Handbook Of

RTHODONTICS
4th
Edition

-
'. I
ROBERT E. MOYERS
____________ FOURTH EDITION _

lIandbook of Orthodontics

ROBERT E. MOYERS, D.D.S., PH.D.,

D.Se. (HON.)
Professor of Dentistry (Orthodontics)
SchooL of Dentistry
FeLLow, Center for Human Growth and DeveLopment
The University of Michigan
Ann Arbor, Michigan

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YEAR BOOK MEDICAL PUBLISHERS,.INC.

CHICAGO· LONDON· BOCA RATON
Copyright Q 1958, 1963, 1973, 1988 by Year Book Medical Publishers,
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of America. •
2 3 4 5 6 7 8 9 0 K R 92 91 90 89 88

Library of Congress Cataloging-in-Publication Data

Moyers, Robert E.
Handbook of orthodontics / Robert E. Moyers. - 4th ed.
p. cm.
Rev. ed. of: Handbook of orthodontics for the student and general
practition~r. 3rd ed. 1973, cl 972.
Includes bibliographies and index.
ISBN 0-8151-6003-8
l. Orthodontics. I. Moyers, Robert E. Handbook of orthodontics , :.
for the student and general practitioner. II. Title.
[DNLM: 1. Orthodontics. WU 400 M938h]
RK52l.M6 1988
617.6'43-dcl9
DNLMlDLC
For Library of Congress 87-34075
CIP

Sponsoring Editor: David K. MarshalllMark-Christopher Mitera

Assistant Director, Manuscript Services: Frances M. Perveiler
Production Manager, Text and Reference/Periodicals: Etta Worthington
Proofroom Supervisor: Shirley E. Taylor
 To my parents, whose many sacrifices made
possible my education

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 CONTRIBUTORS

JAMES K. AVERV, D.D.S., PH.D. RAVMOND J. FONSECA, B.A., D.M.D.

Director, Dental Research 'Institute and Professor of Dentistry, Professor of Dentistry (Oral Surgery), School of Dentistry;
School of Dentistry; Professor of Anatomy, The University of Associate Professor (Oral Surgery), Department of General
Michigan Medical School, Ann Arbor, Michigan Surgery, The University of Michigan Medical School, Ann
FRED L. BOOKSTEIN, PH.D. Arbor, Michigan
Research Scientist, The Center for Human Growth and W. STUART HUNTER, D.D.S, PH.D.
Development; Research Scientist, Biostatistics, School of Professor of Orthodontics, Faculty of Dentistry, University of
Public Health; Research Scientist, Developmental and Western Ontario, London, Ontario, Canada
Reproductive Biology; Associate Professor of Geological ROBERT E. MOVERS, D.D.S., PH.D., D.Sc. (HON.)
Sciences, College of Literature, Science, and the Arts, The
University of Michigan, Ann Arbor, Michigan Professor of Dentistry (Orthodontics), School of Dentistry;
Fellow, Center for Human Growth and Development, The
ALPHONSE R. BURDI, M.S., PH.D. University of Michigan, Ann Arbor, Michigan
Professor of Anatomy, Director, Inteflex Program, The MICHAEL L. RIOLO, D.D.S., M.S.
University of Michigan Medical School; Research Scientist,
Research Investigator, Center for Human Growth and
Center for Human Growth and Development, The University
of Michigan, Ann Arbor, Michigan Development, The University of Michigan, Ann Arbor,
Michigan '
KATHERINE W. L. DRVLAND VIG, B.D.S., M.S.
PER RVGH, DR. ODONT.
Associate Professor of Dentistry (Orthodontics), School of
Dentistry, The University of Michigan, Ann Arbor, Michigan Chairman, Department of Orthodontics and Facial Orthopedics,
Faculty of Dentistry, University of Bergen, Bergen, Norway
DONALD H. ENLOW, PH.D.
ARTHUR T. STOREY, D.D.S., PH.D.
Professor and Chairman, Orthodontics, Assistant Dean for
Graduate Studies and Research, Thomas Hill Distinguished Professor and Head, Department of Orthodontics, School of
Professor of Oral Biology, Case Western Reserve University, Dentistry, University of Texas Health Science Center at San
Cleveland, Ohio Antonio, San Antonio, Texas

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/
/ /

vii

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He that publishes a book runs a very great hazard, since
nothing can be more impossible than to compose one that
may secure the approbation of every reader.-MIGUEL
CERVANTESSAAVEDRA,DON QUIXOTE
The favorable reception of previous editions of this book, the
appearance of Spanish, Japanese, and Portuguese editions, * and
important recent changes in the field of orthodontics have en-
couraged me to undertake this fourth edition.
The nature of dental practice in these years has been re-
markably altered by fluoridation of communal water supplies, the
proliferation of govemmentally sponsored dental programs and
dental insurance, a literal revolution in dental materials and in-
strumentation, and a large increase in the number of practicing
dentists. These factors have altered the public's desires and aware-
ness of dental services and have forever changed the previous
primary preoccupation of dentists with restorative and prosthetic
procedures, thus forcing a broader perception of our profession.
Unfortunately, dentists and patients change their views more read-
ily than dental school curricula are modified. So there persists a
need for further information about orthodontics for both student
and practitioner alike. Sources of sound orthodontic knowledge
are often not as available as in other dental fields, and dentists
usually have far less orthodontic background; therein lies a major
problem for both dentists and the public.
Dentists who wish to improve their skills and knowledge in
orthodontics now may choose from many available short courses,
yet often such offerings are not sponsored by dental schools or
societie~ but are private entrepreneurial efforts. Many such courses
in the United States are taught by clinicians with little or no formal
training in orthodontics, and emphasis is frequently on one favored
appliance. Courses for general dentists on the basic subjects of
diagnosis and growth and development are more rare, but might
be more practical and rewarding.
The present enthusiasm to integrate orthodontics into general
practice poses difficulties for lay people, too, since few are aware
of the divergences of training provided dental students in the sev-
eral clinical fields. They know their family dentist is a skillful
-.
PREFACE TO THE
FOURTH EDITION
DE
restorative dentist and may logically assume him/her to 'be equally
well trained in orthodontics, but that is rarely so.
Orthodontics is not only one of the most difficult clinical
fields in dentistry, it is also one of the most rapidly changing. It
is hard to learn and hard to keep abreast of current best practice.
This book is written to provide the dental student with a firm
foundation in the basics of growth and development and to provide
a healthy approach to orthodontic diagnostic and treatment pro-
cedures. It is NOT a compendium of all orthodontic information,
nor can reading it serve as a substitute for direct instruction or
supervised clinical experience. It is written, too, to provide the
family dentist with modem, fair perspectives of orthodontics and
its place in general practice. The book is widely read by specialists
in orthodontics and seems to have been especially useful for be-
ginning graduate students and residents.
This fourth edition, as in previous editions, has three sections:
Growth and Development, Diagnosis, and Treatment. Each section
IS introduced by a "mini-essay" written to define the scope and
purpose of the section and to provide a foretaste of problems and
challenges of that particular section's chaptFs. Growth is the busi-
ness of the orthodontist, variations in' growth and morphology
provide the need and basis for a diagnosis, and growth is the raw
lT1ilterialfrom which treatment changes are wrought. The difficult
intrtcacies of growth, more thanflny other factor, separate ortho-
dontics from the rest of dentistry. Several dental specialties are
defined by their particular techniques; orthodontics is defined by
the clinical problems created by developmental variability. The
section on growth is enlarged, particularly by a splendid chapter
*There have also been unauthorized versions of the third English
edition in three different countries, although I am not sure whether they
are due to the worthiness of the book or the laxity of international copy-
right conventions.
ix
X Preface to the Fourth Edition
by Professor Storey, and purposefully occupies a major portion of
the book. The secti~n on diagnosis has been written to sharpen
discriminatory insights and to enhance the ability to recognize
subtle deviations in growth and morphology. Ear more serious
mistakes are due to the failure to discern significant clinical dif-
ferences between similar appearing malocclusions than are due to
inappropriate selection of an appliance. The section on treatment
has been expanded to include separate chapters on early, adoles-
cent, and adult treatments. Improved techniques and the availa-
bility of prefabricated appliances have permitted shortening the
chapter on orthodontic techniques.
/
This fourth edition is more than a revision of the third: it is
a new book written to address the theoretical and practical needs
of the most rapidly changing field in a changing profession.
ROBERT E. MOYERS, D.D.S., PHD.
;;.
 ACKNOWLEDGMENTS
... because if 1'd a known what a trouble it was to make a
book I wouldn't a tackled it .... -MARK TWAIN, HUCKLE-
BERRY FINN, CHAPTERXlm
Making a book is a trouble, as Mark Twain said, but it is
made much easier by those who aid in its production, for no one
really writes a book, such as this, alone,
I am most indebted to my co-authors, Professors James K,
Avery, Donald H. Enlow, Arthur T, Storey, Alphonse R, Burdi,
Fred L. Bookstein, W, Stuart Hunter, Per Rygh, Michael L. Riolo,
Katherine W, L. Dryland Vig, and Raymond J, Fonseca. All are
close associates and friends, some for over 30 years, and I note
with pride that three are former students, Their knowledge of
orthodontics and allied fields brings authority to their writing and
completeness to this book,
The craniofacial group at The Center for Human Growth and
Development has, since the last edition, become one of the most
active and well known in craniofacial biology, We collaborate to
sponsor symposia, secure research funds, train young colleagues,
publish monographs, give courses, etc" but one important activity,
not well known, must be acknowledged here, viz" the critical
reading of one another's writing. Katherine Ribbens, editor for
The Center for Human Growth and Development, has been a:
constant help as this new edition progressed, Stanley Gam, David
Carlson, Jim McNamara, Fred L. Bookstein, Peter Vig, and Mi-
chael L. Riolo have each read several parts of this book and have
responded with criticism, comments, and suggestions in the most
detailed and supportive manner. I am especially grateful for their
candor, perseverance of correctness, and willingness to help with
this writing: I am indeed lucky to be a part of such a group,
Since the first edition, Year Book Medical Publishers, Inc,
has given counsel, support, and much patience, all of which is
valued and noted with gratitude,
New drawings and charts have been prepared by the talented
-.
group at Technical Illustration, Division of Research Development
and Administration, University of Michigan (Dale Austin, Eugene
Leppanen, and David Oliver), and Terryl Lynn, Tom TenHave,
biostatistician at The Center for Human Growth and Dovelopment,
has provided most of the statistics and tables, and he and Richard
Miller, also of The Center for Human Growth and Development,
have generated all computer plots used herein, Pamela Dietrich
and Gail Sonnett have typed most of the manuscript with its many
revisions.
A very special mention must be made of the role a writer's
family plays when a book is being written, especially when the
gestation is prolonged as was this. Through the past years my wife,
Barbara, and daughters, Mary and Martha, have made sketches,
read drafts critically, checked references, and even served as pho-
tographer's models. Those efforts, while helpful, are not their
principal contribution, which is the continual support and tolerance
they have given to the selfish, time-consuming, isolating madness
called writing. They know I am grateful, but readers should know,
too, lest when they are tempted to begin such an undertaking, they
think they can do it alone.
" I am pleased to acknowledge my gratitude to all these people,
but errors and omissions that may have occurred are solely my
responsibility. In the past, friendly critical readers have helped
rectify such problems and have made many useful suggestions. I
invite you to do so, too, and assure you that comments sent to me
at The Center for Huml!~ Growth and Development, The Univer-
iril}' of Michigan, 300 N: Ingalls SI., Ann Arbor, Michigan 48109,
Will be received with gratitude and appreciation.
ROBERT E. MOYERS, D.D.S., PHD.
xi
 CONTENTS

