally recognized. Serial extraction requires: a) Broad experience in the orthodontic treatment of all types of malocclusion in order to discriminate between extraction and nonextraction irregularities. b) Orthodontic appliances in the later stages for final repositioning of the remaining permanent teeth. Therefore; it is essentially and basically an orthodontic treatment responsibility. Mechanical appliances as interceptors of malocclusion should be used carefully, when wrongly used in growing children; it may actually interfere with proper dentofacial development by inhibiting the growth of the jaws and interfering with normal tooth arrangement.
2. Corrective orthodontics:
It is the procedures of correction of dental irregularities, requiring the reposition of teeth by functional or mechanical appliances to establish normal occlusion and pleasing facial contours. Corrective orthodontics has three phases; active phase, retention phase and occlusal equilibration phase.
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1. Preventive orthodontics
Preventive orthodontics consists chiefly of the following: 1) Differentiate between normal occlusion and malocclusion in deciduous, mixed and permanent dentitions. 2) Appraise developmental processes (teeth, jaw and face) by the use of casts, radiographs e.g.: cephalometrics etc. 3) Recognize early deviations from norm, in deciduous teeth development, eruption and exfoliation, and development and eruption of the permanent teeth. 4) Recognize predisposing factors of malocclusion. 5) Recognize of harmful dentofacial habits. 6) Be familiar with the classification of malocclusion. 7) Advise on need for orthodontic care, and refer to orthodontists. 8) Promote and maintain normal occlusion by: extraction of retained teeth, remaining roots and supernumerary teeth. 9) Caries control and restoration of carious deciduous and permanent teeth to their normal form in order to maintain occlusion. 10) Refer patients to medical specialists for the diagnosis and treatment of systemic conditions with dentofacial correlations. 10) Refer patients with clefts of lips and the palate for surgical treatment. 11) Use space maintainers where indicated, in cases of premature loss of deciduous tooth or teeth, to maintain the space of the permanent teeth.
SPACE MAINTAINERS:
Appliances used to maintain the space for the eruption of the permanent teeth after premature loss of their deciduous predecessors. Indications for space maintenance: 1. Time elapsed since loss of the deciduous tooth. If the space loss occurred, space regainer is indicated to regain lost space before holding it for the eruption of the permanent tooth. 2. Age of the patients: The developmental age is much more important than the chronologic age of the patient. The dentist must depend upon the dental X-ray instead of the eruption tables, for the relative time of tooth eruption. 3. Amount of bone covering the unerupted may affect the eruption time of the tooth. 4. Sequence of eruption of teeth. tooth
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5. Delayed eruption of the permanent tooth. 6. The congenital absence of the permanent tooth. Prerequisites for space maintainers: 2. Should maintain the mesiodistal dimension of the lost tooth. 3. Should be functional or at least prevent the overeruption of the opposing tooth or teeth. 4. Should be simple and strong as possible. 5. Not endanger the remaining teeth. 6. Easily cleaned and not serve as stagnation area for food debris. 7. Not restrict normal growth and development or interfere with mastication, speech or deglutition. Factors affecting type of space maintainers: 1. The tooth or teeth lost. 2. The age of the patient. 3. The state of health of the remaining teeth. 4. The type of occlusion. 5. Possible speech involvement. 6. Patient cooperation. 7. The manual dexterity and preferences of the operator.
Types of space maintainers: I. a) Functional: to maintain space mesiodistal and occlusal, mastication, speech and esthetic. b) Nonfunctional: to maintain the mesiodistal space only. II. a) Fixed (band or chrome steel crown and loop maintainer, fixed lingual arch, cantilever maintainer to prevent the mesial migration of the 1st permanent molar during eruption, space regainer). b) Removable (acrylic partial denture). c) Semi-fixed (cantilever). III. a) Active space regainer. b) Passive space maintainer e.g. band and loop space maintainer.
2. Interceptive orthodontics
It is the procedures used to intercept a malocclusion that has already developed or is developing, to restore normal occlusion. The dentist must eliminate the causes of malocclusion, and if self-adjustment cannot restore normal occlusion, he must resort to limited corrective procedures. Study models and full dental radiographs are essential. Interceptive measures: 1. Occlusal equilibration, to eliminate premature contacts and occlusal disharmony that can develop traumatic occlusion
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2. 3. 4.
5. 6.
and tooth guidance problems. The most frequent forms of t o o t h g u i d a n c e i n t h e d e c i d u ous a nd mi xe d de ntition a r e the anterior mandibular displacement. Correction of anterior cross-bite if it is a purely localized irregularity, and not a part of a more generalized malocclusion. Frenectomy of abnormal labial frenum, and closing incisor diastema. Control of abnormal habits, before causing irreparable harm to the developing dentition, by placement of habit-breaking appliance e.g. oral screen for mouth breathing habit. Muscle exercises, to increase the tonicity and the restraining influence of the lips. Serial extraction: It is practiced under the assumption that it is possible to predict at early age that there will be a lack of space to accommodate all of the permanent teeth. The actual increments in arch size and intercanine width that will occur during growth are difficult to estimate in advance and jaw growth is far from complete during the mixed dentition period.
Indications of serial extraction: Indications for serial extraction depend on: 1. The difference between the combined mesiodistal crown diameters of the deciduous canines and molars and the permanent canines and premolars (Leeway space). 2. The actual changes in arch size which will occur during the change from the deciduous to the permanent dentition. 3. The individual variations in arch size and in the Leeway space, which can result in favorable or unfavorable arrangement of the permanent dentition. 4. The relative position of the 1st premolar and the permanent canine. When X-ray examination shows that the canines might erupt before the 1st premolars, extraction of the 1st deciduous molars is indicated before extracting the deciduous canines to prevent the canines from erupting before the 1st premolars. The benefits of serial extraction are: 1. To avoid loss of labial alveolar bone. 2. To encourage eruption of permanent teeth in a favorable direction. 3. To reduce malpositions of individual teeth. 4. To reduce treatment time when major orthodontics is required. Contraindi cation: 1. Class I malocclusion where the lack of space is slight and the teeth are only slightly crowded. 2. Class MI and Class II, division 2 malocclusion. 3. When oligodontia or other deficiencies of teeth are present. 4. In the presence of midline diastema as and deep overbite. 5. Openbite should be treated before undertaking serial extraction. 6. When fixed appliances cannot be used to avoid arch collapse. Stages in serial extraction: DEWEL'S Method; 1. Early extraction of deciduous canines to provide space for the
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incisors to assume correct alignment. 2. Extraction of the 1 st deciduous molars to permit early eruption of the 1 st premolars, 3. Extraction of the 1st premolars to allow space for the canines to erupt in the space formerly occupied by the 1 st premolars. The interval between the three stages and the sequence of eruption varies with the individual patient from 6 months to a year. TWEED'S Method: When diagnosis shows that a discrepancy exists between tooth and basal bone (basal arch) and the patient is between the ages of 7 to 8 years, serial extraction is performed. 1. At the age of 8 years all four deciduous 1st molars are extracted. 2. When the 1st premolars erupt to about the level of the crest of the alveolar mucosa they are extracted. The deciduous canines are extracted at this time.
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CHAPTER 15: ORTHODONTIC TOOTH MOVEMENT

Orthodontic treatment is based on the fact that it is possible, to move the teeth through the alveolar bone, by applying appropriate forces, without causing permanent damage to either the teeth or their supporting tissues. When a force is applied to the crown of a tooth, it is transmitted through the root of th e tooth to the periodontal ligament and alveolar bone. According to the direction of the force, there will be areas of pressure and areas of tension on these supporting structures. For the tooth to move and to maintain the integrity of the attachment mechanism there must be resorption and deposition of alveolar bone in response to pressure and tension areas respectively. In effect, the socket of the tooth is moved, concomitant with tooth movement through the alveolar bone. In other words, successful orthodontic tooth movement is ended by moving the tooth with its investing tissues (periodontium) through the supporting bone. Tissue reactions in response to orthodontic force: I. Force not sufficient to occlude the blood vessels of the periodontal ligament: 1. Hyperemia within the periodontal ligament. 2. Osteoclasts and osteoblasts appear in the periodontal ligament. 3. Resorption of bone of the lamina dura occurs from the periodontal side beneath the areas of pressure, accompanied by osteoclastic activity. 4. Apposition of osteoid tissue occurs on the inner surface of the socket beneath the area of tension, accompanied by osteoblastic activity. This tissue becomes calcified within about 10 days, to form mature bone. 5. As the tooth and socket move through the alveolar bone, remodeling occurs to re-establish and maintain the Integrity of the socket wall. This involves the addition of bone to the endosteal surface beneath the areas of pressure, and resorption of bone from the endosteal surface beneath the area of tension. 6. The periodontal ligament fibers attaching the tooth to the bone become reorganized. Progressive reattachment occurs, possibly by the production of new fibers and attachment to existing intermediate fibers and to bone fibers which become progressively uncovered. II. Force sufficient to occlude the blood vessels of the periodontal ligament: 1. Occlusion of the blood vessels in the areas of pressure. Dilatation of vessels in the areas of tension. 2. Appearance of cell-free areas in the periodontal ligament in the pressure areas (hyalanized zone).
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3. Period of stasis, when the tooth does not move because no resorption occurs on the periosteal surface of the socket. 4. Increased endosteal vascularity, and endosteal resorption of the socket wall under the cell-free areas (undermining resorption). 5. Relatively rapid movement of the tooth, accompanied by bone deposition within the socket beneath the areas of tension. The tooth may become slightly loose. 6. Healing of the periodontal ligament, re-organization of fibers and remodeling of the socket wall when forces are removed. III. Grossly excessive force: 1. Necrosis of the periodontal ligament tissue. 2. Massive undermining resorption. 3. Possibly root resorption. 4. Healing may be by ankylosis. 5. Possible tooth devitalization. Ideal orthodontic force: The appropriate force for successful orthodontic tooth movement, should not exceeding capillary blood pressure (32 m m H g . o r b e t w e e n 5 0 t o 7 5 g r a ms ) . I t d e p e n d s o n t h e s i z e and shape of the tooth and size and number of the roots. Types of orthodontic forces: 1. Continuous force: It is steady force applied to the crown of a tooth or teeth. 2. Intermittent force: It is force act for a short period of time with a series of interruptions. 3. Dissipating force: It is a continuous force but decreases within short period of time. Limitations of tooth movement: 1. Size and form of the basal bone, the apex of the tooth must remain on the basal bone. 2. Adverse forces on the teeth brought about by the oral musculature. The teeth position at the end of treatment to be stable, the muscular forces acting OR the teeth must be sufficient to hold the teeth in their new position. It is called a position of (muscle balance). Factors affecting orthodontic tooth movement: 1. Types of forces: Orthodontic tooth movement can be continuous or intermittent according to the type of force used. 2. Force magnitude: The ideal orthodontic force used is that force that should result in tooth movement of about one mm every month. 3. Age of the patient: In children the supporting periodontium is much more active than in the adult age. So there is less hyalinization and the rate of tooth movement will be greater. 4. Individual variation: The density of the alveolar bone and the vascularity of the periodontal ligament vary considerably with different individuals. The more active alveolar bone and periodontal ligament the greater the rate of tooth movement.
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5. Sex of the patients: Periodic slower of the orthodontic
tooth movement is reported during menstruation in females.
Types of tooth movement: 1. Tipping movements: The simplest movement, in which the force is applied at one point on the crown of a tooth, and the tooth, will tilt away from the force. Several factors affect the position of the fulcrum (center of rotation). The closure the force to the incisal edge and heavy forces, move the fulcrum away from the apex, and if the force is light enough, the fulcrum could be at the apex. In tipping movement the incisal edge moves in one direction and the apex in the opposite direction. 2. Rotational movements: The tooth rotates along its long axe in its socket, by the use of force couple i.e. applying opposite forces to different areas of the crown. There is a much greater tendency to relapse after rotational movement. 3. Bodily movements: It is the complete movement or translation of alt parts of the tooth, in the same direction, to a' new position. The force must be applied directly over a wide area of the crown, and any tipping movements must be restricted. Bodily movement of tooth requires two to three times the force needed for simple tipping of the same tooth. 4. Torque movements: It is the opposite of the tipping movement; the root is moved with little movement of the crown in the opposite direction. It is achieved by applying a force couple to the crown of the tooth, at the same time restricting crown movement in the opposite direction. 5. Vertical movements: Vertical movements are essentially bodily movement but in the vertical direction, and the force must be applied over a wide area of the crown. According to the direction of the force applied, the movements are either: a) Extrusion movement; to move the tooth from its socket or; b) Intrusion movement; to move the tooth through its socket. 6. Multiple tooth movement: Orthodontic treatment frequently involves the application of force to move a number of teeth simultaneously. In such cases, the total force applied will often exceed that required for individual tooth movement, because the force will be spread over several teeth.
Pulp vitality and tooth movement:

There is no difference in the degree of movability of devitalized and vital teeth. A devitalized tooth can be moved as long as the periodontal membrane is intact. When the apical blood supply is discontinued (pulpectomy), that supplied by the periosteum and the
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gingival vessels keeps the periodontal membrane in function. Tissue reaction in the periodontal ligament does not differ in nonvital teeth from that found in vital teeth.
Theories of tooth movements:

1. Pressure-tension theory; The classical theory: a. Assumes that the changes which occur by orthodontic force are confined only in the periodontal ligaments (PDL). b. During tooth movement there are a pressure side and tension side in the PDL. c. Cell replication decreases in the pressure side due to vascular constrictions and increases in tension side due to stretching stimulation of fibrous content of PDL. d. Fibrous content undergoes disorganization and its production decreases on the pressure side and increases on the tension side. e. Bone remodeling of alveolar process by resorption from pressure side and apposition on the tension side and these are the only changes which occur in the alveolar bone. f. So the classical theory considered that tooth movement occurs due to direct effect on the PDL fibers and not relies to distant factors than the PDL fibers-alveolar bone interface. B. Alveolar bone distortion or bending theory: Bio-Electrical potential differences, (Piezoelectric Hypothesis): The effect of physiological distortion of the alveolar bone by the forces from orthodontic appliances may be responsible for the cellular reaction observed. Many investigators have shown that even relatively light forces on the teeth as those in the orthodontic treatment, cause bending of the alveolar bone. That bone which is deformed by stress becomes electrically charged, concave surface takes a negative polarity and convex surface takes positive polarity. As a result of this bio-electric potential difference, bone is added to the concave surface and resorption from the convex surface, in the dento-alveolar system this will result in tooth movement. C. The third theory suggesting that bone apposition could be induced by: a. The load exerted by stretched fibers of the periodontal ligaments (PDL), could end by slight bending of the alveolar bone.
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b. Direct resorption by unloading of the alveolar bone in the case of low forces. c. Indirect resorption as repair due to ischemia following the application of high forces.
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CHAPTER 16: EXTRACTION IN ORTHODONTICS