Preface to the Fourth Edition ix C. Changing Concepts and Hypotheses of

Craniofacial Growth 48
SECTION I GROWTH AND D. Controlling Factors in Craniofacial
Growth 51
DEVELOPMENT 1
E. Regional Development 53
F. Overall Pattern of Craniofacial
I / Introduction to the Study and Practice of
Growth 67
Orthodontics 2
G. Racial and Ethnic Differences 67
by Robert E. Moyers
H. "Adult" Craniofacial Growth 67
A. Problems in Studying Orthodontics 2
B. What is Orthodontics? 3 5 / Maturation of the Orofacial Musculature 73
C. The Purpose of This Book 4 by Arthur T. Storey
D. How to Use This Book 5 A. Orofacial Muscles 74
Summary 5 B. Methods of Study 76
6 C. Basic Concepts of Orofacial Neuromuscular
2 / Basic Concepts of Growth and Development
Physiology 79
by Robert E. Moyers D. Reflex Determinants of Mandibular
A. Classes of Alterations in Biologic
Activities 7 Registration Positions 84
8 E. Growth and Adaptation of Orofacial
B. Principles and Themes of Development Muscles 89
C. Some Definitions 8
F. Interaction of Orofacial Muscles With
D. Divisions of Developmental Science 9
Development of the Craniofacial Skeleton and
E. Methods of Studying Growth and the Dentition 94
Development 10
F. Variables Affecting Physical Growth 11 6 / Development of the Dentition and the
G. Pattern 12 Occlusion 99
H. Variability 13 by Alphonse R. Surdi and Robert E. Moyers
I. Timing 16 A. Prenatal Dental Development 100
J. The Evaluation of Physical Growth 16 B. The Mouth of the Neonate 105
C. The Primary Teeth and Occlusion 106
Summary 17
D. Development of the Permanent Teeth 111
3 / Prenatal Facial Growth 18
E. The Permanent Dentition 119
by lames K. Avery
F. Dimensional Changes in the Dental
A. Period of Organization of the Face 19 Arches 121 -
B. Development of Oral Structures 26 G. The Mixed Dentition Period 126
C. Differentiation of Supporting
H. Dentitional and Occlusal Development in the
Structures 31
Young Adult 140
D. The Fetal Period-Third to Ninth
I. Clinical Implications 142
Month 34
Summary 35 7 / Etiology of Malocclusion 147
by Robert E. Moyers
4 / Growth of the Craniofacial Skeleton 37 148
A. The Orthodontic Equation
by Robert E. Moyers and Donald H. Enlow B. Primary Etiologic Sites 149
A. The Role of Craniofacial Skeleton Growth in C. Time 151
Orthodontics 38 D. Causes and Clinical Entities 151
B. Rudiments of Bone Growth 39 Summary 162

xiii
xiv Contents

SECTION 11 DIAGNOSIS 165 E. Techniques of Tracing Cephalograms 255

F. Geometric Methods 255
8 / The Cursory Orthodontic Examination 167 G. Understanding and Using the Cephalogram-
by Robert E. Moyers Cephalometric Analyses 263
A. Before the Examination 169 H. Some Problems and Limitations of
B. The Cursory Examination 169 Cephalometries 281
Summary 182 I. The Future of Cephalometries 283
Appendix: A Brief Cephalometric
9 / Classification and Terminology of Atlas 283
Malocclusion 183
A. Overall Facial Dimensions 284
by Robert E. Moyers B. Regional Anatomic Dimensions 296
A. What is a Classification System? 184
C. Craniofacial Constants 296
B. Purposes of Classifying 184
C. When to Classify 184
D. Systems of Classification and SECTION III TREATMENT 303

Terminology 186
E. Class I Syndrome 191 13 / Force Systems and Tissue Responses to Forces in
F. Class 11 Syndrome 191 Orthodontics and Facial Orthopedics 306
G. Class III Syndrome 194 by Per Rygh and Robert E. Moyers
H. Limitations of Classification Systems 195 A. Forces Within the Masticatory
System 307
la / Analysis of the Orofacial and Jaw
Musculature 196 B. Force Systems in Orthodontic and Functional
Jaw Orthopedic Appliances 308
by Robert E. Moyers
C. Periodontal and Other Tissue Responses to
A. Evaluation of Sensory and Motor
Orthodontic Forces 313
Abilities 197
D. Controlled Alteration of Craniofacial
B. Muscle Groups 198
Growth 322
C. Examination of Specific Neuromuscular
E. Other Effects of Orthodontic
Functions 206
Treatment 324
D. Analysis of Temporomandibular Joint
F. Retention, Relapse, and Occlusal
Dysfunction 216 Stabilization 326
Summary 218
14 / Planning Orthodontic Trea!ment 332
11 / Analysis of the Dentition and Occlusion 221
by Robert E. Moyers
by Robert E. Moyers
A. Selection of Orthodontic Cases in General
A. Diagnostic Data 222 Practice 333
B. Analysis of Tooth Development 226
C. Size of Teeth 228 B. Treatment Planning in the Primary
Dentition 340
D. Arch Dimensions 240
E. Prediction of Future Occlusal C. Treatment Planning in the Transitional
Dentition 340
Relationships 241
D. Treatment Planning in the Permanent
F. Registration of Jaw Relationships 242 Dentition 340
G. The Temporomandibular Joints 244
E. Limiting Factors in Orthodontic
H. Relationships of the Teeth to Their Skeletal
Therapy 340
Support 245 F. Some Common Mistakes 342
Summary 245
15 / Early Treatment 343
12 / Analysis of the Craniofacial Skeleton:
by Robert E; Moyers and Michael L. Riolo
Cephalometries 247
A. Understanding Early Treatment 345
by Robert E. Moyers. Fred L. Bookstein. and W. Stuart . 347
Hunter B. Defining Goals in Early Treatment
C. Assessment of the Results of Early
A. Purposes of Cephalometries 249
Treatment 347
B. History 250
D. Clinical Problems and Procedures 348
C. Obtaining the Cephalogram 250
D. Anatomic Structures in the
Cephalogram 251
 Contents xv

16 / Adolescent Treatment 432 18 / Orthodontic Techniques 511

by Robert E. Moyers by Robert E. Moyers
A. Understanding Adolescent Treatment 434 A. Basic Laboratory Techniques 512
B. Defining Goals in Adolescent B. Basic Clinical Techniques 513
Treatment 434'
C. Fixed Appliances 518
C. Assessment of Results of Adolescent
D. Attached Removable Appliances 524
Treatment 435
E. Loose Removable Appliances (Functional
D. Clinical Problems 440
Appliances, Functional Jaw Orthopedic
17/ Adult Treatment 472 Appliances, Etc.) 531
by Robert E. Moyers, Katherine W. L. Dryland Vig, and F. Myotherapeutic Exercises 542
Raymond J. Fonseca G. Correction of Deleterious Oral Habits
A. Orthodontic Treatment for Adults With Good 543
Oral Health 473 H. Occlusal Equilibration (Occlusal
B. Orthodontic Treatment of Malocclusions Adjustment) 551
Complicated by Periodontal Disease and Loss
of Teeth 475
Index 561
C. Orthodontic Treatment Combined With
Orthognathic Surgery 494

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 SECTION I
Growth and Development
Robert E. Moyers, D.D.S., Ph.D.
GROWTH
Growth, in common English usage, is a word with several
different meanings. Cities, crystals, crops, and cancers "grow."
Habits "grow" on a person, stocks "grow" in value, a face
"grows" pale when one is frightened, and one "grows" in wisdom
as one ages. Such varied usages tend to reduce the import of a
particular meaning.
In biology, growth is the increase in size or mass accompa-
nying normal development; however, in orthodontics growth, and
the verb grow, are used quite loosely in several ways, which can
present real and unfortunate semantic traps for the unwary. The
following quotations (all gathered in one day from conversations
with colleagues, notations in case histories, and articles in the
orthodontic literature) illustrate the broad and imprecise common
usages of the words. They also reveal misconceptions about the
biologic processes involved, misunderstandings of the specifics of
craniofacial development, admixtures of wishful thinking and facts,
and just plain nonsense.
• "The mandibular length grew 6 mm." (description of a
specific dimensional increase).
• "This face grew bigger." (description of a general in-
crease in size).
• "The mandible grows downward and forward." (descrip-
tion of a population vector).
• "Marie's mandible exhibits 'clockwise' rotation in
growth." (description of a specific vector).
• "He grew rapidly during adolescence." (comment on an
increase in rate of general growth).
"
• "1 expect the mandible to show a 'spurt' in growth within
the next 18 months." (prediction of a specific increase in
timing and rate of growth).
• "She had a typical Class III growth pattern." (assumption
of group vectors of change).
• "1 feel this patient has very little growth left." (estimate of
future amounts of size change).
• "He is a bad grower." (qualitative description of growth).
• ''I'm going to do a 'growth prediction'." (assumption of
ability to estimate practically future growth).
• "1 think I'll wait for some growth before 1 start treat-
ment." (expectation of an increase in rate of growth,
which will presumably aid therapy).
When this important word-growth-is used casually or im-
precisely in orthodontics it not only reflects a person's carelessness
bot also reveals how much must yet be learned and applied in
practice. Students may justifiably ask how they can ever compre-
hend a subject so important, so complicated"and so misunderstood,
but they must try, for growth is the raw material of orthodontic
treatments. Without the biologic dynamics of natural and contrived
chal}ges in craniofacial morphology no occlusion can be improved,
no fate made more esthetic.
The first chapters of this book contain fair summaries of our
knowledge of craniofacial developmental biology at this time, but
the field is an active area of much research, so orthodontists follow
the literature carefully to keep up with current ideas. Nothing
typifies orthodontics better than its dependence for clinical progress
on advances in craniofacial biology.
CHAPTER 1

Introduction to the Study and

Practice of Orthodontics

Robert E. Moyers, D.D.S., Ph.D.

Nothing is known in our profession by guess; and I do not

believe, that from the first dawn of medical science to the
present moment, a single correct idea has ever emanated from
conjecture: it is right, therefore; that those who are studying
their profession should be aware that there is no short road
to knowledge.-SIR ASTLEY PASTONCOOPER, in A Treatise
on Dislocations and Fractures of the Joints

OUTLINE A. PROBLEMS IN STUDYING

ORTHODONTICS
A. Problems in studying orthodontics
I. For the dental student 1. For the Dental Student
2. For the dentist in practice Many undergraduate orthodontic courses consist of a few
B. What is orthodontics? hours of instruction late in the curriculum, with very little clinical
I. History experience. When orthodontic teaching begins, the student's at-
2. Scope titudes toward dentistry may have been set by good teaching in
C. The purpose of this book other courses in which success is based on other concepts or dif-
D. How to use this book fen~nt clinical goals. For example, good restorative dentistry tra-
ditionally has required a higher proportion of technical skills than
The complicated nature of dental occlusion, including its devel- of biologic knowledge. Orthodontics', perhaps more than any other
opment, maintenance, and correction, is the primary reason for field of dentistry, is dependent on a thorough working knowledge
the existence of dentistry as a separate healing arts profession. of the developmental biology of the face. Unwittingly, the dental
However, we have tended to emphasize in the past the restorative students may have acquired the idea that dental problems are solved
aspects of occlusion rather than its development and correction. by t~chniques alone. The student l1}ay think that the only thing
The problems of occlusal development and correction are just as separating the several clinical branches of dentistry is variation in
much the responsibility and concern of the general practitioner as technical procedures. Much of clinical dentistry is related to repair
of the orthodontist; therefore, basic knowledge concerning occlusal or restoration, but orthodontics is carried out primarily by guidance
development, facial growth, and the correction of malocclusion of growth. The strategies and tactics of growth and development
should be part of the training of every dentist. It is ilot the tradition are conceptually quite different from replacing lost parts.
in many dental schools to spend mU,ch time on growth and de- Most dentists (including teachers) are frank to admit that they
velopment or training in the diagnosis and treatment of malocclu- know less about orthodontics than any' other branch of clinical
sion; therefore, some problems arise for the dental student or dentistry. The teaching of undergraduate orthodontics is difficult,
practicing dentist who wishes to study orthodontics. since usually there is little time in the curriculum. Teachers in