It is fairly generally accepted in current orthodontic practice that if the jaws are not large enough to accommodate the dentition, there is no satisfactory alternative to extraction. Indications for extraction: 1. For the relief of crowding. 2. For the correction of antero-posterior dental arch relationship. 1. Extraction for the relief of crowding: The size of the dental arch is governed mainly by the basal bone size and the function of the oral musculature. If the dentition is too large to fit in the dental arch without irregularity, it is necessary to reduce the dentition size by extraction of teeth. 2. Extractions for the correction of dental arch relationship: It is frequently necessary to remove teeth to give space for correction of discrepancies in arch relationship, particularly in Class II relationship. Factors govern the decision on which teeth to be extracted: a) The condition of the teeth: Fractured, hypoplastic, grossly carious teeth and teeth with large restorations are the teeth of choice for extraction in orthodontics. Tooth condition must be balanced with other considerations of tooth position in deciding extractions. b) The position of the teeth: The position of the tooth apex must be considered, as i t i s mor e d i ffi c u l t t o m o v e t h e a p e x t h a n t o mo v e t h e crown. Severely malposed teeth and which are difficult to align, are the teeth of choice for extraction. c) The position of crowding: Pleasing final appearance, occlusal balance, the final tooth position and interdental contacts, must be considered before extraction. The first premolars, is tooth of choice for the relief of crowding as well as the correction of the dental arch relationship.
Balancing extraction: The extractions must be balanced to maintain lateral s y m me t r y o f t h e d e n t a l a r c h e s i . e . i t i s n e c e s s a r y i n a f u l l or crowded arch to avoid movement of teeth across the central line.
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Choice of teeth for extraction: 1. Incisor teeth: Should not be extracted unless damaged beyond repair. Extraction of mandibular incisor teeth can lead to disturbance of the entire occlusion e.g. abnormal overbite and cusp-to-cusp occlusion of the buccal series of teeth. 2. Canines: Should not be extracted because of their importance in maintaining facial expression and balance. It may be necessary to extract a canine when impacted or in ectopic eruption. 3. First premolars: are the teeth of choice in cases of dental arch basal arch discrepancies, as well as dental arches malrelationship. 4. Second premolars: They are extracted instead of the first premolars if they are, impacted, severely malposed, unsound and if forward positioning of the molars are indicated in the course of treatment. 5. First permanent molars: they may be extracted when beyond repair. The effects on occlusion of asymmetrical extraction of all four permanent first molars show itself in a high degree of loss of interdental contact and traumatic occlusion with tooth shifting. 6. Second permanent molars: They are extracted if distal movement of the buccal segments is indicated or when growth is insufficient for normal eruption of the 2 nd and/or 3rd molars. Their extraction are contraindicated when; upper 3 rd molars are too high or show delayed eruption, poor angulation of the 3 rd molars, 3rd molars of small size and absence of the 3 rd molars. It is usually advisable to extract the 2nd molars in the maxillary dental arch and the 3rd molars in the mandibular arch. If not unfavorably situated, extremely carious, or showing signs of being ankylosed. 7. Third permanent molars: Impacted 3 rd molars that show evidence of interfering with treatment or retention, or are the cause of reflex pain or infection, should be extracted. NB. Prophylactic extraction of the third molars in orthodontics is a matter of continuous debate up till now. Reasons against early extraction in orthodontic therapy: 1. Growth of the face can change the pattern established by extraction. The patient may show an older appearance of the face. 2. May produce flat faces. 3. Relapse may show itself in spacing at the site of extraction.
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CHAPTER 17: ORTHODONTIC APPLIANCES

Orthodontic appliances fall into three broad categories: 1. Passive appliances: generally used for: a. Space maintenance after extraction (Space maintainers) b. Maintenance of tooth position after active orthodontic tooth movement (Retainers). c. Habit-Breaking appliances e.g. Oral screen. 2. Active appliances: which bring about movement of the teeth, through incorporate active force components within the appliance. 3. Functional appliances: Transmit forces from another source, usually the muscle of mastication (Activator - Andresen) or the circumoral musculature (Frankele - oral screen). The above orthodontic appliances could be: 1. Fixed: The appliance is fixed to the teeth by cementation or direct bonding. 2. Removable: The applianc can be removed by the patient. 3. Fixed-removable: Is a combination of the above two types. Requirements of orthodontic appliances: 1. Comfortable and readily acceptable by the patient. 2. Well tolerated by the oral tissues. 3. Strong enough to stand up the stresses of oral function. 4. Do not constitute a hazard to oral health. 5. Firmly positioned in the mouth, without producing any damage to the teeth or oral soft-tissues. 6. Readily cleanable by the patient. Active orthodontic appliances need certain components to produce tooth movement; such as: 1. Force component: The force which brings about tooth movement can be provided by: 1) Deformation of elastic components; and which will tend to return to its original form can be used to apply force to the teeth. a. Nitinol or stainless steel wire in the form of springs or arches. b. Latex elastic in the form of elastic bands or elastic chain; the elastic force provided will readily bring about tooth
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movement . 2) Progressive change in the form of the appliance; e.g. the use of expansion screw between two parts of an appliance, the force applied is intermittent. 3) The use of muscular forces; the orthodontic appliance is used as static component in a system which transmits muscular forces to the teeth to produce tooth movement (functional appliances). 4) The use of extra-oral forces; for either moving the tooth or for anchoring their movement. These force provide either: a. Force for extra-oral traction; force sufficient to move tooth, blocks of teeth or the whole arch. b. Force for extra-oral anchorage; it is the extra-oral force used to cancel out the reciprocal action of the incorporated force in the intra-oral appliance. 2. Anchorage component: is the resistance used to withstand an applied force. In order to move t eeth, resistance is needed from which the force applied to the teeth to be moved is to originate. In order for a force to make it felt, it must meet resistance. Fixed orthodontic Appliances
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Direct bond orthodontic Edgewise appliance; round-and rectangular arch wire
Clear brackets compared with metal brackets
Gold fixed appliance
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Self-lig gation brack ket
Lingual-inv visible appl liance stainl steel and gold less

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Low-continuous force, Niti closed coil spring used for treatment of Class II and Class III similar to a Herbst appliance
Herbst appliance
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Acid etching before brackets bonding
Applying powerchain ligatures 1. Removable orthodontic appliance These types of appliances are limited to tipping and simple r o t a t o r y m o v e me n t o f t e e t h . T h e y d e p e n d o n c o - o p e r a t i o n and a certain degree of skill on the part of patient. Components: (Figures 7 and 8). 1. Retention: mainly provided by Ada ms clasps (perma nent molars and pre mol ars) and Jackson clasps (deciduous molars). Other aids to retention are; various arch wires and clasps, adhesion and tooth undercut area and muscle pressures. 2. Connecting framework usually made in acrylic resin. If active appliance, it must have; 1. Force component: mainly provided by springs, elastics and screws.
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2. Anchorage component: anchoring the movement of a few teeth with a large number of teeth within the same arch and the contact of the appliance with large area of the plate.
Upper and lower Hawley removable retainers And could be used as removable appliance
Tongue thrust habit breaking removable appliance
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Orthodontic Positioner
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Hussam M. Abdel-Kader for Undergraduate: 2009
Orthodontics
Adams clasp
(0.7 mm)
Low short labial arch (0.7 mm)
High labial arch (1.0mm and auxiliary springs 0.5mm) Figure 7
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Hussam M. Abdel-Kader Undergraduate: 2009
Orthodontics for
Palatal spring (0.5mm)
Z spring (0.5m m)
Finger spring (0.5mm)
Canine retractor (0.7mm)
Premolar retractor (0.7mm) Figure 8
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Advantages of removable appliances: 1. The appliance is removable by the patient and can therefore maintain his good oral hygiene during therapy. 2. It is difficult to apply severely excessive force to the teeth. 3. It is constructed in the laboratory, so chair time is short. 4. Not expensive. Disadvantages of removable appliances: 1. Can bring about only a limited type of tooth movement. 2. Anchorage of tooth movement is sometimes difficult. 3. Retention of the appliance is difficult. 4. Co-operation and a certain amount of skill are necessary from the patient and essential in therapy. 2. Fixed orthodontic appliance Fixed appliances act through attachments fitted directly to the teeth. The attachments may be: 1. Welded to stainless steel bands which are cemented to the teeth or; 2. Direct bonded to the teeth through one of the acid-etch retained bonding systems. The attachments may be bonded to the labial and buccal surfaces of the teeth or to the palatal or lingual surfaces (Lingual or invisible technique). Types of attachment: 1. Tubes, which are usually fitted to the last, banded molars in the arch. They may be round or rectangular in section, to take either round or rectangular arch wire. Large round Large round tube are used in combination with round or rectangular tube (combination tube), to take extraoral arches. 2. Brackets: are usually fitted to all other anchor teeth and teeth to be moved. There are different types of brackets, but the most common is the Edgewise brackets. It has slot rectangular in section, different in angulations according to the techniques used (the most common straight wire technique and Begg technique), made in a variety of diameters and single or double. Brackets are made from stainless steel, some from the plastic or porcelain. The plastic and porcelain brackets could of different colors or clear) 3. Hooks, buttons and cleats can also be added to the teeth for attachment of auxiliary forces.
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Components of fixed appliances: 1. Attachments. 2. Force component; stainless steel springs, arch wires, or elastics (elastic could be clear or of different colors) 3. Anchorage component; can be achieved intermaxillary, intramaxillary or extra-oral. Advantages of fixed appliances: 1. Multiple forces can be applied to the teeth simultaneously, thus facilitating multiple tooth movement, reducing the time required for treatment. 2. Less skill is required from the patient. 3. Tooth movements are more controlled, so that bodily and torquing movements are produced. Fixed appliances are used for the treatment of complex malocclusion. Disadvantages of fixed appliances: 1. The problem of oral health, it is more difficult to maintain a good oral hygiene during treatment. 2. It is possible to produce adverse tooth movement, and damage the supporting structures of the teeth. 3. They should only be applied by skilled and experienced orthodontists. 3. Fixed-removable appliances Fixed-re movable appliances are used for localized tooth movements of a type which could not be achieved with removable appliances alone, but the use of removable component facilitates oral hygiene and makes the construction of the appliance simpler.
Lip bumper
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4. Functional appliances Functional appliances are removable appliances, but the force components originate in the oro-facial and masticatory musculature. They work best in the mixed dentition and during active growth phases. They act by: 1. Using forces of the muscles of mastication. 2. Using forces of the orofacial muscles. 3. Inducing tooth movement and bone growth by relieving adverse muscle forces on the dentition. 4. Inducing changes in the basal part of the jaws, by modifying mandibular or maxillary growth. Functional appliances incorporate two principles: 1. The Andresen appliance, activator or monoblock; it consists of a single block of acrylic into which both upper-and lower dental arches fit. Arch wires are incorporated to apply force to the teeth. It is most frequently used in the correction of Class II malocclusion. It is made so that it fits the upper arch, and the lower arch will only fit into the appliance with the mandible in a predetermined postured position. Thus, when it is worn the muscles of mastication are stretched beyond their position of postural tonus. It has been suggested that this has two effects: a. The muscles of mastication exert a force on the mandible in attempting to return to their resting position, resulting in a force being exerted on the mandibular teeth and an opposite force on the maxillary teeth. b. The postural position of the mandible modifies or induces growth at the mandibular condyles and TMJ fossae, which effectively alters the basal bone relationship. c. It is used only at night, since it would interfere with speaking, eating and respiration during physical exertion. So, it applies intermittent forces to the teeth. 2. The oral screen or vestibular screen: It is a screen of ba se material (acrylics) which is made to fit in the vestibule of the mouth. By differential relief of various areas on the construction models it can be used either to apply the forces of the circumoral musculature to certain teeth, or to relieve those forces from the teeth, thus producing or allowing tooth movement. 3. The Frankel function corrector: It used the principles of the above two appliances. It is made to a postured occlusion to utilize the forces of the masticatory muscles and it carries screen to relieve the forces of the circumoral musculature.
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Activator; functional appliance
Frankel; functional appliance
Fixed Twin Block Functional Orthopedic Technique
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Lip bumper Selected cases with different dental malocclusion before and after orthodontic treatment
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CHAPTER 18: ORTHODONTIC ORTHOPEDIC APPLIANCES FACEMASK AND MIDPALATAL EXPANDER

Orthodontic treatment dealing with dentoalveolar deviation from accepted normal dental occlusion (dental malocclusion) uses different types of orthodontic appliance (orthodontic force) to achieve the orthodontic treatment objectives. On the other hand, orthodontic orthopedic treatment dealing with maxillomandibular basal discrepancies, in the early stage, uses different orthopedic appliances (orthopedic force). Facemask and midpalatal expander appliances are among these appliances. The following is a brief illustration of the two orthopedic appliances. I. Facemask: Facemask is now-a-days commonly used in orthodontics. The good results which could be achieved by the face-mask, as a maxillary protraction devise, encourage broad sectors of orthodontists to use it as a routine treatment modality. The orthopedic effects of the protraction forces induced by the facemask therapy in early treatment of Class III malocclusion cause-effect relationship; is a matter of controversy and continuous debates. The effects of facemask as maxillary protraction device could be due to circumaxillary sutural remodeling concomitant to maxillary forward movement by the facemask. The postero-anterior protraction effects of the facemask induced changes in the circumaxillary sutural system, including sutural opening, stretching of the sutural connective tissues and new bone deposition along the stretched fibers maintains the new sutural width. Various orthopedic therapies, including headgear, facemask, and functional appliances could induce sutural strain, leading to modification of otherwise natural suture growth. On the other hand, facemask (FM) and rapid maxillary expansion (RME) therapy are able to induce a significant enhancement of the maxillary forward growth. The orthopedic approach in early treatment of Class III cases will be more effective during the early mixed dentition stage compared to the late mixed dentition stage. In instance in which no transverse change is necessary, the maxillary splint still is activated, usually once a day for 1 week to 10 days to disrupt the circumaxillary sutural system, before the use of facemask. Circumaxillary sutural system: A. The maxilla is halted to the cranium by six pairs of sutures, six sutures on each side; 1) frontomaxillary suture 2) zygomaticomaxillary suture 3) zygomaticotemporal suture 4) pterygopalatine suture 5) zygoma t i c ofr onta l s ut ur e a nd 6) f r o n t o n a s a l s u t u r e . T h e s e s u t u r e s are all oblique and mere or Jess parallel to each other. Thus, growth ha these areas would serve to move the maxilla downward and forward.
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B. T h e i n c r e a s e o f w i d t h o f t h e m a x i l l a r y c o m p l e x i s b y f i v e s u t u r e s ; 1) median palatine suture 2) ethmoid suture 3) lacrimal suture 4) zygomatic suture and 5) nasal suture. The early closure of the premaxillary suture limits the width of the palate in this area. II. Midpalatal expander: Maxillary transverse constriction is among the most common malformations in orthodontics. Treatment usually requires rapid palatal expansion with banded or bonded expanders after eruption of the maxillary first molars. The history of palatal expansion goes back nearly 150 years and has retained its popularity ever since. However, patient/guardian compliance in activating the screw with a key is required. Because it is difficult to see the hole on the screw, it is hard to insert the key through the hole. Furthermore, the chance of injuring the palatal mucosa with the pointed wire key and the risk of swallowing or aspirating the key are common undesired outcomes, and both occur in daily orthodontic practice. To overcome these unwanted incidences and make palatal expanders more patient-friendly, a new design of palatal expander has to be developed for a safe, rapid, and effective expansion with minimum patient cooperation. A newly developed keyless expander has a built-in activation arm, which patients can activate them. RME therapy induces a significant increase in the transverse dimension of the maxillary arch in growing subjects without causing permanent injury to the periodontal bony support of anchoring teeth. After rapid palatal expansion (RPE) therapy all patients showed a constant and important increase in the values relating to both skeletal and dental structures, a significant reduction in the mean nasal resistance. Background: Posterior crossbite occurs when the top back teeth bite inside the bottom back teeth. When it affects one side of the mouth the lower jaw may have to move to one side to allow the back teeth to meet together. This movement may have long term effects on the growth of the teeth and jaws. It is unclear what causes posterior crossbites and they may develop or improve at any time from when the baby teeth come into the mouth to when the adult teeth come through. Several treatments have been recommended to correct them. Some treatments widen the upper teeth whilst others are directed at treating the cause of the posterior crossbite e.g. breathing problems or sucking habits. Most treatments have been used at each stage of dental development. A palatal expander, also known as a rapid palatal expander, rapid maxillary expansion appliance, palate expander or orthodontic expander is used to widen the upper jaw so that the bottom and upper teeth will fit together better. It is thought this can only be done when
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the patient is still growing, unless surgery is used to separate the two halves of the palate, however there is evidence to the contrary. It is most often followed by braces to straighten out all the teeth now that room has been created. Patients who have expanders may experience extra saliva and lisps (Pronouncing the letter S as a T sound). Additionally, patients may also feel a sore on their tongue from contact with the expander's metal bars. Although it may vary from person to person, most usually feel slight pressure on their teeth. As the patient turns the expansion screw using the key, a space develops between the front two teeth. Some may notice a larger space while others do not notice a space at all. It usually takes several days to adjust to eating and speaking after first receiving the rapid palatal expander. Patients may experience hematoma, pain and headaches while wearing palatal expanders.
Palatal expander to expand the palate laterally
Palatal expansion screw with removable orthodontic appliance

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Quad Helix palatal expansion appliance
Extraoral appliance; face-mask
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Attached facebow of a Headgear
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CHAPTER 19: ANCHORAGE IN ORTHODONTICS