2

other departments may have little understanding of orthodontics;
consequently, orthodontic concepts are not reenforced and inte-
grated well into general clinical teaching. Finally, the subject does
not lend itself well to the semester or quarter module, nor to class
rotations through the orthodontic department for periods of a few
weeks. To be effective, orthodontic teaching must be spread over
months or years while cases are being treated or the child is ma-
turing to the moment when treatment can be begun. Growth changes
take time and cannot be compressed to fit into a single term to
suit the schedule.
2. For the Dentist in Practice
The dentist in practice who has had an inadequate under-
graduate orthodontics course, and seeks further training, may be
surprised to learn the kind of courses offered in orthodontics for
the generalist. Scarcely any short course can include clinical ex-
perience because of the time necessary to treat a malocclusion.
Most orthodontic books are written for the specialist. Finally, the
attitudes finely developed to ensure success in the other branches
of dentistry may handicap the generalist as he or she begins to
study orthodontics; for example, a fine clinical sense (If compro-
mise in treatment goals (see Chapter 14, in which the limiting
factors in orthodontic treatment are discussed). The dentist in prac-
tice who would learn orthodontics may have to overcome a lack
of basic undergraduate training and may have difficulty in obtain-
ing extensive postgraduate training of a practical clinical nature.
This book was written specifically to help the general dentist and
dental student start to overcome these difficulties.
B. WHAT IS ORTHODONTICS?
Orthodontics is that branch of dentistry concerned with the
study of the growth of the craniofacial complex, the development
of occlusion, and the treatment of dentofacial abnormalities.
1. History
Hippocrates' was among the first to comment about crani-
ofacial deformity:
"Ol IpO~OL ot J.LEV KlYpLEplYVXEVE<;, tUXVpL KlYL T&AAlY KlYL
OUTEOlUlV. ot OE KElplYAlYA-yEE<; KlYL wmppvTol. TOVTEOlUlV
U'TTEPli>m KOLAm KlYL 606vTE<; 'TTlYPTjAAlYl'J.LEVOl."
(Among those individuals with long shaped heads, some have thick
necks, strong parts and bones. Others have strongly arched palates,
their teeth are irregularly arrayed, crowding one another, and they
are bothered by headaches and otorrhea.)
Adamandios,! writing in the fifth century A.D., noted that "those
persons whose lips are pushed out because of cuspid displacement
are ill tempered, abusive shouters and defamers:"
"OUOl KlYTa TaU<; K1JVOOOVTlY<; KOPV<PoUTm
KlYK08vJ.LOl, U~plUTlYL, KpaKTm. E'TTEU~OAOl.
(<I>1JUlOI'VWJ.LlKOL<;). "
Introduction to the Study and Practice of Orthodontics 3
FIG 1-1.
Ancient Greek skull (circa 300 B.c.) shows use of gold wires to align
and stabilize mandibular incisors in an adult whose malocclusion has
been complicated by periodontal disease. (Courtesy of Professor
Vasili Haralabakis. Aristotelean University of Thessaloniki. Greece.)
Crude appliances that seemingly were designed to regulate
the teeth have been found as archaeologic artifacts in tombs of
ancient Egypt, Greece, and the Mayans of Mexico (Fig I-I).
Orthodontics, as we think of it today, however, probably has its
roots in France in the eighteenth century, when Pierre Fauchard,
that most famous of all dentists, described an orthodontic appliance
easily recognized as such by any modern dentist. Other articles
concerning the development of the dentition and facial growth
were written in the same period, but certainly John Hunter's (1728-
1793) natural history of the human teeth is of the most interest to
orthodontists.
In the United States of America in the latter part of the nine-
teenth century, Kingsley, Farrar, Talbot, and Guilford presented
pioneer writings on the treatment of malocclusion. Most North
Americans maintain that orthodontics, however, really had its or-
igin at the turn of the century, when Edward H. Angle published
A System of Appliances for Correcting Irregularities of the Teeth
and established a school for the training of dentists as orthodontic
specialists.
" The field developed differently in North America than in
Europe. Angle was an intellectual and mechanical genius who
dominated the orthodontic scene.in the New World more than any
one person in Europe. Further, he improvised clever appliances
for the precise positioning of the individual teeth, since, from the
start, he emphasized the,)mportance of correct occlusion. In Eu-
r6pe" on the other hand', early leaders in the field studied more
the role of the craniofacial skeleton in dentofacial anomalies and
malocclusion. Perhaps this is the reason that in the United States
the field is called orthodontics (from the Greek orthos, meaning
straight, and odontos, meaning tooth), whereas in Europe such
terms as dental orthopedics, orthopedie dentofaciale, and Gebiss-
und Kieferorthopedie are used. Although the terms generally are
Ta XELATj, interchangeable, they reflect differences in emphasis during his-
"
torical development and they betray differences in the aims of
appliance therapy among various countries. In recent years the
4 Growth and Development
terms "orthodontics" and "dentofacial orthopedics" have some-
times come to be used almost interchangeably throughout the world,
a reflection of the increased exchange of ideas and concepts.
Most dental specialities developed within the profession,
gradually evolving their own literature, specialized skills, and ad-
vanced training programs but maintaining strong ties to the mother
profession. In the United States of America, orthodontic concepts,
techniques, and specialized training, on the other hand, developed
largely from within the specialty. Orthodontics in North America
from the time of Angle has been a bit more apart from dentistry
than any other dental specialty. Therefore, North American con-
cepts of orthodontics, as well as mechanics, have been oriented
differently from European concepts. The specialty of orthodontics
has .flourished intellectually, clinically, and scientifically and has
attracted some of the finest teachers, scientists, and clinicians in
dentistry, yet orthodontic training in the undergraduate curriculum
still is generally superficial. As a result, most dentists really are
not well trained in orthodontics. On the other hand, graduate train-
ing programs have been strengthened, their scientific base has been
broadened, and the numbers enrolled have increased until today a
high percentage of all graduating dentists go on to orthodontic
specialty training. Indeed, the number of orthodontics in the United
States has increased so greatly in recent years that many areas
where there once was a shortage are now well supplied, and the
family dentist in these regions feels less obligation to treat severe
mal occlusions than he or she did when orthodontic colleagues were
not available.
The extensive adoption of insurance and third party payment
plans has had as much impact on orthodontics as other branches
of dentistry. Such plans make good dental care possible at low
cost for a large percentage of American families. Good dental care
which includes orthodontics and malocclusion treatment is now
more available and feasible than at any other time. National health
schemes in other countries include orthodontics. Therefore, there
continues to be an increasingly important role for orthodontics in
the practice of dentistry throughout the world.
2. Scope
Orthodontic therapy is directed to malocclusion, abnormal
growth of the complex of craniofacial bones, and malfunction of
the orofacial neuromusculature, which alone or in combination
may cause any of the following:
a) Impaired mastication.
b) Unfortunate facial esthetics.
c) Dysfunction of the temporomandibular articulation.
d) Susceptibility to periodontal disease.
e) Susceptibility to dental caries.
f) Impaired speech due to mal positions of the teeth.
Orthodontic therapy involves the three primary tissue systems
concerned in dentofacial development, namely, the dentition, the
craniofacial skeleton, and the facial and jaw musculature. By means
of suitable appliances, muscle function is improved and teeth are
positioned more favorably to provide better esthetics, occlusal
function, oral health, and speech. Correction of the craniofacial
skeleton, however, is a different matter, since it is more difficult
to alter the craniofacial skeleton than it is to position teeth. It is
possible, however, to direct and alter favorably the growth of the
craniofacial skeleton in young children. In older patients, whose
facial growth is mostly completed, the teeth are positioned to
camouflage disharmonies of the facial skeletal pattern. In the most
extreme cases orthognathic surgery is utilized in conjunction with
orthodontics. Finally, the neuromusculature, an important part of
improved function and esthetics, is used in orthodontic treatment
to modify the growth of the craniofacial skeleton. Orthodontic
treatment may utilize many procedures, although perhaps the most
frequent is the precise positioning of the individual teeth with
orthodontic appliances. However, appliances for orthopedic cor-
rection of the craniofacial skeleton, surgery, myotherapy, and even
psychotherapy are all used in modem orthodontic practice. Dentists
interested in providing high-quality orthodontic service for their
patients have the obligation to gain as much knowledge as possible
in order to serve well the patients they treat themselves and refer
others to a specialist for cooperative treatment. The next section
provides additional perspectives on this matter.
C. THE PURPOSE OF THIS BOOK
Most books in orthodontics are written for the orthodontic
specialist and intended for practitioners with considerable knowl-
edge of the subject. This volume presupposes very little orthodontic
background on the part of the reader. It reaily has two purposes:
to serve as an introductory text for dental students and to supply
basic orthodontic knowledge for the dentist who does not specialize
in orthodontics.
Orthodontics traditionally has never occupied a large place
in the dental curriculum; therefore, the teacher of orthodontics has
the difficult job of presenting a complicated and exciting clinical
field in just a few hours. Additionally, the basic science underlying
orthodontics--craniofacial growth and d~velopment-usually must
also be taught in the same orthodontic course. The new dental
graduate soon learns that he or she is more poorly prepared in
orthodontics than in any other clinical field, yet sees malocclusions
every' day. Which should be treated? How? Which should be re-
ferred? When? Which should be observed for later action? Why?
In brief, every dental student and practitioner needs a source of
fa~ts concerning growth and orthodontics (I) to augment formal
lectures, (2) to extend knowledge, and (3) to provide a ready-
reference manual when confronted with clinical problems. Ortho-
dontics is a part of dentistry; therefore, all dentists need some
orthodontic knowledge if for no other reason than that most mal-
occlusions are diagnosed first by the family dentist, not the
orthoflontist.' ~.
Some see two ways in orthodontics: a high road and a low
road. High-road treatment is comprehensive, precise, well done,
and limited by expense to but a few-the way of the specialist.
Low-road treatment is thought to be clumsy, utilizing simpler
appliances and compromised goals but providing some service for
a large proportion of the population-the way of family dentists.
This myth of two quality levels in orthodontics is perpetuated by
those who make extravagant or ill-founded claims, for example,
"If you use this appliance, you never need to extract teeth"; "The

periodontal response is different with this appliance"; "A ce-
phalometric analysis is not necessary with this system"; "This is
a general practitioner's appliance," Of course, there is only one
way in orthodontics-a way open to all dentists. Some, because
of more training and experience, can travel farther along the same
road-that is all. Modern dentists dedicated to the highest standards
in all other branches of dentistry do not accept the invitation to
lower their standards. They prefer to provide their patients with
the best possible care, to travel the high road as far as their knowl-
edge and skills will permit. The purpose of this book is to help
each dentist do all the orthodontics possible of the highest quality.
D. HOW TO USE THIS BOOK
Since this volume is intended to be a handbook rather than
an exhaustive text, its plan differs from that of many dental books.
It is suggested that one first read the entire book in sequence,
studying those portions of most interest. There should be no dif-
ficulty in using the book for consultation concerning clinical prob-
lems if the arrangement of the subject matter is understood. The
book is divided into three sections, Growth and Development,
Diagnosis, and Treatment, the outlines of which can be seen in
the Table of Contents. In addition, each chapter's contents are
outlined again at the beginning of the chapter. A list of "Key
Points" is provided at the beginning of most chapters as is a brief
summary at the end.
In addition to the References, a list of Suggested Readings
are included at the end of chapters. The latter are intended to aid
the reader interested in pursuing further the subject under discussion.
Although it is quite true that one cannot move teeth without
some sort of appliance, it is equally true that orthodontic treatment
cannot be successful without a thorough knowledge of the under-
lying theory. More malocculsions are mismanaged because of ig-
norance of the facts of growth and diagnosis than by lack of
knowledge of appliances. Gadgetry is so much fun, but in ortho-
dontics it is useless without basic knowledge. Section III will be
of little use to the clinician who does not understand Sections I
and 11on Growth and Development and Diagnosis.
When aid with a specific clinical problem is desired, the
following procedure is suggested: (I) Locate that section where
the problem is discussed. (2) While reading, compare the photo-
graphs and drawings with your problem. (3) Each section of Chap-
ters 15, 16, and 17 generally follows this order: (a) introduction
to the problem, including a discussion of etiology; (b) differential
diagnosis; (c) specific steps in treatment; (d) general discussion.
As you read, make comparisons with the facts you have gathered
concerning your case. (4) Refer back to earlier chapters, when it
is indicated, for a more detailed discussion of the predisposing
conditions of the case. As familiarity with the chapters on Growth
Introduction to the Study and Practice of Orthodontics 5
and Development and Diagnosis is gained, such references will
be less necessary. (5) During the discussion of steps in treatment,
reference will be made to techniques described in Chapter 18.
The conditions that underlie a satisfactory plan of treatment
are presented, but no attempt is made to describe all the possible
methods of therapy for a given problem. Only one procedure,
which will give adequate results in the hands of the nonspecialist
doing orthodontic work, is usually described. It will be easy for
most readers to think of other satisfactory methods of treatment,
and any orthodontist who chances on these pages will know many
ways of achieving similar results. Many problems are beyond the
scope of this book as far as treatment details are concerned, but
the principles are given. No attempt is made to provide details of
appliance construction or manipulation, but the principal methods
are introduced.
No book is a substitute for experience or good training, nor
can any set of rules take the place of good judgment or spare one
from thinking. Orthodontics, more than any other branch of den-
tistry, defies distillation to an ever-applicable axiom or procedure.
Ortega y Gasset' wrote about the economy of good teaching,
that is, the presentation of the least amount of information that
will provide the student with an understanding of the subject. Some
books are written to impress the reader, some to provide an ex-
haustive source of material for reference; this book was written to
further the role of orthodontics in the daily practice of dentistry.
SUMMARY
Orthodontics presents special problems for the dental student
because the course is traditionally brief and often late in the cur-
riculum. Furthermore, success in orthodontics is more dependent
on a working knowledge of craniofacial growth and development
than in other clinical fields. It is difficult to provide good post-
graduate clinical training in orthodontics for the general dentist
because of the time involved for growth and treatment.
Orthodontics has a lengthy history and today includes the
study of craniofacial growth, the development of occlusion, and
the·treatment of dentofacial abnormalities.
Orthodontic knowledge is needed by all dentists, not just by
orthodontists. This book serves as a text for dental students and
as a reference manual for general dentists in practice .
.,.
REFERENCES
I. Adamandios: Quoted by Haralabakis HN: Presidential ad-
dress. Trans Eur Orthod Soc 1964; 46-47.
2, .Hippocrates: Epidemics VI, 1,2.
3. Ortega y Gasset J: Mission of the University, London,
Routledge & Kegan Paul, Ltd, 1946.
CHAPTER 2

Basic Concepts of Growth and

Development
Robert E. Moyers, D.D.S., Ph.D.

Life is change; for when you are through changing, you are through.-BRucE BARTON

KEY POINTS status of the patient, recognize any pathologic

deviations, and plan treatment.
1. Growth and development are different from short-
term biologic alterations and long-term evolutionary OUTLINE
change.
2. Development includes all of the undirectional, A. Classes of alterations in biologic activities
normal changes in life from fertilization to death. I. Short-term physiologic or morphologic alterations
3. Development = growth + differentiation + , 2. Long-term genetic and evolutionary changes
translocation. 3. Developmental events
B. Principles and themes of development
4. Development is characterized by changes in
I. Principles
complexity, a shift to fixation of function, and more
" 2. Major themes in development
independence, all of which is under genetic control,
a) Changing complexity
yet modified by the environment. b) Shifts from competent to fixation
5. Developmental science includes many fields of study, c) Shifts from dependent t6 independent
basic and clinical, biological as well as behavioral. d) Modulation by environment
6. The methods of gathering and analyzing growth data C" Some definitions ,.-.
affect greatly one's ability to use them. • :'.1. Growth
2. Development
7. Physical growth is varied by many factors, both
3. Differentiation
genetic and environmental. 4. Translocation
8. There is great variability in the expression of growth 5. Maturation
and development within a given population. D. Divisions of developmental science
9. "Normal" refers to the expected or typical but is I. Molecular biology
misused as a goal of treatment or when confused 2. Developmental biology
with the ideal. 3. Physical growth
10. Growth is evaluated in clinical practice to assess the 4. Behavioral development

6
 Basic Concepts of Growth and Development 7

E. Methods of studying physical growth and development older. Biologic scientists study all the various types of alterations
I. Types of growth data in biologic activity.
a) Opinion
b) Observations
c)Ratings and rankings
d)Quantitative measurements
I) Direct data A. CLASSES OF ALTERATIONS IN
2) Indirect growth measurements BIOLOGIC ACTIVITIES
3) Derived data
2. Methods of gathering growth data 1. Short-term Physiologic or Morphologic Alterations
a) Longitudinal The skin may develop a bruise after trauma, the adrenalin titre of
I) Advantages of the longitudinal method our blood rises and falls with changes in our emotions, our body
2) Disadvantages of the longitudinal temperature varies according to the time of day and general bodily
method
activities, and animal pelts show variations in color and texture
b) Cross-sectional
with the seasons. All such alterations are sporadic biologic ad-
I) Advantages of the cross-sectional justments to changing environmental stimuli. The changes usually
method
are reversible, the organism returning to a state not very different
2) Disadvantages of the cross-sectional from what it was originally. Such short-term alterations in biologic
method
activity are not part of the systematic changes of development.
c) Overlapping or semilongitudinal data There are two kinds of development occurring simultaneously:
3. Evaluation of growth data evolutionary development and life cycle development. Life cycle
F. Variables affecting physical growth developments are connected to one another by a single-celled stage,
I. Heredity the fertilized egg. When we look at a whole series of life cycles
2. Nutrition
changing over a long time, we are studying evolutionary
3. Illness
development.
4. Race
5. Climate and seasonal effects on growth
6. Adult physique 2. Long-term Genetic and Evolutionary Changes
7. Socioeconomic factors
Basic alterations in the genetic make up of an orga-
8. Exercise
nism-mutations-may be inherited by offspring. If the mutation
9. Family size and birth order changes the organism in such a way that it cannot compete as well
10. Secular trends
in its environment, it may not survive. On the other hand, the
11. Psychological disturbance mutant may be better fitted for survival than its unchanged neigh-
G. Pattern
bors and thus the mutation contribut~s to the process of natural
1. Definition
selection. The summation of the surviving mutations contributes
2. Contributions to pattern to the evolution of many species. Long-term genetic and evolu-
3. Clinical implications tionary changes are quite different from the short-term changes
H. Variability mentioned above. Much more time is needed for the new variety
I. Concepts of normality to be obvious in its population. Interest in the changes centers not
a) Statistical on the individual but on the alterations in the genetic pool within
b) Evolutionary the. population. In order to understand the significance of genetic
c) Functional ~volutionary changes, population biologists must study large pop-
d) Esthetic ulations within which genetic changes are occurring.
e) Clinical
2. Age equivalence
3. Significance of variability 3. Developmental Events
I. Timing There are changing biologic activities that occur in a pro-
J. The evaluation of physical growth gt~sive fashion in the 'life history of every organism and that
I. Why assess? can~ot be considered under the two preceding classifications. Con-
2. Questions to be asked sider the life cycle of a typical mammal (Fig 2-1). The pace of
3. General growth standards the changes is too slow to be considered a short-term alteration
and far too fast to reflect changes in the gene pool or evolutionary
All of us have been aware since early childhood that a basic trends. There are other important differences: all of the changes
characteristic of life is change. We have watched the short-term are progressive, sequential, and irreversible, leaving the organism
biologic activities of animals as they gather food, protect them- unalterably changed from its former state. Single cells develop as
selves, play, and reproduce. We have noticed the slower changes do unorganized populations of cells, specific organs, and individ-
in plants and animals that occur in response to the changing sea- uals. Developmental scientists are concerned with all of the changes
sons. We have watched ourselves and friends change as we get of an organism from conception to death.
8 Growth and Development
FIG 2-1.
Developmental events in a single life cycle. (After Sussman M: Growth
and Development, ed 2. Foundations of Modern Biology Series. En-
B. PRINCIPLES AND THEMES OF
DEVELOPMENT
1. Principles
No principles or mechanisms of development are unique to
embryos, the face, man, or even mammals. For this reason prin-
ciples and mechanisms of development are best understood through
use of a generalized model system. As a model of himself, man
can be used only descriptively, not experimentally. Much that we
have learned about human development has been learned by the
formulation of such general models during studies of species other
than man.
2. Major Themes in Development
a) Changing Complexity
Changes in complexity take place at all levels of organization
from the sub-cellular to the whole organism. Ordinarily complexity
increases with development, as in the nervous system, but the most
complex period of the developing dentition occurs when the pri-
mary teeth are erupted and functioning while the permanent teeth
are developing in the jaws. The system is thus simplified with the
loss of the primary teeth and the complete eruption of the per-
manent teeth.
b) Shifts From Competent to Fixation
Undifferentiated cells are capable of becoming any of several
cell types through development, but after they are fully differen-
tiated they become fixed and cannot ordinarily become another
type. This is like the student entering the university who still has
DEATH
glewood Cliffs, NJ, Prentice-Hall, 1964. Reproduced by permission.)
the chance to be a physician, engineer, philosopher, or dentist.
However, advanced standing usually "fixes" one's career and it
is more difficult to change.
c) Shifts From Dependent to Independent
Development brings greater independence at most levels of
organization. The totally dependent fetus becomes the somewhat
'less dependent child who finally develops into the totally inde-
pendent adult.
d) Ubiquity of Genetic Control Modulated by Environment
At all levels the genetic control of development is constantly
being modified by environmental interactions which persist through
life,
C. SOME DEFINITIONS'
Semantic difficulties are present when the words growth and
devetopment are considered. Each term carries concepts not pres-
ent in~the other and yet there is ove)"lap in their usage. Sometimes
they are synonyms, sometimes they are not. Practice varies with
the user and the fields of science. The definitions which follow
are in common use in developmental biology and will be used
throughout the rest of this book.
1. Growth
Growth may be defined as the normal changes in amount of
living substance. Growth is the quantitative aspect of biologic