Anchorage in orthodontics is the resistance used to withstand an applied force. While the teeth are the most frequent units used for anchorage, other structures are available; e.g.: the palate, the lingual alveolar supporting bone in the mandible, the occipital area and the back of the neck. Source of anchorage: 1. The bone in which the teeth are situated. 2. Root area of the tooth. 3. Muscular pressure. 4. The teeth offer more resistance if the movement is opposite to the direction of natural active growth of the teeth. 5. The manner of interlocking of the cusps. 6. Stabilizing plates which engage the oral mucosa and the interdental spaces (Nance appliance, transpalatal arch etc...). 7. The skull in occipital and cervical anchorage. 8. Mini-implants Types of anchorage: I- Intraoral anchorage: A. Intramaxillary: 1) Simple; a. single, b. compound. 2) Stationary; a, single, b. compound. 3) Reciprocal; a. simple single, b. simple compound. c. stationary single, d. stationary compound. B. Intermaxillary: I) Simple: a. single (primary), b. compound (reinforced). 2) Stationary; compound. 3) Reciprocal; a. simple single, b. simple compound, c. stationary compound. II- Extraoral anchorage: 1. Occipital (headgear) 2. Cervical (strap) I. Intraoral Anchorage A. Intramaxillary anchorage: Anchorage is obtained from the teeth in one jaw to move other teeth in the same jaw. 1. Simple: a. Single: A tooth with greater support in the alveolar process is used to move another tooth with lesser support. The anchor tooth will be tipped if it cannot overcome t h e r e s i st i n g fo r c e o f t he t o o t h t o b e mo v e d . A mul t i -rooted
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tooth, root with a large surface area, a longer root and a triangularly-shaped root, the tooth will offer greater resistance to movement. b. Compound: A number of teeth of greater support are used to move teeth of lesser support. 2) Stationary: True stationary anchorage is impossible to achieve in living organism. The anchor teeth have to move bodily when used as stationary anchorage. a. Single: There is no tipping movement of the anchor tooth, but if it moves it must move bodily. b. Compound: More than one anchor tooth in a dental arch is used to move a tooth or teeth with less resistance in the same jaw. If the anchor teeth move they must move bodily. 3) Reciprocal: There is reciprocal force exerted between the tooth and teeth to be moved. a. Simple single: One tooth to be moved is used as anchorage to move another tooth in the same jaw. b. Simple compound: More than one tooth is opposed to more than one malposed tooth in the same jaw. c. Stationary single: One tooth is used to bodily move another tooth in the same dental arch. The anchor tooth also may be moved bodily. d. Stationary compound: Reciprocal anchorage where more than one tooth is used to move more than one tooth bodily in the same jaw. The anchor teeth may move bodily. B. Intermaxillary anchorage: Anchorage which uses teeth in the opposing jaw. 1) Simple: a. Single: a tooth in one dental arch is used as resistance to force required moving a tooth in the opposing dental arch (Movement is by tipping). b. Compound: More than one tooth is used as resistance to move more than one tooth in the opposing dental arch. 2) Stationary: Compound: All the teeth in one jaw are used to move a tooth or teeth of lesser resistance in the opposing jaw. 3) Reciprocal: a. Simple single: Where a tooth in one dental arch is moved by opposing it to a tooth, also to be moved, in the opposite arch. b. Simple compound: Where more than one tooth to be moved in one jaw are opposed to more than one tooth to be moved in the opposing jaw. c. Stationary compound: It is used to move both dental arches in opposite directions by intermaxillary force.
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II. Extraoral Anchorage Extraoral anchorage can be used to exert force in combination with practically any type of orthodontic appliance. 1. Occipital anchorage: depends on the resistance offered by the posterior portion of the skull (occipital area). 2. Cervical anchorage: depends on the resistance offered by the neck (cervical area). Extraoral anchorage eliminates the forward and vertical displacement of mandibular molars and other teeth, when intra-oral anchorage is used. Reinforcing anchorage: 1. The use of stabilizing plates. 2. The use of lingual arches. 3. Combined labiolingual arches. 4. Edgewise arches with second order bends. 5. Ribbon or flat arches. 6. The use of extraoral anchorage. 7. Reduction in the number of teeth to be moved at one time. 8. Mini implants.
Minis-crews used as anchor unit
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Nance and transpalatal arch to reinforce anchorage
Headgear to reinforce anchorage
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CHAPTER 20: MYOFUNCTIONAL THERAPY

Rogers related the normal development of the face, jaws and dentition to the normal functional balance of the facial muscles. He proposed certain exercises to establish proper tonicity and function of facial muscles. 1. Pterygoid muscle exercises: are indicated in the treatment of distocclusion, as the weakness of this muscle can be responsible for this type of malocclusion. The exercises consist of: a. bringing the mandible forward so that the mandibular incisor teeth are held anterior to the maxillary incisors, provided that the maxillary incisors are in normal position. b. then the patient is instructed to relax the muscles, and allow the mandible to recede to the point where the dental arches are in their relatively correct mesiodistal relationship. 2. Masseter-temporal muscles exercises: they assist in the correction of infraocclusion and in correction of distocclusion. This exercise should not be performed if the patient is unable to place the mandible in its correct position. The exercise consists of the contraction and relaxation of the masseter group of muscles with the mandible in normal position. The patient places the tip of the forefinger over the muscle near the angles of the mandible to feel the contracting and relaxing movement. 3. Tongue exercise: is an adjunct to the masseter-temporal exercise. The patient is instructed to place the tip of the tongue against the mucous membrane directly behind the mandibular incisors, and with each contraction of the masseter-temporal group of muscles to press the tongue against the anterior section; at the same time, by widening the tongue to force it against the lateral sides of the alveolar process. This exercise trains the tongue to remain in its proper position and has tendency to prevent the narrowing of the mandibular arch, facilitating the earlier removal of retentive appliances. 4. Mentalis muscle exercise: includes the development of the orbicularis oris and the associated muscles. The exercises should be started as soon as the protrusion has been reduced to the extent that it is possible for the patient to close the lips without stretching them. Three exercises are recommended: A. The exercise to develop the upper lip: 1) Grasp the chin firmly between the thumb and index finger with the lips relaxed. 2) Hold the lower l i p down.
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3) Close the lips. 4) Relax and repeat from 10 to 50 times at a specified time, as before meals. B. The exercise for the enunciation of the letter "p": 1) The sound should be made forcibly. 2) It should be made before a mirror. 3) The patient should be instructed how to make the sound. 4) Whether the mentalis shows excessive muscular activity at the beginning of the sound must be noted. 5) Two exercise periods of 5 or 10 minutes each must be observed daily. C. Whistling: is an exceptionally fine exercise for the orbicularis oris, mentalis and the associated muscle. The muscular activity is much more vigorous and powerful than that used in making the sound "P". The higher the note, the greater the muscular activity. 5. Orbicularis oris and facial muscle exercise: A. Orbicularis oris exercise is best performed with the aid of an exerciser designs so that it is difficult to keep it within the oral orifice unless the orbicularis oris muscle is contracted properly. The exerciser is made of two curved bars of acrylic or stainless steel, and united near their centers by a joint to which handle at right angle is attached. There are notches at one end of the bars, to which elastic bands are attached so that there is a resistance to approximate the free ends of the bars. The free ends are shaped to engage the angle of the mo u t h . T h i s e x e r c i s e i s c on t i n u e d wi t h on e e l a s t i c ba n d during the first week or two, and contractions are increased daily until they reach 50 to 60 a day. B. General Tonic exercise: influence not only the orbicularis oris, but also the muscles which work with the orbicularis oris. It consists in taking a generous mouthful of a warm saline solution, at a temperature which is bearable to the mucous membrane of the mouth, and with the teeth held firmly in occlusion the solution is forced through the interproximal spaces into the buccal cavity and then back into the lingual space. The exercise is usually performed morning and night. The patient is directed to continue each exercise until the muscles are slightly fatigued. From an orthodontic view, it is highly beneficial not only as a tonic, but for mouth hygiene.
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CHAPTER 21: ADULT ORTHODONTICS

Adults make up approximately 20% of average orthodontic patients load. Conventional wisdom maintains that adult orthodontic treatment when compared with traditional adolescent orthodontic treatment is more difficult, take a longer time to complete, less effective and the long term stability of treatment outcome is very questionable. Tissue changes in orthodontics could clarify this hypothesis. The histological difference in the periodontal structures of adults and adolescent have been studied and compared both before and after tooth movement. 1. In adolescent, the supporting investing tissues of the teeth appear to be in a state of proliferation: there are large number of connective tissue cells and an extensive blood supply even before orthodontic treatment. 2. Adults, on the other hand, appear to be a state of rest, the alveolar bone is denser, cell populations are reduced, and there is less vascularity. After the initiation of tooth movement, it takes about 2 weeks for adults to reach the same state of proliferation as the adolescent and furthermore it takes about 4 days longer to see evidence of bone apposition in the adult as compared with the adolescent. 3. In comparing the effectiveness and duration of tooth movement between these two groups, this short delay may not be of clinical significance over duration of treatment. 4. In adolescent differential mandibular growth changes contribute to 70% of total molar correction in Class II division one malocclusion, as example, and orthodontic tooth movement accounted for the remaining 30%. On the contrary, in adults, however, tooth movement alone accounted for the total molar correction. In adult orthodontics we are using the same principals and concept commonly used for adolescent. The only differences could be that; a) We must give special attention to have healthy investing tissues (periodontium). b) Type of fixed appliances; most adult patients preferred the lingual technique. c) Duration of orthodontic treatment is usually a common problem. d) Lastly how to approach them, they are dependant and decision maker and in need to have special approach which could be completely differs from that of the adolescent. We must understand clearly their motives and what they could expect from orthodontic treatment.
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e) Unrealistic adult orthodontic patients will never ever be satisfied with the orthodontic treatment outcome; Carful probing of that type of patients is of prime importance in our specialty.
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CHAPTER 22: OCCLUSAL EQULIBRATION IN ORTHODONTICS

Orthodontics is divided into three phases: 1. Active treatment phase, in which we used different orthodontic appliances to achieve accepted normal occlusion. 2. Retention phase, in which we used different types of retainer to achieve long-term stable treatment outcome. 3. Occlusal equilibration phase, to achieve occlusion without traumatic cusp interference. This will be reflected on the long-term stability of orthodontic treatment outcome and healthy periodontium. The first two phases are discussed in details in the above mentioned chapters. Occlusal equilibration, the third phase, is a very important phase in orthodontics if we are looking for long term stability of our orthodontic treatment outcome. After active orthodontic treatment whatever it is extraction or non-extraction orthodontics, most probably we will have areas of premature contacts which form areas of traumatic occlusion. These areas of traumatic occlusion have adverse effect on the periodontium, as well as, the stability of orthodontic treatment outcome. Relieving them is a very essential. Procedure of occlusal equilibration: 1. Study model mounted on adjustable articulator in centric occlusion. 2. Occlude the upper model on the lower one in centric occlusion on horse-show articulating paper. 3. The points/areas of premature contact will be clear as red and blue marks on the occlusal table of the teeth. 4. Spot grind the marked area carefully. 5. Repeat steps from 2 to 4 until you have homogenous distribution of the colored marks allover the occlusal table. 6. Repeat steps from 2 to 5 but in protrusive and lateral movement. 7. In each step record the points, cusp surface and the amount to be removed until we achieved occlusion without cusp interference. 8. Apply the above mentioned technique on the patients
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putting in consideration the record taken from the study models as mentioned above. To test the accuracy of occlusal equilibration done we can use either the manual photo-occlusion analyzer or the computerized photo-occlusion analyzer until we achieved occlusion without traumatic cusp interference.
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CHAPTER 23: ORTHODONTIC PATIENTS AT HIGH OR MODERATE RISK OF INFECTIVE ENDOCARDITIS

Orthodontic patients who are at high or moderate risk of infective endocarditis are in need of special approach and prophylactic antibiotics in certain procedures. The following table summarizes these procedures and the need of prophylactic antibiotics. Procedure Taken impressions Taken radiographs Teeth separation Cleaning and polishing of teeth before banding or bonding Placement and adjustment of removable appliances Placement and cementation of bands Bonding of brackets Placement of arch wires with elastics or ligature wires Exposure of teeth Application of traction to exposed teeth either with replaced or excised flaps Need of antibiotic prophylaxis No No Yeas Yes No Yes No No Yes No
Mucosal trauma during arch wire yes placement
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CHAPTER 24: COMUNICATION SKILL AND CONSENT FORM IN ORTHODONTICS A. Communication skill in orthodontics
The clinicians professional communication skill through the process of orthodontic treatment negotiation, simplicity in explaining the case and the proposed orthodontic treatment plan in the simplest direct words a way from the hard technical terms, respecting the other side point of view, as well as, their dignity form the main corm of successful treatment. The computer imaging program is good, as long as, it is used within its limitation as an orthodontic treatment aid in addition to the other diagnostic aids. It could make the communication easier, but it must be clear from the very beginning that our treatment outcome will be within the range of the illustrated computer image and not exactly the same. On the other hand, the patients side should have almost the total responsibility to determine and accept or refute what orthodontic treatment will be performed in view of very clear vision from the orthodontist side. B. Signed consent form in orthodontics Is a signed consent form, form an essential document before commencing orthodontic treatment? And what points it should cover? The answer is yes. From the medicolegal prospective the following points are fare enough to satisfy the requirements of the medicolegal prospective: 1. The consent must be written in sample clear direct words in such a way that the proposed treatment and the associated risk if any must be clearly understood by the patients side whatever their socio-educational level are. 2. The orthodontist must be dead sure that all raised points are clearly understood by the patients side without any bias. 3. Extraction of any tooth/teeth, if any, is vital point to be considered in the consent form. It must be very clear which tooth/teeth will be extracted in the proposed orthodontic treatment plan, and to clarify that the extraction space(s) will be completely used in favor of approaching the assigned treatment outcome. 4. To clarify that orthodontic treatment will have two phases; active phase and retentive phase and to stress on the importance of retention as an essential and vital part of the treatment protocol. 5. To clarify to the patients side any camouflaging treatment which could be undertaken as the last choice and any long-term risk of that treatment protocol if any. 6. Respecting the appointment schedule and if their will be any banality for the broken appointments and/or the orthodontic appliance. 7. Broken appointments, broken appliance(s) or ignorance of the oral
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hygiene measures to the extent that it could adversely affects the progress of the proposed orthodontic treatment, the clinician will have the right to terminate treatment after written notice to the patients side, and how to estimate the finical coast at that stage. 8. Treatment total cost must be included and the amount and time of each installment. 9. To clarify for the patients side that, the diagnostic records especially facial photographs are to be used only for the benefit of the patient, and if they will be used in a published work, presented in scientific conference or marketing, prior written permission from the patients side should be taken. 10. The patients side has the right to terminate orthodontic treatment on their own responsibility at any time without any responsibility on the clinicians side and how to estimate the finical coast at that stage. 11. The policy of patients transfer to another clinicians on the patients side request, without any responsibility on the clinicians side, the necessary documents given and how to estimate the finical coast at that stage. 12. A representative of the patients side should be present at the scheduled visits.
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CHAPTER 25: MATERIALS USED IN ORTHODONTICS