~
~"~,~
development and is measured in units of increase per units of time,
for instance, inches per year or grams per day. Growth .is the result
of biologic processes by means of which living matter normally
gets larger. It may be the direct result of cell division or the indirect
product of biologic activity (e.g., bones and teeth). Typically, we
equate growth with enlargement, but there are instances in which
growth results in a normal decrease in size, for example, the
thymus gland after puberty. Growth emphasizes the normal di-
mensional changes during development. Growth may result in
increases or decreases in size, change in form or proportion, com-
plexity, texture, and so forth. Growth is change in quantity.
2. Development
Development refers to all the naturally occurring unidirec-
tional changes in the life of an individual from its existence as a
single cell to its elaboration as a multi functional unit terminating
in death. It encompasses the normal sequential events between
fertilization and death. Note that development to the biologist refers
to the individual in contradistinction to species. Life of the indi-
vidual does not start as gametes or zygote, but as primordial germ
cells which give rise to gametes. In some invertebrates and in
plants life starts from almost any cell which is properly stimulated
and maintained. The term "multifunctional unit" emphasizes the
elaboration of multiple functions rather than multiple cellularity.
Unidirectional changes continue until death. Thus,
development = growth + differentiation + translocation:
These terms are not synonymous.
3. Differentiation
Differentiation is the change from generalized cells or tissues
to more specialized kinds during development. Differentiation is
change in quality or kind.
4. Translocation
Translocation is change in position. The chin point is trans-
located (moved) downward and forward far more than any growth
at the chin itself. Indeed, most of the growth is taking place at
the condyle and ramus while the entire mandible is translocated
ventrally (Fig 2-2).
5. Maturation
The term maturation is sometimes used to express the qual-
itative changes which occur with ripening or aging. We speak, for
Basic Concepts of Growth and Development 9
FIG 2-2.
A bone may move by two means: It can grow
(cortical drift) by selective deposition and re-
sorption (A) or it can become displaced from one
position to another (translocation) (B). (From
Enlow OH: The Human Face. New York, Hoeber
Medical Division, Harper & Row, 1968. Repro-
duced by permission.)
example, of the ripening of the ovum and we think of pubescence
as a period of rapid maturation as well as accelerated physical
growth.
D. DIVISIONS OF DEVELOPMENTAL
SCIENCE
Growth and developmental studies do not exist apart from
other biologic disciplines or their techniques. Studies of devel-
opmental events require the knowledge and methods of gross and
microscopic anatomy, psychology, biochemistry, physiology, ge-
netics, anthropology, and other disciplines. There are, however,
four large divisions within the broad field of growth and
development.
1. Molecular Biology
During the 1920s and 1930s, physical scientists developed a
fantastic array of exciting concepts and very precise new instru-
mentation, for example, the electron microscope. During the same
time, in the field of biochemistry, equally important advances were
being made in concepts and in precision of methods. When it
became possible to elucidate the detailed roles of specific mole-
cules in 1iving systems by means of these new tools of biochemistry
and biophysics (the study of physical phenomena in living proc-
esses), an exciting new era in biology began. We are in the midst
of a biologic revolution that is as important for man as the atomic
revolution. The discovery of RNA and DNA and deciphering the
-genetic code are among the most exciting events in the history of
science. Molecular biology includes such fast-developing new dis-
ciplines as molecular genetics, biophysics, and genetic engineering.
i: l?evelopmental Biol~gy
Because a fertilized egg starts as a single microscopic cell
and eventually, by development, becomes an adult comprising
millions of cells, the biologists who study this fascinating series
of events represent several areas of speciality. The fieid of de-
velopmental biology includes workers from cellular biology, em-
bryology, teratology, reproductive biology, perinatal biology, and
other disciplines. Developmental oral biology is the area of re-
search and teaching concerned with craniofacial growth and
development.
10 Growth and Development
3. Physical Growth
The field of physical growth is really the study of organ and
body growth and includes analysis of such problems as morpho-
genesis, height and weight, growth rates, retarded growth, met-
abolic disturbances in growth, developmental 'physical fitness,
pubescence, and morphometrics. Developmental scientists work-
ing in physical growth include pediatricians, anthropologists, en-
docrinologists, nutritionists, and dentists. Dentistry can take pride
in the fact that research orthodontists probably have contributed
more to the knowledge of the postnatal growth of the head and
face than any other single discipline. Clinical orthodontics has
often been described as the applied study of the physical growth
of the head and face.
4. Behavioral Development
As the child grows physically, patterns of interaction develop
with the env'ironment (i.e., behavior). Behavior appears in typical
sequences during development just as the physical attributes of the
body appear in an expected pattern. Scientists studying behavioral
development include embryologists, developmental psychologists,
psychiatrists, physiologists, physiologic psychologists, and
geneticists.
Previously these large divisions of growth and development
were viewed as a linear spectrum from the molecule to the behaving
adult individual, but the exciting new breakthroughs in molecular
biology cause us to view these divisions in a more circular pattern.
The molecular aspects of brain activity, for example, may provide
the answers to how we think, reason, remember, and forget.
E. METHODS OF STUDYING GROWTH AND
DEVELOPMENT
How do we study man's development? Not always by study-
ing man himself. It is useful that the basic principles of devel-
opment are common to many living organisms since all of man's
development is not accessible to ready study by experimentation.
Irrespective of the source of the growth data, the way the data are
analyzed is important.
1. Types of Growth Data
a) Opinion
When Aunt Tillie says "My, how Johnny has grown. I do
believe he's going to be taller than his father, " no one really takes
her seriously, for this is but a friendly lay opinion of growth
prediction based on no quantitative data and intended primarily as
flattery. However, opinion does creep into our textbooks and sci-
entific journals, where it is not so easily labeled as opinion, since
one expects substantiated facts in such places. Opinion is, at best,
a clever guess based on experience. Much scientific knowledge
began as an intuitive hunch made by a careful observer, so opinions
are not to be derided. However, they are the crudest form of
scientific knowledge and are not to be accepted' when better data
are available. They should always be designated for what they
are~ne person's biased guess .
b) Observations
Observations are useful for studying all-or"none phenomena,
for example, congenital absence of teeth. Observations also are
used in a limited way when more quantitative data are not possible,
for example, "In cursory visual examination of 67 Eskimo children
ranging between 6 and 11 years, not one case of Class II mal-
occlusion was observed."
c) Ratings and Rankings
Certain data are difficult to quantify and thus may be com-
pared to conventional rating scales. Such scales may be based on
developmental stages, on typical forms or patterns, or on standard
color charts. The method is used for the evaluation of breast de-
velopment, pubic and axillary hair patterns, ear shape, eye col or,
and fingerprints. Tooth shape (square, tapering, and ovoid), facial
form, and tooth development are common examples of the use of
ratings or rankings. Whereas ratings make use of comparisons with
conventional accepted scales or classifications, rankings array data
in ordered sequences according to value. Thus, one reads such
statements in the literature as "When the ten tallest boys were-
compared with the ten shortest boys in the sample it was
found .... "
d) Quantitative Measurements
Science is concerned with quantitation. Indeed, if one cannot
express an idea or a fact as a meaningful quantity, one has scarc.ely
begun to think about it in a scientific way. Quantitation minimizes
misunderstanding and permits the testing of hypotheses by other
workers. Any scientist has the right to be skeptical of another's
opinion, no matter how renowned the holder of that opinion, until
it can be reduced to numbers for testing and further study.
1) Direct Data.-Direct data are derived from measurements
taken on the living person or cadaver by means of calipers, scales,
measuring tapes, and other measuring devices. Measuring the size
. of the teeth with a Boley gauge in the mouth of a patient produces
direct data.
2) Indirect Growth Measurements.-Indirect growth meas-
urements are those taken from images or reproductions of the actual
person, for example, measurements made from photographs, den-
tal casts, or cephalograms.
',.
3) Derived Data.-Derived data are obtained by comparing
at least two other measurements. "When we say that a person's
mandible grew 2 mm between ages 7 and 8, the 2 mm have not
actually been measured; rather, the mandibular length at 7 years
has been subtracted from)he mandibular length at 8 years and the
inc;einent thus derived is assumed.,to represent growth.
2. Methods of Gathering Growth Data
a) Longitudinal
Measurement made of the same person or group at regular
intervals through time are longitudinal measurements.
1) Advantages of the Longitudinal Method.-
• Variability in development among individuals within the

group is put in proper perspective.
• The specific developmental pattern of an individual can be
studied, permitting serial comparisons.
• Temporary temporal problems in sampling are smoothed
out with time, and an unusual event or -a mistake in meas-
uring is more easily seen and corrections made.
2) Disadvantages of the Longitudinal Method.-
• Time. If one wishes to study the growth of the human face
from birth to adulthood by means of longitudinal data, it
will take a lifetime to gather the data.
• Expense. Longitudinal studies necessitate the maintenance
of laboratories, research personnel, and data storage for a
long time and thus are costly.
•• Attrition. The parents of children in longitudinal studies
change their places of residence or lose interest in the
study, and some children die. The result is a gradual dimi-
nution in sample size. The attrition in a typical longitudinal
study often reaches 50% in 15 years.
• Averaging. The changes in average size of a group of indi-
viduals do not adequately indicate the sequence of events
that is followed by any single individual.
b) Cross-Sectional
Measurement made of different individuals or different sam-
ples and studied at different periods are cross-sectional measure"
ments. Thus, one may measure a group of 7-year-old boys and
on the same day, at the same school, measure a group of 8-year-
old boys. Changes between 7 and 8 years of age in boys at that
school are thus assumed after study of the data obtained.
1) Advantages of the Cross-Sectional Method.-
• It is quicker.
• It is less costly.
• Because it is simpler to get large samples by the cross-sec-
tional method, statistical treatment of the data sometimes is
made easier.
• The method allows repeating of studies more readily.
• The method is used for cadavers, skeletons, and archaeo-
logic data.
2) Disadvantages of the Cross-Sectional Method.-It must
always be assumed that the groups being measured and compared
are similar. Cross-sectional group averages tend to obscure indi-
vidual variations. This is particularly obfuscating when studying
the timing of developmental ev~~ts, for example, the onset of
pubescence or the adolescent growth spurt.
c) Overlapping or Semilongitudinal Data.
Longitudinal and cross-sectional methods are combined by
some workers to seek the advantages of each. In this way, one
might compress 15 years of study into 3 years of gathering data,
each subs ample including children studied for the same number
of years but started at different ages. For example, subsample A
Basic Concepts of Growth and Development 11
may go from 3 to 6 years of age, subs ample B from 4 to 7,
subsample C from 5 to 8, and so forth.
3. Evaluation of Growth Data
The evaluation of growth data is one of the most complicated
and fascinating branches of statistics. Many facts of growth lie
hidden in clinicians' or scientists' crude hunches and can be bared
for further study only by careful and imaginative statistical dis-
section. Those who deride statistical studies of growth and clinical
data usually are totally ignorant of the possibilities of modem
statistical methods. Although the statistical treatment of biologic
data is beyond the scope of this book, in my opinion, an intro-
ductory working knowledge of statistics is a necessity for every
physician and dentist; otherwise, one has no way of evaluating the
significance of the findings regularly presented in clinical and
research journals.
Orthodontists and other craniofacial growth scientists have
developed the field of cephalometrics in order to study grov.::th,
quantify morphology, and assess the progress of treatment (see
Chapter 12). There is no better example of the evaluation of growth
data than the day-to-day use of cephalometrics in research and
practice.
F. VARIABLES AFFECTING PHYSICAL
GROWTH
Variability may be seen in the rate, timing, or character of
growth as well as the achieved or ultimate size.
1. Heredity
Genetic studies of physical growth make use of twin and
family data. Differences between monozygotic and dizygotic twins
are assumed to be differences due to environment. There is genetic
control of the size of parts to a great extent, of the rate of growth,
and of the onset of growth events, for example, menarche, dental
classification, the eruption of teeth, ossification of bones, and the
start of the adolescent growth spurt. Not all the genes are active
at birth. Some only express themselves in the surroundings made
possible by the physiologic growth of later years; such effects are
. called "age limited." An important point for orthodontics: there
is a considerable degree of independence between growth before
and growth during adolescence.
2. Nutrition
':' '. Malnutrition delays' growth and may affect size of parts, body
prbportions, body chemistry, and the quality and texture of some
tissues (e.g., teeth and bones). Malnutrition may also delay growth
and the adolescent growth spurt, but children have fine recuperative
powers provided the adverse conditions have not been too extreme.
During rather short periods of malnutrition growth slows up and
waits for better times. With the return of good nutrition growth
takes place unusually fast until the genetically determined curve
is neared once more and subsequently followed. Though "catch-
up growth" is seen in both sexes, girls seem to be better buffered
against the effects of malnutrition and illness.
12 Growth and Development
3. Illness
Systemic disease has an effect on child growth, but the plas-
ticity of the human organism during growth is so great that the
clinician must differentiate between minor illnesses and major
illnesses. The usual minor childhood illnesses ordinarily cannot
be shown to have much effect on physical growth. On the other
hand, serious prolonged and debilitating illnesses have a marked
effect on growth. The pediatrician is concerned not only with the
diseases that may kill or maim the child but also with those that
affect the growth process as well. Some of the effects of disease
on facial growth are discussed later in this book (Chapter 12).
4. Race
Anthropologists studying the racial aspects of growth have a
problem in the definition of race. Some so-called racial differences
are clearly due to climatic, nutritional, or socioeconomic differ-
ences. However, gene pool differences account for the fact that
North American blacks are ahead of whites in skeletal maturity at
birth and for at least the first 2 years of life. This progress is
associated with advanced motor behavior and earlier ability to
crawl and sit up. North American blacks also calcify and erupt
their teeth about I year earlier than whites.
S. Climate and Seasonal Effects on Growth
There is a general tendency for those living in cold climates
to have a greater proportion of adipose tissue, and much has been
made of the skeletal variations associated with variations in cli-
mate. There are seasonal variations in the growth rates of children
and in the weights of newborn babies. Contrary to popular belief,
climate has little direct effect on rate of growth.
6. Adult Physique
There are correlations between the adult physique and earlier
development events. For example, tall women tend to mature later
and there are variations in the rate of growth associated with
differing somatotypes.
7. Socioeconomic Factors
Socioeconomic aspects obviously include some growth fac-
tors mentioned previously (e.g., nutrition); yet, there are discrete
differences. Children living in favorable socioeconomic conditions
tend to be larger, display different types of growth (e. g., height-
weight ratios), and show variation in the timing of growth, when
compared with disadvantaged children. Some of the causes of these
differences are obvious and some of the implications are puzzling.
As our society becomes more affluent, how long will we get bigger
and mature earlier? Are such changes really improvements? It is
interesting to note that many of the positive relationships are as-
sociated with socioeconomic "class" and not with family income.
8. Exercise
A strong case for the effects of exercise on linear growth has
not been made in a quantitative fashion. Although exercise may
be useful for the development of motor skills, for increase in the
muscle mass, for fitness, and for general well-being, those children
who exercise strenuously and regularly have not been shown to
grow more favorably.
9. Family Size and Birth Order
There are differences in the sizes of individuals, in their
maturational levels of achievement, and in their intelligence that
can be correlated with the size of the family from which they
came. First-born children tend to weigh less at birth and ultimately
achieve less stature and a higher I.Q.
10. Secular Trends
Size and maturational changes in large populations can be
shown to be occurring with time that, as yet, have not been well
explained. Fifteen-year-old boys are approximately 5 inches taller
than l5-year-old boys were 50 years ago. The average age at onset
of menarche has steadily become earlier throughout the entire
world. Both of these facts seem to be true when race, socioeco-
nomic level, nutrition, climate, and other differences have been
carefully controlled in the samples. Such changes are called secular
trends in growth and, although thoroughly and meticulously stud-
ied, have yielded no really satisfactory and generally accepted
explanation for such interesting findings.
11. Psychological Disturbance
It has been shown that children experiencing stressful con-
ditions display an inhibition of growth hormone. When the emo-
tional stress is removed they begin again to secrete growth hormone
normally, and "catch-up" groWlh is seen. It is suspected that the
same thing may happen under less extreme conditions and thus
account for lesser variations in individuals' growth, but the evi-
dence is scanty.
G.PATTERN
1. Definition
In biology the word "pattern" has many meanings and uses:
arrangement of parts, values, or events; arbitrary lists of statistics;
or relations among measurements. All include the concept of per-
sistence or invariance, in contrast to the word growth, which con-
veys the idea of change in size. The biologic usage applicable in
craniofacial growth is that which defines pattern as a set of con-
strai!lts operating to preserye the integration of parts under varying
conditions or through time (see Ch~pters 4 and 12).
2. Contributions to Pattern
The fundamental plan of growth is laid down very early within
the safety of the uterus where bones show their well-defined shapes
before function and interaction with the environment begins.
Therefore, genetic factors are important, but the interactions
throughout life between heredity and the environment are clearly
what determines the expression of pattern. However, it is very
 Basic Concepts of Growth and Development 13

difficult to determine quantitatively the relative contributions of normality varies and is often a source of misunderstanding.
each.

3. Clinical Implications a) Statistical

In orthodontics, use of the word pattem..has both a morpho-
logic and a developmental application (see Chapter 4). "That child
has a Class 11facial pattern" may be a typical morphologic state-
ment of pattern, while "Susie has a vertical growth pattern" is a
statement applying the definition to development.
H. VARIABILITY
. Variability is the law of nature. Because of the infinite number
of genetic possibilities, no two individuals (except possibly mon-
ozygotic twins) are ever exactly alike. Variations in response to
environment cause increasing differences among similar individ-
uals with'time. Variability may be demonstrated in many ways.
In physical growth, variability is demonstrated by the use of sta-
tistics, which express quantitatively the range of differences found
in a large population of individuals of similar age, sex, socioec-
onomic background, and race. Such comparisons evoke the logical
question "What is normal?"
1. Concepts of Normality
Normal refers to that which is usually expected, is ordinarily
seen, or is typical, but usage of the word normal and the concept
In statistics, there are specific mathematical ways for por-
traying the central tendency of a group or population, for example,
the mean (an average of values), the median (that value midway
between the greatest and smallest measurement, i.e., an average
of position), the mode (the most frequent measurement, i.e., an
average of popularity or frequency), and the standard deviation
(SD, a mathematical expression of the distribution of individuals
around the mean) (Fig 2-3).
b) Evolutionary
All forms of life today have passed the critical test of survival.
Bizarre and abnormal forms, unable to cope, have been lost.
c) Functional
It is normal for most biologic forms to establish effective
homeostasis with the environment in order to adapt and survive.
d) Esthetic
Often we forget the role that culture plays in determining
what within a given group is considered normal. The feet of baby
girls have been bound to produce warped, distorted growth; wooden
plates have been inserted into the lips of women; scarring of the
face has been practiced, etc. What one would consider normal for
the feet, the lips, or the facial musculature would, of course, be
affected, in these instances, by the particular culture.

A X
I c
,6 ??oo
-5 5000
,5 ??oo
-4 5000
., ??oo
-3 5000
., ??oo
-25000
., ??oo
-1 5000
., ??oo
. 5??oo
o
- Median and Mode
5??oo '----""Mean
1??oo
1.5000
B , ??oo
2.5000
, ??oo
, 5000
'??oo
, 5000

D2
., ??oo
-5 5000
FIG 2-3. ,5 ??oo
'4 SOOO
., ??oo
A, measures of central tendency. The standard deviation is a way -3 5000
~- -3 oooc
of depicting the spread of values around the mean (X). Given a ~;. -2 5000
•• -2 QOOO
normal curve, ± 1 SO = 67% in all cases, ± 2 SO = approximately -I 5000 ~~Mode
., ??oo
95%, ± 3 SO = approximately 98%. B, an array of a sample of • 5COOO -----,Median
o
severe malocclusions will likely not reveal a normal distribution but 5??oo
, ??oo ------Mean
may, depending on the utility of the measures, show the presence , 5000
, ??oo
of "types" (see subgroups superimposed on the distribution). C, se- , 5000
, ??oo
vere malocclusions, > ± 1 SO, occur in less than one-third of the , 5000
'??oo
population, while those ± 2 SO from the population mean, are so , 5000

rare it is difficult to accumulate a number sufficient for meaningful

statistical analysis. 0, distribution of molar relationship in a sample values and distribution. Mean is an average of value (i.e., 50% per-
of dental casts from 7-year-old children. 0-1, left-side (SO = 1.5 centile). Median is an average of position, in this instance, the meas-
mm). 0-2, right-side (SO = 1.7 mm). Note left-right differences in ure of the 62nd child. Mode is the most frequent measure.
 14 Growth and Development

e) Clinical necessarily found in' anyone individual of the group.