The principles of orthodontic tooth movement are based on dispensing forces to the teeth or modifying the biological forces influencing jaw development. Most of these interventions are made through the medium of appliances. The technical skill and knowledge necessary for the construction of these appliances demand a familiarity with the specific materials, instrumentation and procedures. Besides the bands and auxiliaries, the materials most currently used in orthodontics are wires, coil springs, elastics, acrylics and orthodontic adhesives. I. Wires: Depending primarily on their composition and the manner in which they have been produced, wires will have different degrees of these properties: Strength: the highest force necessary for its fracture. Elastic limit: the maximum stress that can be applied before the wire is permanently deformed. Modulus of elasticity: the ratio between the stress and deformation. Resiliency: its potential to return to its original shape after force application. The most current materials used have been; Gold alloys (historical; Angle), Stainless steel, Chrome-cobalt and nickel titanium (nitinol). 1. Gold: Pure gold is too soft for orthodontic purposes, adding platinum and some copper are therefore used. The copper addition permits modification of strength and ductility by heat treatment. In the last few decades the better quality of stainless steel and chrome-cobalt alloys has replaced the use of gold in orthodontics. 2. Stainless steel: Steel used in orthodontics is the austenitic type (the 18-8 type). It contains 18% chromium and 8% nickel added to the steel. The 18-8 stainless steel wire has a higher maximum deflection load than gold wire; the ratio of their modules of elasticity is 1.8:1. The properties of stainless steel wire of value in orthodontics are its tensile strength, high modulus of e l a s ti c it y a n d re s i s ta nc e t o c o r r o s i o n b y t h e f l u i d s i n t h e mouth. Soldering stainless steel: It depends on mechanical adaptation, since there is no alloy union or fusion between the parts soldered. Solder for stainless steel is an alloy of silver, copper and zinc, and the Flux used for soldering contains potassium fluoride, boric acid and hydrochloric acid. A fine needle flame should be used (about one cm.), and sufficient heat should be used to melt the
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solder only in one heating, and the soldered joint should immediately be quenched in water. Spot-welding stainless steel: It is produced by holding the pieces to be welded together under pressure between hard copper electrodes and passing high amperage current through them for a specified length of ti me. The electrical resistance of stainless steel is high so that the temperature generated at the contact causes fusion and the pressure of the copper electrodes completes the weld. The requisites for spot-welding are: 1) Pressure, 2. Current and 3.Time. The apparatus used for spot welding is the spot-welder. Stainless steel is used in different forms: 1) Spring hard wires of different diameters and of varying forms e.g. round, rectangular, square etc., for different forms of arches. 2) Soft round wires for ligatures or separation of teeth. 3) Hard stainless steel, for different forms of attachments. 4) Tape for the construction of bands. 3. Chrome-cobalt alloy (Elgiloy): The chrome-cobalt alloy has been developed recently and contains approximately 40X cobalt, 20% chromium, 1536 nickel, 7% molybdenum, 2% manganese, 0.15% carbon and about 1536 iron. Many of i t s properties are similar to those of 18-8 stainless steel. It differs, however, in that heat treatment produces a greater change in resiliency and that it has a greater resistance to corrosion and fatigue. 4. Nickel titanium (Nitinol) Orthodontic arch wires are supplied in different forms (strands, preformed arches etc), different cross section (round, square, rectangular etc), single or multistrand (orthoflex) and different diameters. 5. Fibred-reinforced polymer composites: This material is used recently for the fabrication of orthodontic arch wire. Such an arch wire could be made with a tooth-colored appearance and with stiffness properties similar to metallic arch wires. N.B. The above mentioned arch wires could be Teflon coated to be with the tooth color or with different colored. The brackets and legations elastic modules and different elastics used in orthodontics could be of different color as well, to satisfy the patients need. The different arch wires are to be fixed to the brackets by ligature wires or elastics. Recently self-legated brackets were introduced into orthodontics.
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II. Coal springs: Coil springs are either made of 18-8 stainless steel, chrome cobalt alloy or nitinol. The diameters of the wire are from 0.006 to 0.009 inch; and the diameters of the lumen of the coil are from 0.020 to 0.036 inch. They are of two types; open coil spring or closed coil spring. III. Elastics: They are made of Latex, which is composed of minute particles of coutchouc in suspension. It has been shown that rubber bands stretched in mouth fluids exhibit 20% decrease in effectiveness. The force dispensed depends on the cross section of the elastic and the lumen of the band. After the first day there will be sharp drop in the force magnitude average a 50% drop. The drop must be considered in clinical use. Elastics are supplied in different form (bands, modules, elastic chains etc), different colors and different force magnitude. IV. Acrylic: Acrylics are used for the construction of removable appliances, either retainers or active appliances. The particular acrylic resin used most often in orthodontics is a polymeth-acrylate, an ester of methacrylic acid. The liquid monomer methacrylate is mixed with the polymer ( i n powder form). These acrylics have been well tolerated in the oral cavity. There are extremely rare cases of allergic reactions to methyl methacrylate, when more than 5% monomers were left free. One disadvantage of this acrylic is that it retains water by absorption. V. Composites and acid etching gel or liquid (Orthodontics adhesives): Different orthodontic adhesives chemically cured (mix-o mix adhesives) and light cured are used to direct bond the brackets to acid etched enamel surface of the teeth (Orthophosphoric acid 39% applied for 15-30 seconds. VI. Glassionomer cement: Used for cementing orthodontic bands, and there is new generation could be used for brackets direct bond. VII. Orthodontic cement: Orthophosphoric acid cement used for cementing orthodontic bands. N.B: Fluorides could be added to orthodontic materials (elastics, cements etc) for carious prevention.
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CHAPTER 26: RETENTION AND RELAPCE IN ORTHODONTICS

I. Retention: R e t e n t i o n i s t h e att e mpt t o r e t ai n t h e t e et h a nd t h e dental arches in the position obtained for them by active orthodontic treatment. Retention of the orthodontically moved teeth should be used until); all of the tissues involved in their support and maintenance in their new positions shall have become thoroughly modified, both in structure and function to meet new requirements. Retention is a continuation of treatment. Factors in retention: The following factors are essential either before or during retention; 1. Normal occlusion a) Proper relationship of the inclined planes of the teeth, and proper intercuspation. b) Proper dental arch form and relationship and correct overbite. c) Normal interproximal contact of the teeth within the dental arch. 2. Removal of causative factors. 3. Proper muscle tone and pressure. 4. Postoperative observation until the active growth period is past. 5. Good general health and normal health of the oral tissues. 6. Use of simple retainers. Period of retention: All major corrections should be retained at least six months on 24 hours wearing of retainer followed by 6 months night wear only, followed by wearing 3 nights a week with a gradual tailing off if the case appears stable. Rotated tooth need early treatment or overtreatment and a longer retention period. Factors influencing the type and length of retention: 1. The age of the patient. 2. Type of orthodontic correction and the rapidity with which it performed. 3. The degree and number of tooth, rotations required and the depth of the cusps. 4. The health of the investing tissues. 5. The distance that the teeth are moved. Conditions that require no retention: 1. Anterior crossbite, if there is sufficient overbite. 2. Posterior crossbite, after proper intercuspation has been established and where there is no abnormal tipping of teeth to correct the crossbite.
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Methods of retention: 1. Functional: Rogers and others have stressed the value of exercises to maintain tooth position, particularly lips exercises. An oral screen or a monoblock (Andresen appliance) may be used as functional retainers. 2. Natural: This is used to describe the situation in which the tooth occlusion prevents relapse, as after the labial movement in case of anterior crossbite. 3. Appliances: a. Removable retainers: they have the advantage of permitting the teeth normal function while they are being retained. This allows the periodontal ligament and investing tissues to recover, e.g. Hawley retainer. b. Fixed retainers: As bonded lingual arch wire from canine to canine. II. Relapse: It is the tooth movement or free movement of the teeth, toward their original position following cessation of orthodontic force (after active orthodontic treatment). In other words: the tendency of the teeth to undergo change of position immediately upon the removal of the orthodontic appliances. Causes of relapse: 1. Occlusal interferences (premature contacts and traumatic occlusion). 2. Placement of the teeth outside the area of functional tolerance. 3. Abnormal axial position of the teeth to their respective arch. 4. Persistence of abnormal pressure habits. 5. Inherent growth. 6. The relative large tongue size in relation to the oral cavity. 7. Failure to place the incisor teeth over the basal arch. 8. Overexpansion of the dental arch. 9. Improper retention after orthodontic treatment.
Removable Hawley retainer

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Fixed lingual retainer; canine to canine direct bonded retention
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CHAPTER 27: BIOMECHANICS IN ORTHODONTICS

Biomechanics does not means; orthodontic technique, clinical procedure as different wire bending nor the type of orthodontic appliance(s) we are used. But it means how to relate the application of forces, force systems and stresses to alter tooth positions or to produce certain bony changes to solve our orthodontic problem(s). As stated by Burstone; It answers such questions as: 1. What is the relationship between the appliance and the force system? 2. What is the optimal force system to produce different centers of rotation? 3. What is an optimal force? 4. What is the relationship between stress and strain? 5. What are the biological changes in the periodontal ligament and in the bone? 6. What are the proper materials for optimal appliance design? In brief; scientific biomechanics is that it is not dependent on any given appliance or technique. During orthodontic treatment, the clinicians would like to have controlled specific tooth movement(s) to satisfy the treatment objectives. This could be achieved by having a proper moment and force exerted through the brackets by different specific arch wire materials and design. As an example during anterior teeth retraction to reduce overjet, we are in need of lingual root torque to prevent the roots of being displaced labially, this the proper force system in this regards. The point is not the orthodontic system, if it is straight wire or not, but the required force system to achieve our goal. The design of an orthodontic appliance must be based on the required force system to achieve specific controlled tooth movement(s); tipping mechanics, torque mechanics, bodily mechanics, rotation mechanics, sliding mechanics or non-sliding mechanics, friction or non-friction mechanics, retraction mechanics, protraction mechanics etc. If we dont follow-up the scientific way in force system design; proper bracket design-and position on the proposed malposed teeth and the arch wire, we can develop secondary dental malocclusion which could be much more problematic the primary one. Force system must be based on sound basis of physics and biomechanics. The periodontium of the teeth experience and transmit mechanical stresses generated during mastication to the supporting bone. This concept could be applied during orthodontic treatment of dental malocclusion. The teeth periodontium transmit the mechanical stresses generated by orthodontic force to the supporting bone resulting into the required tooth/teeth movement(s). On the other hand, cranial and facial sutures experience and transmit mechanical stresses generated by different orthopedic appliances.
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Biomechanics of craniofacial sutures and orthopedic implications: Jeremy et al stated that: A. The patterns of sutural mechanical stresses in mastication can be summarized as follows: Cranial and facial sutures experience and transmit mechanical stresses generated during mastication. Sutural mechanical stresses during mastication are complex because of momentary changes in force direction, muscle function, complex sutural forms, and the irregular shape of craniofacial bones. Strain patterns vary between sutures. Adjacent sutures can experience tensile or compressive stresses. Although our understanding of suture mechanics has gained solid ground, much additional work is needed to study unexplored sutures, and in many species. B. Patterns of orthopedically induced sutural mechanical strain are summarized as follows: Orthopedic loading on the dentition produces mechanical stresses experienced in facial and cranial sutures. Upon simplified loading such as headgear, different sutures experience characteristic tensile or compressive strains. Engineering waveforms of exogenous forces, such as static and sine wave at various frequencies are expressed as corresponding strain waveforms and strain rates in sutures, providing the basis for applying novel mechanical stimuli to engineer sutural growth. Sutures absorb large mechanical stresses upon exogenous loading, with bony edges displaced either in tension or compression, suggesting that sutural cells and extracellular matrix molecules experience these mechanical perturbations. Mechanical stresses are not transmitted in the skull as a continuing gradient, for different sutures are capable of redefining a propagating mechanical force into predominantly tensile or compressive strain.
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C. Thus, the common threads of craniofacial orthopedic devices can be summarized as follows: 1. All craniofacial orthopedic devices generate forces that are likely transmitted as bone strain and sutural strain. Sutural growth likely is a function of certain optimal parameters of mechanical stimuli that remain to be determined instead of a particular type of orthopedic appliance. 2. New concepts in suture mechanics and suture mechanobiology likely will facilitate innovative design of new devices, improvement of current orthopedic appliances, and new concepts in clinical craniofacial orthopedics including orthodontics.
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D. In conclusion: 1. Experimental evidence unequivocally indicates that sutures experience, absorb, and transmit mechanical stresses generated from either functional activities such as mastication or exogenous forces such as orthopedic loading. Certainly true in mechanics and may be also true in connective tissue biology, to connect means to withstand forces. 2. Mechanical stresses experienced in sutures, given the right characteristics, are capable of modulating sutural growth. 3. Because mechanical stresses transmit through bone, their effects are experienced in a hierarchical manner sequentially as tissue-level bone strain, interstitial fluid flow that in turn induces cell-level strain on bone cells. 4. Subsequent anabolic or catabolic responses; what optimal stimuli induce anabolic and catabolic sutural responses, both of which contribute directly to separate craniofacial orthopedic goals, are presently unknown. 5. Current clinical orthopedic devices exert static forces on craniofacial sutures for sustained periods of time. Recent experimental evidence indicates that repeated application of cyclic forces for as short as 10 minutes per day for 12 days was sufficient to induce significantly more sutural growth than static forces of matching peak magnitude and duration. 6. From the experimental bone strain data, it is clear that at least some of the current orthopedic devices such as headgear exert sutural bone strain, whereas other devices are untested. It is probable though that any mechanical force capable of modulating craniofacial growth exerts its therapeutic effects by generating mechanical strain in craniofacial sutures.
MECHANICS IN ORTHODONTICS
Cantilever mechanics: A cantilever is, in principle, any piece of wire, whose end is inserted, on one side, into a bracket or a tube, or included in the acrylic of a removable appliance, while the other one is tied to another unit, with only a one-point contact. When using the cantilever, the orthodontist can easily estimate the force system on both units, just measuring the length of the appliance and its force by means of a dynamometer -in the direction of its activation- and thereby predict the clinical result Example of cantilever application in orthodontics:
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This figure shows that a cantilever is used to obtain the buccal displacement of tooth 1.4 which is in cross bite The cantilever may have many different configurations and uses in orthodontic therapy. The cantilevers may be utilized in all the planes of space. They can be applied both buccally and lingually. Instead of a complete list, some examples are shown: 1. Control of the labio-lingual position of the incisors and canines and the bucco-lingual position of the molars and premolars. 2. Control of rotation of teeth with buccal cantilevers or palatal and lingual arches, used in a statically determinate way 3. Vertical control, through extrusion or intrusion of lateral and anterior teeth. 4. Generation of a third order control (torque) to the anterior as well of the buccal segment. 5. Generation of molar or canine uprighting. Within the individual segments, a large number of different applications are possible too. Cantilever Force System: Considering the biomechanical force system generated by a cantilever, it is important to remember that a combination of a moment and a force is produced at the unit into which the cantilever is inserted, whereas only a single force is developed with respect to the point of force application of the other end. The magnitude of the two forces is equal and opposite, according to the third law of Newton, and the activation can be measured by a dynamometer. The value of the moment is equal to the length of the cantilever multiplied by the force: M = F x d An important characteristic of the force systems generated by the cantilever is their high degree of constancy over time and deactivation. In other words, the forces at its two ends maintain their direction and decrease in a linear manner, proportionally to the cantilever deactivation. In
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addition, there is also a high degree of constancy of the MOMENT/FORCE ratio (with respect to the bracket). This means also a homogeneous dental movement. The force system being always directed towards the treatment goal, this is rapidly achievable, with a minimum of round tripping and iatrogenic damage. Cantilever Length and Load Deflection Ratio: On the basis of the previous statements, it is evident that cantilevers should be as long as possible, if their aim is to produce only a moment, while the force is less desirable. If, for example, a cantilever is used for the uprighting of a molar, which should not be extruded, the cantilever should be as long as possible or counteracted by a second cantilever. The same applies to those cantilevers used for rotation, e.g. a cantilever which should not displace, but only rotate the canine. If, on the contrary, the effect of the force is desirable and the moment less wanted, the cantilever should be kept short and its cross section dimension reduced, in order to keep the load/deflection rate low. The load/deflection ratio delivered by a cantilever, should -as for all the active elements of the appliance- be as low as possible, leaving the force system with a high degree of constancy. This is another reason for generally keeping the cantilevers long. In those cases where the cantilevers, for different reasons are short, the load/deflection rate can be lowered by the addition of one or more loops, or by using a smaller wire dimension. The latter does, however, also cause a problem, as the play between wire and bracket (tube) may become unacceptable. In this case, a composite cantilever could be advisable. A third and better solution is to choose a wire alloy with a lower stiffness. For this reason and for its high formability, cantilevers are usually made out of beta titanium. Point of Application of the Force:
This figure shows the Cantilever attached to a power arm. The power arm is applied on the lateral incisor bracket, whereby the force, delivered by the cantilever, generates an M/F ratio at the bracket equal to the length of the power arm (if this is perpendicular to the line of action of the force) A factor of extreme importance -when inserting a cantilever and determining its length- is the point of force application where the single
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point contact is made. The type of dental displacement which is produced should be predicted on the basis of the force system, expressed as M/F ratio with respect to the Center of Resistance (CR), and not to the bracket. A single force, perpendicularly applied to the long axis of the tooth at the bracket, produces both a moment and a force with respect to the CR. If the moment has to be reduced, this can be obtained by displacing the point of force application closer to the CR, e.g. by means of a power arm. Wire Selection: Wire selection, when making a cantilever, is principally determined by the length of the cantilever itself. Factors of importance are the load/deflection rate and the maximum elastic moment or yield moment. If a cantilever has to be short (e.g. 10 mm), it is important to use a wire with a low stiffness, i.e. high elasticity as beta titanium 0.018" round. This wire does, however, rotate in the bracket and can thus only be applied when welded to a stiffer, 0.017"x0.025" piece of wire. The yield moment (My) of this wire is 1450gm-mm, thus deforming permanently with 145gm of activation. If the cantilever had a double length (20 mm), its maximum activation would be 72.5gm. In the case of a longer cantilever -e.g. 20 mmit is advisable to use a wire with a more elevated My, as for example beta titanium 0.017"x0.025".A cantilever constructed with this wire can be loaded until 157gm, without a permanent deformation. Another possibility is to use stainless steel, which has an even higher My, but also a stiffness which is 2.5 times that of beta titanium. This means a very and often unacceptable high load/deflection rate. This latter can be reduced, by adding loops to the stainless steel appliance. The use of stainless steel as cantilevers is thus recommended, only in the case they are longer than 20 mm, if the desired force level is above 70-80gm. Composite Cantilevers:
This figure shows two Composite Cantilevers; two cantilevers made out of beta titanium 0.018" are welded to a beta titanium transpalatal arch Composite cantilevers are made out of two different wires which are joined together by a spot welding. These cantilevers can be very useful since they offer the advantage of having different rigidities in different
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parts. Since beta titanium has the best joining properties most of the time composite cantilevers include stiffer part beta titanium 0.017" x 0.025" and a more elastic part made out of beta titanium with round 0.018" section. Composite cantilevers can be also created joining 0.018" wires to a beta titanium lingual arch or trans palatal arch. Configuration: Another aspect to be considered is the possibility to influence the force line of action, by altering the cantilever configuration. The modification of the cantilever configuration will change the direction of the line of action of the resultant force. Depending on the desired force direction it is possible to add helices, or develop cantilevers with utility shape. As a general rule the line of action of the force will be perpendicular to the structural axis of the wire when activated. Using different configurations a certain variation is, as seen above, possible. In the case of the curvature the activated wire will approximate the straight wire and therefore have a tendency to "curl" up shorten during deactivation. A tip-back bend will make a curvature during activation and straighten during deactivation. Cantilever Configuration
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CHAPTER 28: ADJUNCTIVE ORTHODONTIC TREATMENT

An increasing number of adult patients are becoming more aware of their orthodontic needs, and more willing to pursue treatment. Adjunctive orthodontic treatment for adults could facilitate other dental treatment. In this regards, interdisciplinary approaches to adult orthodontic care are most frequently just one component of a more complex treatment involving several dental disciplines. The potential problems related to the establishment of a treatment plan and the necessity for the patient's full acceptance, and understanding of the pros and cons related to different treatment approaches, is a common factor in this area. In addition, we have to underlines the importance of a well-defined treatment goal. We have to illustrate the team approach and the treatment principles in the combined periodontal, orthodontic, and prosthodontic cases. 1. In periodontally involved teeth
The clinical effects of adjunctive orthodontic treatment of pathologically migrated incisors in adults with periodontitis were studied by many investigators. They concluded that; adjunctive orthodontic treatment to pathologically migrated incisors could improve their periodontal conditions and enhance aesthetic profiles. Elongated and spaced incisors are common in patients suffering from severe periodontal disease. Intrusion and uprighting of incisors might be the logical solution for this problem. Team approach is a must to treatment planning for adult patients with severe localized periodontitis accompanied by marginal bone loss and spacing and elongation of incisors. The treatment could involve the combination of periodontal treatment, orthodontic intrusion, and prosthetic therapy. Controlled intrusion could led to a decrease in the clinical crown length, better access for oral hygiene procedures, better gingival form, and a more suitable distribution of occlusal forces.
2. In the treatment of juvenile periodontitis Historically, the patient with juvenile periodontitis (periodontosis) presented as somewhat of an unknown entity to the orthodontist. With uncertainties concerning etiology still present, the orthodontist may be hesitant to undertake
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orthodontic treatment for the juvenile periodontitis patient. The literature pertaining to proposed etiologic factors and treatment modalities for juvenile periodontitis. Current evidence indicates that juvenile periodontitis patients have a compromised host response which allows an exaggerated susceptibility to certain gram-negative organisms. The disease is characterized by rapidly progressing bone loss, which is not associated with marked local irritation or gingival inflammation. Early diagnosis and conservative periodontal treatment have demonstrated good results. However, cases of advanced lesions or those cases that also involve malocclusion and potential occlusal traumatism may benefit from adjunctive orthodontic therapy. Successful management of cases involving multiple tooth loss along with a moderate degree of malocclusion is strongly dependant on the coordination of periodontic, orthodontic, and prosthodontic care. Orthodontic movement of teeth into previously affected areas could be quite successful after a short healing period following extractions. A protocol for the combined orthodontic, periodontic, and fixed prosthodontic management of the juvenile periodontitis patient is essential. Once the disease process has been arrested, the prognosis of each tooth is evaluated and possible rehabilitations, including orthodontic treatment and fixed prostheses, are planned. Periodontal evaluations should be scheduled concurrently with orthodontic appointments to monitor the condition as tooth movement occurs. 3. In Restorative treatment Some patients who present for restorative treatment; fixed and/removable replacement of missing tooth/teeth, could benefit from adjunctive orthodontic treatment. Among the benefits of such treatment are the use of more ideal and conservative restorative dentistry and the elimination of plaque-harboring areas for improved periodontal health. This includes teeth uprighting, space redistribution and alignment of anterior teeth. 4. Impacted permanent teeth (Orthodontic approach to teeth impaction) The most commonly impacted teeth in descending orders are: third molars, maxillary cuspids, maxillary central incisors and maxillary/ mandibular second premolar. Root resorption of the adjacent teeth, cystic formation and loss of arch length
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are the most common complication of teeth impaction. Localization of impacted tooth is very important before surgical orthodontic approach. Parallax radiographic technique and C.T radiographs are of great importance in this regards. After surgical exposure of the impacted tooth, an appropriate attachment (e.g. orthodontic bracket, hook etc.) will be bonded to that tooth with gold chain or wire extended from it to the pre-surgical bonded orthodontic appliance. After that the flap will be position in place and sutured.
5. In tempromandibular joint disorder in adults The relationship between TMJ disorder and dental malocclusion is a matter of debate. The approach of this area is based primarily on team work. 6. In the treatment of maxillo-mandibular basal discrepancies and cleft-palate cases The approach of these problems is based primarily on team work which include many specialties; orthognathic surgery, orthodontics, prosthodontics, plastic surgery, speech therapy, psychologist etc In conclusion; adjunctive orthodontic treatment as prerequisite measure for the treatment of some dental problems, could be available methods to establish good oral health. But we must realize that all the concepts mastering our routine orthodontic treatment must be strictly respected.
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Figure 28: Model a : analysis a and surge ery for orthogna athic sur rgery
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Ort thodontics for Undergraduate 2009 e:
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Two orthognathic surgery cases (Skeletal lass 2 and 3 respectively) before-and after surgery and the surgical procedures used in each case; before and after
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Intraoral distractor combined with fixed orthodontic appliance
Case of cleft lip and palate before treatment and at the end of different lip and-palate surgery, maxillofacial surgery, orthodontic and fixed prosthodontic procedures (Example of team work)
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CHAPTER 29: RISK FACTORS IN ORTHODONTIC TREATMENT

1. Root resorption: Systematic review of the literature revealed that external root resorption is the most common sequel of the orthodontic treatment. It is an inflammatory process that leads to an ischemic necrosis localized in the periodontal ligament when the orthodontic force is applied. The onset and progression of root resorption are associated with risk factors related to the orthodontic treatment such as the duration of treatment, the magnitude of the force applied, the direction of the tooth movement, the method of force application (continuous versus intermittent), the orthodontic movement. Patient-related risk factors are the individual susceptibility on a genetic basis, some systemic diseases, anomalies in root morphology, dental trauma, and previous orthodontic and endodontic treatment. The prevention of root resorption during the orthodontic treatment may be performed controlling the risk factors. Historical and contemporary evidence implicates injury to the periodontal ligament and supporting structures at the site of root compression following the application of orthodontic force as the earliest event leading to External root resorption. The periodic radiographic control during the treatment is necessary in order to detect the occurrence of root damages and quickly reassess the treatment goals. 2. Allergy to orthodontic materials: This includes; allergic reaction to metal orthodontic appliances, different elastics and or orthodontic adhesives. Nickel hypersensitivity is not uncommon among orthodontic patients treated by metal orthodontic appliances. The literature is very rich in this regards and in conclusion orthodontic treatment, per se; do not seem to affect the prevalence of nickel-or other orthodontic materials serious sensitization. 3. Trabecular and cortical bone as risk factors for orthodontic relapse Dental relapse of the mandibular incisors after orthodontic treatment is a common among orthodontic patients with thinner mandibular cortices. 4. Tempromandibular disorder (TMD
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Traditionally, four groups of factors have been identified in the etiology of tempromandibular disorder (TMD): anatomical variation in the masticatory system; psychosocial characteristics; pain in other body regions and orthodontic treatment could be cited both as a protective and harmful factor in TMD etiology. In conclusion the cause-effect relationship between dental malocclusion and/or orthodontic treatment at the one hand and tempromandibular disorder at the other hand is a matter of debate till now. Further studies are needed to investigate TMD etiology, these studies could help to identify patients whose risk of developing TMD is heightened following orthodontic treatment, hence serving as a risk marker useful in planning orthodontic care. 5. Enamel decalcification and gum disease: Enamel decalcification-decay (permanent white markings) or gum disease can occur if patients do not brush and floss their teeth properly and thoroughly during the period of orthodontic treatment 6. Cross infection Cross infection is a major serious problem in orthodontics as well as other dental specialties. Infection control protocol must be strictly followed. 7. Injuries from orthodontic appliances Activities and foods that can damage the braces should be avoided. A mouth guard should be worn during any activity, which an injury could occur. Broken appliances could have serious effects on the oral soft-tissues and in reported case; it could be swallowed by the patient During the removal of the braces, there is a possibility of chipping or fracture of a tooth enamel or filling. Headgear instructions must be followed carefully. A headgear that is pulled outward while the elastic force is attached can snap back and poke into the eyes or face. Be sure to release the elastic force before moving the headgear from the teeth. Do not use headgear during physical/contact activities.
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Enamel decalcification and white spots
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Root resorption of the central incisors
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Trauma to the cheek
Brocken bracket surgical eruption of impacted canine
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Swallowed broken orthodontic transpalatal arch wire
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CHAPTER 30: ETHICS AND MEDICOLEGAL PROSPICTIVE IN ORTHODONTICS

Orthodontic practice as any other dental-and medical specialty is covered by certain fundamental ethics which will be taken strictly in consideration and strictly respected. The following are some points of special consideration in this very critical issue: 1. Inform before perform is our golden role. After we have the decision to start orthodontic treatment, the full details of the proposed treatment plan must be explained to the patients side from A to Z using the best available methods of demonstration at hand. This step is very essential before starting any active phase in the treatment protocol. 2. Making orthodontic decision is not our sole responsibility, but we have to respect the moral and legal authority of the parents. We are the guide leader for taking the decision on very sound bases putting in consideration the patients benefit as the first priority to conduct orthodontic treatment. Use the best available evidence to explain your point of view to the patients side, take the appropriate time, whatever it is, before starting treatment. During treatment, we must have enough time at each recall visit to explain to the patients side the progress of treatment and any remarks on the patient performance. 3. Benefits and risk-and limitation of orthodontic treatment: If we can explain to the patients the benefits of a pleasant smile and healthy teeth with orthodontic treatment, we have on the other equally recognized that there are some risks and limitations. These potential risks and limitation seldom contraindicate treatment but should be considered and understood by the orthodontists while making the decision of treatment. 4. Treatment time: The total time of treatment of dental malocclusion could be estimated on an average according to the severity of dental malocclusion. The total time of treatment can be delayed beyond our primary estimation; broken appointments and/or broken appliance are the most common factors in this regards. concerning the broken appliance we have to be honest and differentiate between our responsibility and the patient responsibility. 5. Non-ideal orthodontic treatment outcome: We must be clear from the very begging that we are treating our patients to the standard norm, putting in consideration our psychosomatic norm. Occasionally a person who has grown normally and in average proportions may not continue to do so. If growth
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becomes disproportionate, the jaw relationship can be affected and treatment objectives may have to be compromised. Skeletal growth disharmony is a biological process beyond the orthodontists control. Due to the size and shape/missing teeth ideal results may not be possible. Restorative (crowns, bonding, veneers and bridges) may be needed to achieve ideal result. Relapse: After removal of the orthodontic appliance at the end of active treatment phase, retainer will be placed with complete instruction to minimize relapse. Full co-operation in wearing retainer appliances is vital. We will make our correction to the highest standards and in many cases overcorrect to in order to accommodate the rebound tendencies. But we have to be very honest and differentiate between our responsibility and the patient responsibility. If we treat patients beyond our orthodontic limitations, relapse will be the end result. We are treating our patients putting in consideration the long term stability of the treatment outcome. In this regards we have to establish good occlusion without any premature occlusal contacts, occlusal equilibration is an essential phase in orthodontic treatment after the active treatment phase. Informed consent form: The consent form must be very clear and written in a very simple languish, a way as much as we can from sophisticated medical terms, in such a way to be understandable by the parents side, whatever their educational level. The orthodontist should explain the reasons for treatment, the orthodontic procedures to be used, the risks, the alternatives, and patient and parent responsibilities during treatment. On the other hand, the importance of recall visits particularly for critical risks such as relapse, caries, and periodontal problems. Medicolegal concern regarding the diagnostic orthodontic radiographs: It is a firm obligation from the medicolegal responsibility to screen the pretreatment orthodontic radiographs to exclude, first of all, any pathology-and or anatomical anomalies before taken any other specialty consideration. Second opinion could be essential in some cases. Patients orthodontic records: All patients orthodontic records must be filed in good condition after orthodontic treatment for appropriate time. Some countries recommended 4 to 10 years. Second, do not use patients records in any publications whatever it is, especially extraoral photographs, without patients clear written approval. Third, please do not take any additional records such as radiographs and photographs for the purpose of research work only. Again patients clear written approval is a must.
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10. Transfer patient to another orthodontist: If we transfer our patients to another orthodontist for any reason, keep copy of the patient records, and transfer all patients records to the concerned doctor with covering letter summarizing honestly, clearly and carefully the patients case from the very begging to the last visit. 11. Touching our patient: From the medicolegal point of view, it is only acceptable to touch the patients face by three fingers for support; the fifth, the fourth and the third finger. As a firm obligation; do not touch physically the patient by any part of your body. This obligation is applicable for both sexes; patient side and doctor side, other wise you will be faced by the dilemma of sexual harassment, even between the same sexes. 12. Dental assistant: It is a form obligation to have a dental assistant all the time in the operating room and one of the patients relatives if it is possible. 13. Orthodontist outlook and behavior: Be carful regarding your dressing, behavior and attitude in the clinic. We have to differentiate carefully between words of appreciation and complements and words which could be considered as a way of sex harassment. 14. Infection control: Infection control protocol must be strictly followed.
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CHAPTER 31: PATIENTS DIFFERENT AGES IN ORTHODONTICS

The following are the patients ages commonly used in orthodontics, as well as, other dental and medical specialties: 1. Chronological age; is assessed from the date of birth as it is written in the birth certificate. 2. Dental age; is assessed by recording the date of development and eruption of teeth either clinically or radiographically. 3. Skeletal age: is assessed from the hand-wrist radiographs; by counting the developmental stages of certain specified growth indicators in the carpel-and metacarpal bones and bones of the five fingers e.g.: hook of hamates, pisiform, adductor sesamoid of the first finger, epiphysis and metaphysis of the middle phalanx of the fifth finger and epiphysis and metaphysis of the proximal, middle and distal phalanx of the third finger. 4. Physiological age; is assessed according the date of accomplishment of certain physiological character or function (e.g. menarche in females). 5. Psychological age; is assessed according to the date of accomplishment of certain psychological stage (it has multi-factorial background). 6. Educational age; is assessed according to the date of accomplishment of certain educational stage. N.B.: 1. For each age mentioned above; there is average norm chronological age and +/- standard deviation from the average norm. Deviations from the range of standard norm are reflected as underdevelopment or accelerated development of a person in respect to the specified age within certain race. 2. The stages of development of different indicators (sequence of events) used to assess the dental, skeletal and physiological ages are the same among different races, but the differences are only in the chronological age of accomplishment of such stages among certain race group.
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CHAPTER 32: INFECTION CONTROL IN DENTAL CLINICS
Introduction
Most dentistry, and a range of minor surgery, is carried out in office practice. The principles of infection control apply equally to surgical procedures in hospital settings, in office situations and in mobile medical and dental clinics. Infection control in Orthodontic clinics follow-up the main rules applied in dentistry.
Infection control in specific health care settings:

Office spaces and facilities will vary. Each practice should develop a manual of the protocols required for all procedures. The manual should be developed cooperatively with all health care workers involved in the delivery of the service, and should demonstrate clearly to patients and regulatory bodies that the principles of infection control are understood and practiced. The protocol should be drawn up by reference to the various sections of this manual and recommendations should be tailored to the particular practice. In addition, an office infection control protocol or manual should include information about and specifications for: Methods of hand washing (routine and surgical) Personal protective equipment requirements Setting up the treatment area in preparation for a patient visit Defined areas of contamination that require personal protective equipment and cleaning between patients Changeover procedures between patients Management of blood or body fluid spills Handling and disposal of sharps Waste disposal Management of blood or body fluid exposure Processing of reusable items (cleaning, packaging, sterilization, disinfection, storage); Processing of radiographs; Quality control mechanisms, including documentation of maintenance and monitoring programs for equipment Staff immunization requirements Single-use items Solo operators (professionals who do not have an assistant present during direct patient contact) Continuing education Recording of information during patient treatment Use of computers and computer-run equipment during patient treatment; and Management of water lines that have direct patient contact.
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Sterilization in office practice:

Sterilization by steam under pressure is the preferred method of sterilization in office practice. Dry heat sterilizers with fan-assisted mechanical air convection have had limited application and are not recommended for office practices. When purchasing a steam sterilizer (autoclave) for use in office-based practice, consideration must be given to dentist training, quality control and running costs. For smaller practices, such ongoing expenditure could make the use of an external service (other office practice, hospital or commercial facility) or the use of disposable single-use items a practical and cost-effective alternative. Sterilizers must be used in accordance with the manufacturers instructions. Items must be thoroughly cleaned before sterilizing. If the sterilizer has a built-in drying unit, the items should also be packaged or wrapped. For group practices, the greater volume of instruments required might justify the use of larger, more sophisticated steam sterilizers. Instruments and devices that are used in the treatment of skin and mucosal lesions such as warts and that come into direct contact with the lesions must be single use, disposable or cleaned and desterilized after each patient. This applies to cryotherapy and electrocautery tips and other devices, which should be processed as for other surgical instruments according to the manufacturers recommendations, either by steam or by gas sterilization.
Dental practice:
In addition to the general requirements for office practice, some special considerations and requirements for dental practice should be carefully followed. Adequate eye and face protection should be worn where aerosols are likely to be generated. Gloves should be worn by dentist for all procedures where contact with patient secretions or tissue is possible. Gloves do not need to be sterile for most general dental procedures. However, gloves should be sterile when invasive procedures (e.g. incision into soft tissue or surgical procedures) are carried out. In dental practice, gloves should be worn for most procedures; in these circumstances, allergy or sensitivity can become a significant issue. Patients should be provided with protective eye equipment.
Operating field:
The integrity of the operating field should be maintained during dental procedures. Appropriate use of dental dams, high-volume evacuation and proper patient positioning should minimize the formation of droplets, splatter and aerosols during treatment. The following equipment should be cleaned or barrier protected after each patient use: Any hand-operated control in the operating field, the operating light handle, the X-ray head, the suction tubing and the cradles they rest in. Any intraoral light source (e.g. fibreoptic illuminators, intraoral cameras,
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the polymerizing light and the handle of its light shield) The bracket table and its handle. Protective coverings (plastic wraps, sterile drapes or preformed plastic covers) may be applied to surfaces that have been cleaned at the beginning of each day. Protective coverings should be disposed off after each case.
Materials:
Materials should routinely be predispensed. However, if additional instruments and materials have to be retrieved from outside the operating field, the following procedures should be followed: Gloves must be removed and hands washed to dispense materials from their containers into the field (alternatively, over gloves can be used). Drawers must be opened by elbow touch, degloving or a suitable no-touch technique (e.g. use of transfer tweezers or single-use barriers on handles). Retrieval of instruments or materials from drawers must be by transfer tweezers that are kept separate from the other instruments. Transfer tweezers may be handled with gloved or ungloved hands during a case and should be sterilized at the end of each case. Precut supplies of some materials (e.g. floss, cellulose acetate strips, gingival retraction cord and articulating paper) can be stored in drawers and predispensed before procedures or retrieved with transfer tweezers. All articles within the operating field should be deemed contaminated by the case in progress, and must be removed, cleaned and disinfected or sterilized before the next case can begin. All instruments and equipment used in the mouth must be sterilized after each case.
Intraoral dental hand pieces:

All dental hand pieces should be cleaned according to the manufacturers instructions and sterilized after each case. The manufacturers instructions regarding the choice of lubricants should be followed, and care taken to choose a lubricant that does not compromise the sterilization process. If the hand piece is relubricated after sterilizing, then that lubricant system should be for post-sterilization use only. It is strongly recommended that automatic flush-through and lubricant systems be used for cleaning and lubricating dental hand pieces.
Management of water quality and aspiration:

A hierarchy of water quality is required for dentistry. Water used for surgical procedures should be sterile; water used for mouth rinsing should be of potable standard. Water required for irrigation for tooth preparation and ultrasonic scaling should be of no less than potable standard. Biofilm in dental unit waterlines is an unknown hazard. It is prudent to treat immuno-compromised patients using water in which the number of colony forming units (CFU) per mL is less than 200. CFU levels can be measured using commercially available test strips.
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Air and water lines: Air and water lines should be flushed for a minimum of two minutes, at the start of the day and for 30 seconds between patients. For dental units equipped with an independent water supply, the manufacturers instructions must be closely followed for disinfection procedures. All dental equipment that supplies water to the oral cavity must be fitted with no return valves. Routine maintenance of no return valves is necessary to ensure their effectiveness. Manufacturers should be consulted to establish an appropriate maintenance routine. Aerosols: Materials, equipment and instruments must be kept bagged, covered with an impermeable material or in closed drawers until use, to protect them from contamination by aerosols created in the dental environment. Instruments penetrating tissue are required to be sterile at the time of use and must be kept bagged. All environmental surfaces, apart from those contaminated in the operating field, must be cleaned at least weekly. Dental lasers and air abrasion devices create particular bioaerosol hazards. Extra control measures for these aerosols, such as purpose-built ventilators and high-velocity suction devices, are required. Some pathogenic viruses such as human papilloma virus are not inactivated by laser or electrosurgery procedures, and appropriate filtration masks and suction are necessary to prevent inhalation. Air abrasion devices create alumina dust, which can become a respiratory irritant for both dentist and patients. In such instances, high-efficiency particle arrest (HEPA) filtration and vapor filtration are indicated.
Dental prostheses, impressions and materials:

Although the efficacy of disinfection of dental materials is still undetermined, standard precautions should be applied whenever people handle dental material. Implantable items must be sterile. The most important step is the thorough cleaning of material that has contacted oral tissue (e.g. impressions). Thorough rinsing with cold running water, followed by the application of a diluted detergent and further rinsing should continue until all visible contamination is removed.
Prosthetic work area in the clinic:

Prostheses or appliances that have already been inserted into the mouth require special attention. Any instruments, attachments and materials that contact these prostheses should be cleaned and disinfected between cases. A small amount of pumice should be dispensed for individual use. When the treatment is complete the remainder should be discarded and the container cleaned with a detergent solution and rinsed for dispensing pumice for the next case. All burs and rubber wheels should be steam sterilized and arbor bands
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disposed of. Polishing buff and rag wheels must be cleaned, dried and thermally disinfected or sterilized after each case. Splash guards should be cleaned between cases. People working on such appliances should wear a clean uniform or laboratory coat, single-use gloves, protective eyewear or face-shield, and a mask if necessary. An exhaust fan is recommended. Vacuum exhaust at benches and a fume cupboard should be available for use when required.
Dental laboratories:
All materials transported to and from dental laboratories should be cleaned or disinfected, and placed in sealed containers. All materials transported to and from dental laboratories should first be cleaned or disinfected, and placed in sealed containers. In each case, the method of disinfection should be noted on the laboratory form. Laboratory staff should be aware that laboratory items present a biological hazard; for their own safety, they should practice the necessary precautions in handling biological material. Standard precautions should be applied when handling dental materials. All prostheses should be cleaned before being polished in the lathe working area.
Receiving area:
An area should be set aside to receive incoming cases. The laboratory request form should be checked for details about which cleaning procedures are required before the items are stored. Appropriate personal protective equipment (e.g. disposable gloves, apron, eye protection or a face-shield) should be worn when the container is opened. A mask should be worn where there is a risk of aerosolisation or airborne transmission of infection. Sometimes items are sent to the laboratory without having been cleaned. When this occurs, items should be rinsed in cold running water, cleaned in a mild detergent solution until all traces of blood, debris and body fluids are removed, and then rinsed. All packing materials and waste should be disposed of according to the waste regulations of State/Territory health and environmental authorities. Reusable containers should be cleaned with detergent and then disinfected. The receiving area should be cleaned with detergent between cases. Placing a single-use impenetrable barrier (i.e. plastic or plastic-backed paper) on the surface is recommended.
Work area:
Hands should always be washed before leaving the work area. Food or drink should not be allowed in the work area.
Outgoing prostheses/appliances:
On completion of the laboratory work, items should be cleaned or disinfected, dried and placed in a sealed container for dispatch.
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CHAPTER 33: EGYPTIANS CEPHALOMETRIC MEASUREMENTS AVERAGE NORMS
The Alexandria Standard norm for Egyptians Adults:
Measurements
Male
Female
Total
Mean
S.D.
Mean
S.D.
Mean
S.D.
1. Skeletal
SNA
82.73
4.38
81.06
2.57
81.90
3.67
SNB
80.00
4.31
78.50
2.56
79.25
3.61
ANB
2.75
1.44
2.52
1.42
2.63
1.45
SNPg
81.24
4.73
79.65
2.80
80.44
3.95
Facial A
87.10
3.29
87.60
3.28
87.35
3.28
Angle Conv.
4.29
3.77
3.50
3.60
3.90
179
3.69
Gonial A
123.03
5.04
124.04
5.40
123.54
5.22
Cranial Base A
130.66
5.40
132.58
4.42
131.70
5.01
SN/Md A
31.44
5.23
33.04
5.09
32.24
5.20
SN/Pal A
8.80
3.50
9.86
2.68
9.33
3.15
Pal/Md A
23.12
4.49
23.68
4.42
23.37
4.44
Frank/Md A
25.41
3.45
25.23
3.02
25.31
3.23
Y/Frank A
61.30
3.55
60.14
3.56
60.72
3.58
S-Go
88.98
5.95
79.50
4.65
84.24
7.14
N-Me
133.06
6.34
122.20
9.39
127.63
9.66
ANS-Me
76.20
5.14
68.48
5.12
72.34
6.41
Wits
-0.47
2.68
-1.16
2.30
-0.85
2.45
Bony Chin
2.16
1.57
2.22
1.31
2.19
1.44
2. Dental
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UI/LI A
127.21
8.46
127.14
7.75
127.18
8.07
LI/Md A
95.51
4.98
95.18
4.17
95.35
4.58
LI/Frank A
59.08
3.92
59.59
3.52
59.34
3.72
LI/N-B A
27.22
4.31
27.10
5.12
27.12
4.45
LI to N-B mm
6.69
2.18
5.63
2.31
6.16
2.30
UI/N-A A
23.42
5.26
23.73
4.62
23.56
4.65
UI to N-A mm
4.86
1.95
5.28
1.99
4.95
1.96
UI/Frank A
112.06
5.97
112.68
5.50
112.36
5.64
LI to A-Pg mm
3.98
2.10
3.35
2.23
3.67
2.18
LI/NB: Pg/NB
6.69:2.16
5.63:2.22
6.16:2.19
3. Soft-Tissue
Nose
7.06
4.13
8.09
3.89
7.54
4.10
ULS
-6.28
2.15
-5.50
1.93
-5.89
2.07
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LL
1.03
1.44
0.92
1.51
0.99
1.42
LLS
-5.47
1.49
-4.93
1.55
-5.20
1.53
Z angle
71.65
6.23
75.57
6.24
70.70
8.09
Z-I Angle
65.52
7.01
67.96
5.72
66.90
6.30
Total Chin
16.22
2.34
15.58
2.21
15.90
2.29
H angle
11.41
3.50
9.24
4.01
10.33
3.90
Linear measurements were taken angular measurements in degrees.
in
mm
and
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CHAPTER 34: GROWTH PREDICTION
MP3-F stage (Onset); Onset or the start of the curve of pubertal growth spurt
The epiphysis is as wide as the metaphysis
MP3-FG stage (Acceleration); The ascending phase of the curve of pubertal growth spurt
The epiphysis has a distinct medial and/or lateral border forming a line of demarcation at right angle to the distal border
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MP3-G stage (Peak); The point of maximum growth spurt
The sides of epiphysis have thickened, capping its metaphysis and forming a sharp edge distally at one or both sides
MP3-H stage (Deceleration); The descending part of the curve of pubertal growth spurt
Fusion of epiphysis and metaphysis has begun
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MP3-I stage (End Stage); The end of Pubertal growth spurt
Complete fusion of epiphysis and metaphysis
Fishman (1987) Skeletal maturation index (SMI stages) for the prediction of adolescent growth
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SMI Sages 1-3; The width of the epiphysis is as wide as the diaphysis
Stage 1. 3rd finger proximal phalanx Stage 2. 3rd finger middle phalanx Stage 3. 5th finger middle phalanx
SMI Stage 4;Ossification of the adductor sesamoid
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SMI Stages 5 -7 ;Capping of epiphysis

Stage 5. 3rd finger distal phalanx Stage 6. 3rd finger middle phalanx Stage 7. 5th finger middle phalanx
SMI Stages 8-11; Fusion of epiphysis and diaphysis

Stage 8. 3rd finger distal phalanx Stage 9. 3rd finger proximal phalanx Stage 10. 3rd finger middle phalanx Stage 11. Rdius
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Hassel & Farman

(1995); used the different maturation stages of the cervical vertebrae and CV3 as guide; in the prediction of adolescent growth
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CV3-1st stage (Initiation);

Wedge shaped body, and the superior vertebral border is tapered from posterior to anterior
CV3-2nd stage (Acceleration);

Developing concavity in the inferior border and the body is nearly rectangular in shape
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CV3-3rd stage (Transition);

Distinct concavity is seen in the inferior border, and the body is rectangular in shape
CV3-4th stage (Deceleration); The body becoming more square
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CV3-5th stage (Maturation);

Inferior border with more accentuated concavity, and nearly square to square shaped body
CV3-6th stage (Completion);

The body is square or is greater in vertical dimension than in horizontal dimension
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Percentage of expected adolescent growth according to SMI stages & CV3 stages
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1. SMI-1&2 and CV3-1 (Initiation stage): 80-100% Expected A.G. 2. SMI-3&4 and CV3-2 (Acceleration stage): 65-85% Expected A.G. 3. SMI-5&6 and CV3-3 (Transition stage): 25-65% Expected A.G.
4. SMI-7&8 and CV3-4 (Deceleration stage): 10-25% Expected A.G. 5. SMI-9&10 and CV3-5 (Maturation stage): 5-10% Expected A.G. 6. SMI-11 and CV3-6 (Completion stage): Little or no adolescent growth is expected
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CHAPTER 35: EVIDENCE BASED ORTHODONTICS
Evidence Based Orthodontics

Orthodontics of the 21st century is evidence based
Peck 2005
Evidence base; means the integration between individual clinical expertise with the best available evidence from systematic research
Sackett et al 1996
The best evidence can inform, but can never replace, individual clinical expertise because it is this expertise which decides whether the evidence applies to the individual patient and, if so, how it should be integrated into a clinical decision
Harrison E Jayne 1999
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Absence of evidence is not evidence of absence

Altman DG & Bland JM 1995
ecommendations contained in text books and traditional reviews, may lag behind by more than one decade, in endorsing an effective treatment or continuing to advocate a therapy, long after it has been shown to be ineffective or even harmful
Altman et al 1992
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Text books and literature reviews often cover a broad range of issues related subjects. They can only be as up to date as their most recent reference and, therefore, go out of date quickly, sometimes even before they are published --
In our rabidly changing

world, we are suffering too much from the information overload --
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As we enter the year 2000, every year

approximately two million articles are published world wide in around 20,000 biomedical journals, of which 500 are related to dentistry.
In orthodontics around 320 articles are

published in only 4 of the key English orthodontic journals
Harrison JE 2000
Is it possible for any one clinician to keep on top of all the published information?
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The need to identify and bring

together valid and clinically useful articles from a large number of Journals. This led to the publication of several evidence based secondary Journals, the 1st one on 1991
Journal of Evidence Based Medicine; 1995, Journal of Evidence Based

Dentistry; 1998
These journals aim to screen relevant journals for good, useful evidence on topics applicable to their area of interest.
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Also includes a commentary which places papers in their clinical perspective, highlighting how and where they are relevant to clinical practice, and whether practice should continue or change as a result of the findings
The science of evaluating and implementing the results of medical research, meta-analysis, makes patient care more objective, more logical and more cost effective
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CHAPTER 36: GUIDELINES FOR RESEARCH WRITERS
I. Guidelines to write a Thesis/Research

1. Title and aim of the study:
1. Title: Concise titles are easier to read than long, convoluted ones. Titles that are too short may, however, lack important information, such as study design. The candidate should include all information in the title that will make it both sensitive and specific in reflecting the aim of the study 2. Aim of the study: State the specific purpose or research objective of, or hypothesis tested by, the study; the research objective is often more sharply focused when stated as a question. Both the main and secondary objectives, if any, should be made clear. The hypothesis of the study should be clearly stated.
2. Introduction:
This should contain a very brief literature review that should only address literature that is directly relevant to the study. It should not be exhaustive and as a routine; references should not included except in a very special cases. Provide a context or background for the aim of the study. The introduction should be within two pages.
3. Review of literature:
1. Critical appraisal and meta-analysis are the key stone in our approach to certain topic. 2. Critical appraisal is highly recommended in this area. Critical appraisal is the process of assessing and interpretation of evidence by systematically considering its validity, results and relevance to our practice. 3. On the other hand, meta-analysis which is the science of evaluating and implementing the results of medical research,
200
makes patient care more objective, more logical and more cost effective. 4. An effective method in systematic search will involve the following steps first of all: a. Identify your topic question and break it down into sections. b. Avoid the temptation to start searching before properly thinking through appropriate search term for the question. c. Think through appropriate search term for each section. d. Build a structural search strategy. e. Run your search. f. Review your search results. g. Revise your search strategy if necessary and re-run the search. 5. Finding the evidence to cover the topic rose. 6. It must be appreciated that no single resource can be relied upon to provide all the evidence. 7. Systematic searching the published information; text books, hand searching the key journals for relevant papers and review articles or electronically via the internet 8. Electronic databases a. Medline; is bibliographic and lists primary search b. Cochrane; take the researcher directly to primary or secondary publications of relevant clinical evidence. c. Internet web sites; provide access to databases and evidence based publications or organizations. However browsing the internet can be frustrating, time-consuming and may fail to locate the specific information we require. 9. The decision on whether a paper is worth reading should be based on the research design in general and the method section in particular, rather than the hypothesis, P value, speculation found in the discussion section or the numbers of references. 10. When you find materials that could be consider reliable and useful to your research design, it is the time to collect these materials in organized order in your review section. There are three methods for taking notes; 1. Summary: recording only the general ideas of large amount of information. 2. Paraphrase: recording detailed information on specific sentences and passages, but not in the exact words of the author(s) and 3. Quotation: in other word, copy and past sentence or passage in exactly the same words of the author(s). in this case quotation
201
marks are a must to specify the quoted section from the other parts. 11. This section must be ended by the null hypothesis of the conducted study.
4. Materials and methods:

1. This section should contain the outline of the materials and methods that should be used in the study. 2. Description of the sample model which will be used in the study should be clear, and avoid too much detailed unnecessary information. 3. The Methods section should include only information that was available at the time the study was done. 4. The following point should be covered: a. Design: There should be a description of the type of the study (Example; double blind study, prospective randomized controlled study, retrospective study retrospective studies are not highly recommended, in-vivo or in-vitro study, experimental or clinical study etc...). b. Setting: where the study was conducted should be mentioned. c. Sample: This should state how the sample will be selected. How many participants were studies and were the sample size justified? Any research should include sufficient participants to have a high chance of detecting a difference between groups if there is one and reasonably sure that one doesnt exist if none is found by the study. This is known as the power of the study. Small studies tend to be under powered and are unable to detect an important difference in effect even if there is one present. This is known as a false negative result or Type II or B error. d. Use the appropriate numbers of figures to satisfy the clarity of the materials and methods e.g. photographs, radiographs, tracing etc 5. Statistics: It is important that at the end of this section to give concise hint about the statistical model which was used as well.
5. Results:
1. Did any untoward events occur during the study? Unplanned events e.g. uncooperative patients, broken
202
appointments, measurements not taken or subjects lost to follow up. 2. The results of the study should be collected, tabulated and statistically analyzed using the appropriate statistical test, e.g.: a. Descriptive statistics: Mean, standard deviation, minimum and maximum values. b. T-test: Test of significant difference between two variables means (t-test); Students t-test, Paired t-test etc. c. Correlation analysis: Two variables or more are studied simultaneously to see how they are interrelated. The coefficient (r) could be ranged between -1 and 1, if it comes to (0) this will mean no linear relationship between the variables, if the correlation is positive, means that the variable tend to decrease or decrease together and if it is negative this means inverse relationship between the variables. d. Regression analysis: One particular variable of interest (dependent) and the remaining variables (more than one independent) are studied for their possible aid in throwing light on that particular dependent variable. e. Multiple regression analysis: The relationship between two or more dependent variables and more than one independent variable is performed to predict the dependant variables from analyzing the independent variables. f. ANOVA test: Extension of the t-test: One way ANOVA: One dependent variable is tested against one independent variable. Two ways ANOVA: One dependant variable is tested against two independent variables. Three ways ANOVA: One dependant variable is tested against three independent variables etc.
g. MANOVA test: N.B: Two groups or more of dependant variable is tested in respect to many independent variables. N.B.: Independent variable: The variable systematically varied by the researcher. that is
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Dependant variable: The variable that is observed and whose value is presumed to depend on the independent variable(s). Reliability: The measure is considered reliable if it constantly gives the same answer at different points in time. Validity: The measure is considered valid if it measures what it is supposed to measure. h. Duncan test: Used to examine the relation or difference between dependant and independent variable. T-tests are commonly used to locate mean difference between among pairs of variables within the groups. Without appropriate correction greatly increased probability exists of erroneously concluding that the difference among pairs of variables exists when one does not (Type I Error). Correction may be used to correct for this type of error e.g. Duncan test. i. Chi-square test: Used for statistically analyzing the nonparametric figures in the study. N.B: Types of errors: Type I error: rejecting the null hypothesis, when it should be accepted. Type II error: accepting the null hypothesis; when it should be rejected. To reduce these errors, set the level of significance closer to zero, or you can use Duncan test. 3. Use the appropriate numbers of tables and figures to illustrate the results of the study. The tables should be informative by itself; the title should include the type statistical test used, as well as, unite of measurements; mm, degree, gram etc and the level of significance. 4. Photographs and radiographs must be of high clarity and resolution. Cheating with statistics: It means that the investigator manage all the data into a computer statistical package when analyzing the results of the study and report any results that emerge as
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significant whilst ignoring those where P is more than 0.05. For this reason it is best to limit the number of variables that are assessed, specify which these are going to be the protocol stage of the study and quite the calculated P value, rather than just whether it is greater or less than 0.05.
6. Discussion:
1. The discussion should include a summary of the main findings of the study and then relate them to any deficiencies in the study design or problems in the conduct of the study. They can then be related to previous work in the area, whether they can be generalized and their clinical implications. The interpretation of data is not as clear cut as it may seem and several factors have to be taken into account when trying to determine what the results actually mean. 2. What are the main findings and does the data support them. 3. How do the findings relate to previous work in the area? It is important to give a balance view of previous work and see the results of the new study in context of previous work. Where there is a considerable body of knowledge it is tempting for researcher to overemphasize studies that support the findings and play down those that dont. 4. How are the null findings hypotheses interpreted? Apparently non-significant results need to be interpreted with care. Lack of evidence of a difference in effect does not necessarily mean that there is no difference in effect. Lack of evidence that A causes B does not necessarily mean that this is the case. Again confidence intervals (CIs) are useful in assessing the precision of the results. Narrow CIs that span the point of zero difference, suggest that the study results can be viewed with a great of certainty that there is no difference in effect or causative link found. However, if the CIs are wide and span the point of zero difference it can be indicative that the study is inconclusive and may have been too small (inadequately powered) to detect a difference in effect or causation even if one existed. 5. Put in mind that absence of evidence is not evidence of absent.
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7. Summary and Conclusion:

a. Summary: Give only brief illustration of your study including the aim and its significance and the studied sample. b. Conclusion: The conclusion is often the bottom line of the critical appraisal and meta-analysis. It involves integrating information gained at all the stages of systematic searching the data base integrated with the results of the study. It must be written in brief, in direct way, illustrating the significant findings and if the findings are applicable and the future vision if present.
8. Recommendation:
Write down your recommendation which could be extracted if any.
9. References:
References should be written according to the following format: In the text: 1. References must be in the Vancouver style. They should be numbered in the order in which they appear in the text. 2. These numbers should be inserted as superscripts each time the author is cited in the text In the list of references: 1. References at the end of the work should be arranged in numeric sequence as they appear in the text. 2. References should give the names and initials of all authors up to six. If they are more than six, only the first three should be given followed by et al. 3. Journal reference style: The authors names are followed by the title of the article; the title of the journal abbreviated according to the style of Index Medicus and Index to Dental Literature; the year of publication; the volume; the number/month quoted; the first and last page numbers in full. 4. Book reference style: The authors names are followed by title of the book; place of publication; the publisher; and the year of publication. 5. Chapter in Book reference style: The authors names of the chapter: followed by the title of the chapter; followed by In: followed by the editors names of the book: followed by
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the title of the book; the place of publication; the publisher; the year of publication; the first and last page numbers of the chapter in full. Examples; Journal reference style: 1. Becker A, Shapira J, Chausa S. Orthodontic treatment for disabled children; A survey of patient and appliance management. J Orthod 2001; 28 (2): 145-52. Book reference style: 1. Graber TM, Neumann B. Removable Orthodontic Appliances. 2nd ed. Philadelphia: WB Saunders; 1984. 129-32. Chapter in book reference style: 1. Baumrind S. The decision to extract: preliminary findings from a prospective clinical trial. In McNamara JR. Orthodontic Treatment: outcome and effectiveness. Craniofacial Growth Series. Ann Arbor Center for Growth and Development: The University of Michigan; 1995. 113-38.
N.B. 1. Abbreviations:
Abbreviations are not recommended to be used in the title and rarely used in the text, when used, use the commonly accepted forms. Spell out the term of the abbreviations when used for the first time in the text to avoid puzzling the readers, unless it is a standard unit of measurement, Example: Tempromandibular Joint (TMJ)
2. Arabic summary (if indicated):

Provide Arabic translation of your summary, conclusion and recommendation.
3. Please be informed that:

1. The thesis should be written in simple English langue and avoid using uncommon tough words from the Thesaurus.
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2. Use A4 papers, double spaced with font size 12 Time New Roman. 3. Our mother langue is not the English and we are not expert in statistics, please consult expert professional persons in these areas. 4. Minimizes cut and paste as much as you can and if any part of the text is not in your own words, please use quotation for this part(s) and reference.
II. Guidelines to write a review Article

1. Topic
a. The topic of the review article could be direct and clear, and this the simplest way of evaluating a candidate. The writers of the review article have to systematically searching the database for significant relevant articles. They need to be able to identify those papers which are worth reading and disregard those that will add little to our knowledge or impact on our practice. b. The topic of the review article could be indirect and include words such as; concept, philosophy, in view of future technology, globalization etc. These types of review article are in need of wide vision from the writer and special approach to the topic. c. Critical appraisal and meta-analysis are the key stone in our approach to certain topic. d. Critical appraisal is highly recommended in this area. Critical appraisal is the process of assessing and interpretation of evidence by systematically considering its validity, results and relevance to our practice. e. On the other hand, meta-analysis which is the science of evaluating and implementing the results of medical research, makes patient care more objective, more logical and more cost effective.
2. First of all; an effective method in systematic search will

involve the following steps: a. Identify your topic question and break it down into sections. b. Avoid the temptation to start searching before properly thinking through appropriate search term for the question. c. Think through appropriate search term for each section. d. Build a structural search strategy.
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e. Run your search. f. Review your search results. g. Revise your search strategy if necessary and re-run the search.
3. Finding the evidence to cover the topic.

a. It must be appreciated that no single resource can be relied upon to provide all the evidence. b. Systematic searching the published information; text books, hand searching the key journals for relevant papers and review articles or electronically via the internet c. Electronic databases 1. Medline; is bibliographic and lists primary search 2. Cochrane; take the researcher directly to primary or secondary publications of relevant clinical evidence. 3. Internet web sites; provide access to databases and evidence based publications or organizations. However browsing the internet can be frustrating, time-consuming and may fail to locate the specific information we require. d. The decision on whether a paper is worth reading should be based on the research design in general and the method section in particular, rather than the hypothesis, P value, speculation found in the discussion section or the numbers of references.
4. After collecting the relevant papers from different sources; now to the critical point in illustrating this information.
The point is not how to arrange the data in chronological dogmatic way, but to illustrate the collected data in ascending order of its significant value to clarify the topics core, till we reach the peak of the value. This type of illustration of the relevant papers must end by a significant conclusion; clear enough to be reliable and applicable. We can call it dramatic buildup of the data till we reach the peak key point of the topic.
5. The following points must be taken in consideration during evaluating the relevant articles:
a. Cheating with statistics: when analyzing the results of a study, is to put all data into a computer statistical package and report any results that emerge as significant whilst ignoring those where P is more than the value of 0.05. or this reason it is best to limit the number of variables that are assessed, specify which these are going to be the protocol
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b.
c.
d. e. f.
stage of the study and quite the calculated P value, rather than just whether it is greater or less than 0.05. How many participants were studies and were the sample size justified? Any research should include sufficient participants to have a high chance of detecting a difference between groups if there is one and reasonably sure that one doesnt exist if none is found by the study. This is known as the power of the study. Small studies tend to be under powered and are unable to detect an important difference in effect even if there is one present. This is known as a false negative result or Type II or B error. How are the null findings hypotheses interpreted? Apparently non-significant results need to be interpreted with care. Lack of evidence of a difference in effect does not necessarily mean that there is no difference in effect (Altman and Bland 1950). Lack of evidence that A causes B does not necessarily mean that this is the case. Again confidence intervals (CIs) are useful in assessing the precision of the results. Narrow CIs that span the point of zero difference, suggest that the study results can be viewed with a great of certainty that there is no difference in effect or causative link found. However, if the CIs are wide and span the point of zero difference it can be indicative that the study is inconclusive and may have been too small (inadequately powered) to detect a difference in effect or causation even if one existed. Put in mind that absence of evidence is not evidence of absent. What are the main findings and does the data support them. Did any untoward events occur during the study? Unplanned events e.g. uncooperative patients, broken appointments, measurements not taken or subjects lost to follow up.
6. The discussion should include a summary of the main findings of the different studies and how do the findings relate to previous work in the area?
It is important to give a balance view of previous work and see the results of the new studies in context of previous work. Where there is a considerable body of knowledge it is tempting for researcher to overemphasize studies that support the findings and play down those that dont. They can then be check the soundness
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of the evidence and, whether they can be generalized and their clinical implications. The interpretation of data is not as clear cut as it may seem and several factors have to be taken into account when trying to determine what the results actually mean.
7. The conclusion is often the bottom line of the critical appraisal and meta-analysis.
It involves integrating information gained at all the stages of systematic searching the data base. It must be written in brief, in direct way, illustrating the significant findings and if the findings are applicable and the future vision if present.
8. References.
References should be written according to the following format: In the text: 1. References must be in the Vancouver style. They should be numbered in the order in which they appear in the text. 2. These numbers should be inserted as superscripts each time the author is cited in the text In the list of references: 1. References at the end of the work should be arranged in numeric sequence as they appear in the text. 2. References should give the names and initials of all authors up to six. If they are more than six, only the first three should be given followed by et al. 3. Journal reference style: The authors names are followed by the title of the article; the title of the journal abbreviated according to the style of Index Medicus and Index to Dental Literature; the year of publication; the volume; the number/month quoted; the first and last page numbers in full. 4. Book reference style: The authors names are followed by title of the book; place of publication; the publisher; and the year of publication. 5. Chapter in Book reference style: The authors names of the chapter: followed by the title of the chapter; followed by In: followed by the editors names of the book: followed by the title of the book; the place of publication; the publisher; the year of publication; the first and last page numbers of the chapter in full.
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Examples; Journal reference style: 1. Becker A, Shapira J, Chausa S. Orthodontic treatment for disabled children; A survey of patient and appliance management. J Orthod 2001; 28 (2): 145-52. Book reference style: 1. Graber TM, Neumann B. Removable Orthodontic Appliances. 2nd ed. Philadelphia: WB Saunders; 1984. 129-32. Chapter in book reference style: 1. Baumrind S. The decision to extract: preliminary findings from a prospective clinical trial. In McNamara JR. Orthodontic Treatment: outcome and effectiveness. Craniofacial Growth Series. Ann Arbor Center for Growth and Development: The University of Michigan; 1995. 113-38.
N.B.
1. Abbreviations are not recommended to be used in the title and rarely used in the text, when used, use the commonly accepted forms. Spell out the term of the abbreviations when used for the first time in the text to avoid puzzling the readers, unless it is a standard unit of measurement, Example: Tempromandibular Joint (TMJ) 2. The review article should be written in simple English langue and avoid using uncommon tough words from the Thesaurus. 3. Use A4 papers, double spaced with font size 12 Time New Roman. 4. Our mother langue is not the English and we are not expert in statistics, please consult expert professional persons in these areas.
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CHAPTER 37: STATISTICS IN ORTHODONTICS

Orthodontic etiology and treatment is a multi-factorial subject. Interpretation of the diagnostic records and planning the treatment protocol is in need of good understanding of geometry to correlate these factors or variables to each other. Geometry is an important topic in orthodontics as all our variables are linked to each other by a way or another. Change in only one variable could affect positively or negatively the other variables to the extent that, the net result could be completely differ from what we have in our imagination of the proposed treatment outcome. Critical appraisal of our foundations in view of geometrical background is the key stone of our pyramidal ladder of successful data interpretation and treatment planning. This understanding leads us to another point of interest and great importance; statistical and clinical interpretations of our data. First of all we have to differentiate between statistical significance and clinical significance of the findings. Statistical significance of a variable does not always mean clinical significance of that variable. Second we have to accept the fact that statistical significance per se does not always entail or mean clinical significance. In orthodontic studies we are dealing with numerous cephalometric variables which are measured and tested for their significant effects on our overall treatment planning and outcome. The problem is that how to be able to probe precisely those results which are worth used and disregard those which could add little or nothing to our impact on clinical orthodontics, whatever their level of statistical significance are. The statistically significant results by it self does not rule out the possibilities that the result has arisen by chance. Accordingly statistical testing the correlation between variables must be first of all making sense that there is a form of correlation between them. Some clinicians and researchers could give considerable weight only to variables which have statistical significance and ignore those of statistical insignificant values. This dogmatic way of interpretation of the statistical results of the data is completely prohibited. Some results which are statistically insignificant could have extremely clinical significant and the reverse is true. As an example; the case of maxillary first molar distalization in the treatment of Class II molar relationship to approach Class I. We have many effective techniques in this regards whatever extra-or intraoral. Most of them end with statistical significant changes in some cephalometric variables and the reverse is true for other variables. First molar distal tipping and extrusion could be of statistical insignificance value. But their clinical significance on functional occlusion, lower face height and mandibular plane angle among other geometrically related variables could be of negative effects on the total orthodontic treatment outcome and long-term stability. Another example which could clarify our point is that; metal release from orthodontic appliance could be of negligible amount and statically
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insignificant, but their biological effect on the oral mucosal cells could be of highly clinical significance to the extent that, it could induce DNA damage to the oral mucosal cells. These examples are only two among others which are clarifying the importance of carful interpretation and appraisal of our data, not in view of their P value if it is or 0.05, but in view of their clinical significant effects on other geometrically related variables. From the above it is understood that statistics in orthodontics form the main corm of research design. The following is brief illustrations of some of the most commonly used statistical tests and terms: Parametric statistics: statistical procedures appropriate with variables measured at the interval or ratio level. Examples of parametric statistical tests; t-test, ANOVA, correlation, regression Nonparametric statistics: statistical procedures used with variables measured at the nominal or ordinal level. Examples of nonparametric statistical tests; Wilcoxon signed ranks test, Mann-Whitney U test and Chi-square test. Multivariate statistics: statistical methods investigate the relationship between one or more independent variables and more than one dependent variable. Cross-legged study: a type of longitudinal study in which information about two different variables is gathered from the same sample at two different times. The correlation between variables at the same point in time is compared with the correlations at different points in time. Variance: a mathematical index of the degree to which scores deviate from the mean. Weighting: a mathematical procedure used to adjust the sample to meet the characteristics of a given population. Proposition: a statement of the form if A then B which links two or more concepts. Psychographic research: an area of research examines why people behave and think as they do. Random sample: a subgroup or subset of a population selected in such a way that each unit in a population has an equal chance of being selected. Volunteer sample: a group of people who go out of their way to participate in a survey or experiment. Blind experiment: a research study where the experimenters are the only one who know whether a given subject belongs to the experimental the control or the placebo group. Double blind experiment: a research study where experimenter and other involved in the study do not know whether a given subject belongs to the experimental or the control or the placebo group. Placebo group: a group of patients taken medicine without
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any physiological effects, used in controlled trial. Pilot study: a trial run of a study conducted on a small scale to determine if the research design and methodology are relevant and effective. Hypothesis: a tentative generalization concerning the relationship between two or more variables that predicts an experimental outcome. Null hypothesis: the denial or negation of a research hypothesis. Power: the probability of rejecting the null hypothesis when an alternative is true. Validity: the property of a test that actually measures what it purports to measure. Reliability: the property of a measure that consistently gives the same answer at different points in time. Dependent variable: the variable that is observed and whose value is presumed to depend on the independent variable(s) Independent variable: the variable that is systematically varied by the researcher. Interaction: refers to the concomitant influence of two or more independent variables on the single dependent variable. Probability level: a predetermined value at which researchers test their data for statistical significance. In routine orthodontic statistics, we usually follow the following steps in handling our raw materials or testing the hypothesis:
1. Parametric variables: The first step: After data collection and tabulation of the research results, the first statistics to be used is the Descriptive statistics to reduce data sets and easier interpretation. The tables of descriptive statistics contain the mean, standard deviations, minimum and maximum values and standard error. Descriptive statistics: those statistical methods and techniques designed to reduce data sets to allow for easier interpretation and the first statistical tests to be used. It includes the mean, standard deviation, standard error Mean: the arithmetic average of a set of scores. Median: the midpoint of a distribution of scores. Standard deviation: the square root of the variance (a mathematical index of dispersion). Standard error: an estimate of the amount of error present in a measurement. The second step: After the descriptive statistics is to
215
investigate the differences between two group means. For example, the difference between the mean value of upper canines retraction by elastic chain, and that obtained by magnets and if the difference is of significant value or not. t-test is the appropriate test in this regards. t-test: a statistic used to determine significance between two groups mean score. (Paired t-test: used to compare two group means. Repeated measures t-test: is used to compare the means of more than two groups). One tailed t-test: is appropriate when the direction of anticipated difference can be specified or when statement may be made about which group will have the larger mean. Two tailed t-test; is used in the event that the direction of the hypothesis cannot be specified. Type I error: a rejection of the null hypothesis when it should be accepted. Type II error: a acceptance of the null hypothesis when it should be rejected. To reduce error I and II, set the level of significance closer to zero. The third step: To investigate one dependent variable against one or more independent variables in the same group, ANOVA is the test of choice. Upper incisor teeth retraction as the independent variable and concomitant upper lip retraction as the dependent variable in the concerned group is an example in such cases. But if we are going to investigate more than on dependent variables, MANOVA is the test of choice in this regards. Analysis of variance (ANOVA): a statistical procedure used to decompose sources of variation in two or more independent variables. An ANOVA is classified according to the number of factors involved in the analysis: a one-way ANOVA investigate one independent variable, a two-way ANOVA investigates two independent variables, and so on. A main effect is simply the influence of an independent variable on the dependent variable. Interaction refers to the concomitant influence of two independent variables on a single dependent variable. ANOVA is essentially an extension of the t-test. In fact, the two-sample ANOVA is mathematically equivalent to the t-test. The advantage of ANOVA, however, is that it can also be used in factorial designs, that is, research involving simultaneous analysis of two or more independent variables or factors. In the two-way ANOVA only the interaction is reported and interpreted. Interaction is produced concomitantly by two or more independent variables, rendering the individual influence of each variable essentially meaningless. Multivariate analysis of variance (MANOVA): a multivariate extension of analysis of variance used to study more than one dependent variable. The fourth step: If we would like to investigate the
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relationship between two or more variables simultaneously in on group, correlation analysis is the test of choice in this regards to see how they are interrelated. In others there is one particular variable of interest, and the remaining variables are studded for their possible aid in throwing light on that particular variable, regression, multiple regression and multivariate statistics are of choice in this regards. Correlation analysis: is designed to establish a relationship between two or more variables and assess the strength of that relationship. In such cases several variables are studded simultaneously to see how they are interrelated. Regression analysis: is designed in such cases that there is one particular variable of interest (dependent variable) and the remaining variables (independent variables) are studied for their possible aid in throwing light on this particular variable. Multiple regressions: an analysis of two or more independent variables and their relationship to a single dependent variable. Although it is similar in some way to analysis of variance, the basic purpose of multiple regressions is to predict the dependent variable, using information derived from analysis of the independent variables. In multiple regression analysis two important values must be calculated; the coefficient of regression and the coefficient of correlation. Partial correlation: is a method researchers use when they believe that a confounding or spurious variable may affect the relationship between the independent variables and the dependent variable. It would enable the researchers to determine the influence of the controlled variable. Duncan analysis: it is not commonly used in orthodontics. It is a path analysis essentially creates a causal path to describe the relationship between the independent and the dependent variables. The method is particularly useful in situations involving decision-making processes or selections between several alternatives that might be followed in a given course of action. It does not demonstrate causality; rather, it is a method for tracing a set of causal assumptions made by the researcher.
2. Nonparametric variables:
Statistical procedures used with variables measured at the nominal or ordinal level. The following are examples of nonparametric statistical tests: Wilcoxon signed ranks test, Mann-Whitney U test and Chi-square test. Chi-square statistics: a measurement of observed frequencies vs. expected frequencies.
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REFERENCES
1. Graber TM. Orthodontics principles and practice 2. Graber TM, Swain BF. Current orthodontic concepts and techniques 3. Hitchcock HP. Orthodontics for undergraduates 4. Moyer RE. Handbook of orthodontics for the student and general practitioner 5. Salzmann TA. Practice of orthodontics 6. Sassouni V. Orthodontic in dental practice 7. Proffit WR, Fields HW. Contemporary Orthodontics 8. Harrison EJ. Current products and practice; Evidence-based orthodontics: where do I find evidence? J Orthod 2000; 27: 71-78 9. Peck S. The state of our specialty. Angle Orthod. 2004; 74: 576 10. James L. Ackerman LJ, Marc B. Ackerman BM, Kean RM. A Philadelphia Fable: How Ideal Occlusion Became the Philosophers Stone of Orthodontics. Angle Orthodontist 2007; 77: 192-4 11. Peck H, Peck S. A concept of facial esthetics. Angle Orthod 1970; 4: 284-317 12. Hagler BL, Lupini J, Johnston LS. Long-term comparison of extraction and nonextraction in matched samples of African American patients. Am J Orthod Dentofacial Orthop 1998; 114:393403. 13. Razoog ME, Robinson E. Black Dentistry in the 21st Century. Ann Arbor: University of Michigan School of Dentistry, 1991:24. 14. Ackerman JL, Proffit WR. Communication in orthodontic treatment planning: bioethical and informed consent issues. Angle Orthod 1995; 65: 253-61 15. Jones JW. A medico-legal review of some current UK guidelines in orthodontics: A personal view. J Orthod 1999; 26: 307-24 16. Demirjian, A., Goldstein, H., and Tanner, J. M.: A new system of dental age assessment, Hum. Biol. 1973; 45: 211-27 17. Nolla C. M. 1960. Development of the permanent teeth. J. Dent. Child. 27:4 254263. 18. Aboul-Azm SF, Enany NM, Fahmy MA, Tamish NO, Abdalah HE. The Alexandria analysis: radiographic cephalometric standards for Egyptian Adults. Alexandria Dent J 1984; 9: 1-8 19. Abdel-Kader HM. Medicolegal Perspective; Interpretation of pretreatment Orthodontic Radiographs. WJO 2008; 9: 14 20. Abdel-Kader HM. Sella turcica bridge in orthodontic and orthognathic surgery patients; A retrospective cephalometric study. AOJ 2007; 23: 30
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21. Abdel-Kader HM. Psychosomatic norm in orthodontics; problems and approach. World J. Orthod 2006; 7: 394-8 22. Abdel-Kader H.M. Can we justify a global model of facial attractiveness and beauty? Australian Orthod J 2006; 22: 71-72 23. Abdel-Kader H.M. When should we finish with a Class I molar relationship? AOJ 2007; 23: 157 24. Abdel-Kader H.M. Broken trans-palatal arch wire stuck to the throat of orthodontic patient; is it strange? British J Orthod 2003; 30: 11 25. Abdel-Kader H.M. To find a surgical needle in the oropharyngeal region during screening of orthodontic radiographs is it strange? British J Orthod 1999; 26: 161a 26. Abdel-Kader H.M. The potential of digital dental radiography in recording the adductor sesamoid and the MP3 Stages. British J Orthod 1999; 26: 291 27. Abdel-Kader H.M. The reliability of using dental X-ray film in assessment of MP3-stages of the pubertal growth spurt. Am J Orthod Dentofacial Orthop 1998;114:427
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ORTHODONTICS

Prof. Hussam M. Abdel-Kader Professor of Orthodontics

6th Edition 2009

Orthodontics for Undergraduate: 2009

Orthodontics for Undergraduate: 2009

Prof. Dr. Hussam M. Abdel-Kader

Orthodontics for Undergraduate: 2009

Orthodontics for Undergraduate: 2009

Orthodontics for Undergraduate: 2009

CHAPTER 1: INTRODUCTION AND AIM OF ORTHODONTICS

Orthodontics for Undergraduate: 2009

Orthodontics for Undergraduate: 2009

CHAPTER 2: ORTHODONTIC HISTORY

Orthodontics for Undergraduate: 2009

Orthodontics for Undergraduate: 2009

CHAPTER 3: CONCEPT OF MODERN ORTHODONTICS OF THE 21st CENTURY

Orthodontics for Undergraduate: 2009

Orthodontics for Undergraduate: 2009

CHAPTER 4: GROWTH AND DEVELOPMENT OP THE CRANIOPACIAL COMPLEX I. BONE GROWTH

Orthodontics for Undergraduate: 2009

II. Growth of the craniofacial complex:

Orthodontics for Undergraduate: 2009

Orthodontics for Undergraduate: 2009

Orthodontics for Undergraduate: 2009

CHAPTER 5: NORMAL DEVELOPMENT OF DENTITION AND OCCLUSION

Orthodontics for Undergraduate: 2009

Orthodontics for Undergraduate: 2009

Orthodontics for Undergraduate: 2009

Orthodontics for Undergraduate: 2009

Orthodontics for Undergraduate: 2009

CHAPTER 6: NORMAL DENTAL OCCLUSION

Orthodontics for Undergraduate: 2009

The six keys of normal occlusion by Andrews LF (1972)

Orthodontics for Undergraduate: 2009

Orthodontics for Undergraduate: 2009

Orthodontics for Undergraduate: 2009

CHAPTER 7: FORCES OF OCCLUSION

Orthodontics for Undergraduate: 2009

Orthodontics for Undergraduate: 2009

Orthodontics for Undergraduate: 2009

CHAPTER 8: THE CLOSED FUNCTIONAL SYSTEM AND DEVELOPMENT OF NORMAL OCCLUSION

Orthodontics for Undergraduate: 2009

Orthodontics for Undergraduate: 2009

Cheek and the buccinator mechanism:

Orthodontics for Undergraduate: 2009

Lip morphology and behavior:

Orthodontics for Undergraduate: 2009

Tongue morphology and behavior:

Orthodontics for Undergraduate: 2009

N.B. It is obvious that an act repeated so frequently as swallowing, a relatively

Orthodontics for Undergraduate: 2009

CHAPTER 9: MOVEMENTS OF THE TEMROMANDIBULAR JOINT

Actions Depression mouth)

Orthodontics for Undergraduate: 2009

Retrusion (Retrude chin)

Temporalis Masseter (deep fibres)

Side-to-side movements (grinding and chewing)

Temporalis on same side Pterygoid muscles opposite side Masseter

Orthodontics for Undergraduate: 2009

CHAPTER 10: MALOCCLUSION

1. Malpositions of Individual teeth:

Orthodontics for Undergraduate: 2009