In dentistry we have often equated the term normal with ideal. There are obvious conflicts among these various concepts of
Almost ,every textbook of dentistry includes a picture of "normal normality. The semantic difficulties must not interfere with the
occlusion," showing a perfect intercuspation of 32 permanent clear thinking needed for understanding growth or planning treat-
teeth. The probabilities of such an intercuspation.appearing in an ment (see Chapter 14). Misuse of the concept of normality and
individual are very, very small and thus, from a statistical stand- the term normal has led to many problems in clinical orthodontics,
point, quite abnormal. The concept of normality must not be equated particularly in planning treatment. To use the normal values for a
with the ideal or the desired, nor is it appropriate as a goal of group as the best goal of treatment for an individual is not only
treatment for an individual. Rather, it should be thought of as the illogical and irrational; it may indeed be harmful.
central tendency for the group. Normal measurements are not

82
PLOT OF MALE AND FEMALE MEANS FOR PLOT OF MALE AND FEMALE MEANS FOR ANNUAL CHANGE
MANDIBULAR LENGTH ACROSS AGE IN MANDIBULAR LENGTH ACROSS AGE
80

'5'
z6
'"
w
70
75 6I
I •55
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=> /~ "f

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~ I '"
50
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...
--'
=>
CD
is
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:::<

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w
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Z
Legend ... Legend
tJ. t.4AlES
IU 6 loCALES

9 W 11 12 13 ,. 15
,
16
x F(t.4ALES_
0-'
5 9 10 11 12 13 1~ 15 16
x FEMALES.

AGE (YEARS) AGE (YEARS)

501
70l
l::. xV1

~
MALES
IA1'0
,".
108,79,11
512
615

FEMAlES_
,

STATURE
/
PLOT OF ACROSS AGE
MALE AND Legend
FEMALE MEANS FOR
/-
~
A2
PLOT OF MALE AND FEMALE MEANS FOR ANNUAL CHANGE
IN STATUREACROSS AGE

z'
<:>
w
'"
=>

~
V1 2
~
w.
'"
Z
',-<{
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~Lnn 5 6 7 8 9 10

~G~~ (YEARS)
11
T

12 "T

,.
T 1
15
t>

x
Legend
MALES

FEt.4ALES_

FIG 2-4.
Growth plotted in different ways. A, stature. A-1, note effect of ad-
olescence on population differences in sexual dimorphism. A-2, stat-
ure velocity curves. Note early appearance of effects of pubescence
on rates of stature increase in girls. B, mandibular length (condylion-
pogonion) plotted against chronological age. B-1, accumulated length.
B-2, velocity (incremental) plot. Note population differences between
stature and mandibular length. C, mandibular length and stature
plotted against "dental age." (Zero is not the time of birth, as in
chronologic age, but time of arrival of the first permanent incisor.)
C-1, accumulated mandibular length. C-2, mandibular increments/
year (velocity). C-3, stature. C-4, stature increments. D, comparison
of mandibular and stature changes in two individuals. Note differ-
ences in timing and percent annual change. (Data from University
of Michigan Growth Study, Center for Human Growth and Devel-
opment, University of Michigan, Ann Arbor. ~
 Basic Concepts of Growth and DeveLopment 15

c,
PLOT OF MALE AND FEMALE MEANS FOR ANNUAL
CHANGE IN MANDIBULAR LENGTH ACROSS DENTAL AGE

5' 3
6
I
I-
'"
Z
w
-'
er
-'
<{
~
m
is
z
<{
::t
Legend
tJ. WALES

x fnu.lEs.
2 J " 5
DENTAL AGE (YEARS)

c.
PLOT OF MALE AND FEMALE MEANS FOR PLOT OF MALE AND FEMALE MEANS FOR ANNUAL
STATURE ACROSS DENTAL AGE CHANGE IN STATURE ACROSS DENTAL AGE
.,
.0

55
~
Z er=
w '0
s;
Vl
.,
w
~
er 2

S;
Vl

40 Legend Legend
t::. Ir.CAlES A WALES

>( rE •••AlEs_ 'l( rEWAlES.

35-, o
-2 -, 1 2 3 -, 2 3
DENTAL AGE (YEARS) DENTAL AGE (YEARS)

01 02
PLOT OF % ANNUAL CHANGE IN MANDIBULAR LENGTH PLOT OF % ANNUAL CHANGE IN MANDIBULAR LENGTH
AND STATURE ACROSS AGE FOR SUBJECT 1872 AND STATURE ACROSS AGE FOR SUBJECT 2026
10 10

w w
'" '"
Z z
IU
<{ • <{
IU •

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Legend Legend
tJ. ••• "ND LGTH 6 WAND LGTH

x STATURE _ x STATURE _
o
W 11 12 U M ~ ~ V • w n 12 U U ~ ~ 17

AGE (YEARS) ~~~~

FIG 2-4. (continued.)

16 Growth and Development
2. Age Equivalence
Because individuals develop in different patterns, producing
variability, all individuals of a given chronologic age are neither
necessarily of the same size nor the same stage of maturation and
development. A problem is thus posed for the clinician and the
developmental scientist, namely, how does one compare individ-
uals of the same chronologic age but varying stages of biologic
development? A number of "developmental ages" have been sug-
gested as a method of meeting this problem. Thus, one hears of
skeletal age (SA), usually based on the carpal calcification; dental
age (DA), based on the number of teeth calcified or erupted;
chronologic age (CA), expressed as years and months from birth;
mental age (MA), and so forth. It often is better to compare
individuals at the same stage of biologic development rather than
at the same chronologic age.
3. Significance of Variability
The significance of variation from the norm for the group in
which an individual is found can be understood only if the indi-
vidual's present status is thought of in terms of progress toward
his or her own goal rather than rigidily comparing this person's
progress to the group's progress toward its goal. It thus becomes
necessary to appraise the growth of the individual and to compare
this pattern in the light of his or her familial tendency and the
larger group to which he or she belongs (see Section J, The Eval-
uation of Physical Growth). Gross variation from the central tend-
ency may also be indicative of a pathologic condition or a grossly
abnormal pattern of growth that will markedly affect treatment.
I. TIMING
The timing of developmental events is largely under genetic-
control, yet altered by the environment. The developmental sci-
entist is interested in when growth processes are" turned on," for
example, pubescence, or when they cease. The age of maximum
growth increments during puberty-the adolescent spurt-is not
only of developmental interest but is used as a marker for timing
other growth events (Fig 2-4).
There are sex-related differences in the timing of many growth
phenomena. Usually, girls precede boys, for example, in pubes-
cence, dental calcification, and ossification of carpal bones. Fur-
ther, there are differences related to physique, for example, taller
children tend to reach the adolescent spurt later than short-legged,
stocky types. Such severe environmental effects as disease and
malnutrition not only affect the quality of the growth but may alter
the timing of development as well.
Nowhere is timing more critical than in the fusion of facial
parts in early prenatal growth (see Chapter 3). Cleft lip and/or
cleft palate is a well-known example of a gross craniofacial de-
formity resulting from a failure of facial parts to fuse at a critical
time. When dental and facial skeletal growth are not synchronized,
some malocclusions are produced and others aggravated. Much of
this book deals with the problem of mal-timed developmental
events in the face.
J. THE EVALUATION OF PHYSICAL
GROWTH
1. Why Assess?
The clinician is interested in assessing physical growth for
the following reasons:
a) The identification of grossly abnormal pathologic growth.
b) The recognition and diagnosis of significant deviations
from normal growth.
c) The planning of therapy.
d) The determination of the efficacy of therapy.
Unless the clinician has a clear and quantitative assessment
of growth at the start of treatment, it will be impossible to evaluate
later how well any treatment has progressed.
2. Questions to Be Asked
a) What is the status of the patient at the moment? Most of
the time, the clinician must base judgments on a single examination
and therefore must determine status of the individual by cross-
sectional evaluation alone.
b) What is the progress of growth to date? When serial records
are available longitudinal comparisons to the patient's own pattern
of development can be made.
c) How does he/she compare with others? Comparison with
others of the same age, sex, and race is done with derived growth
standards, but the abuse of growth standards is a sad and unfor-
tunate story. Most of the mistakes in the use of growth standards
are the result of two problems in understanding: (I) the choice of
the appropriate standard; and (2) the nature of biologic variability.
Unless the standards have been derived from a population appli-
cable to the problem at hand, it is better not to use standards at
all. Indeed, for many problems in facial growth, as it relates to
clinical practice, few appropriate standards are available. Fur-
thermore, to choose one or two mean values from a biased sample
and apply them rigidily to all individuals with no understanding
of the entire craniofacial complex and the adaptations and reasons
for the variations from the mean is naive and ridiculous and hand-
icaps-one in planning the treatment.
d) How does he/she fit the family pattern? Only recently have
quantitative studies of familial tendency in facial growth appeared
in the literature, yet much can be learned by studying records of
siblings and parents. Most orthodontists believe that the second
child in a family can be treated better because of what was learned
from treating the first.
e) What will he/she do in the future? The prediction of cran-
iofacial growth is one of the liveliest topics in the literature today
(se\; Chapter 12). The most. popular methods predict coarsely the
growth of an individual from data d,erived from populations. Much
can be learned, but the estimates are more qualitative description
than precise prognostication, more clinical art than science. How-
ever, no one should begin orthodontic treatment without estimating
as well as possible what can be expected in the future. The di-
rection, amount, site, and timing of growth affect the treatment
and the retention of the results of treatment. It would be ideal if
one could, by data derived from a single cephalogram, make quan-
titative predictions of the details of growth and form change for
that individual even during the modifying effects of treatment.

Such predictive methods are now under development and may
some day have a significant impact on orthodontic treatment plan-
ning. The new methods are based on sophisticated computer ma-
nipulation of large data bases and the use of strikingly original
approaches to mathematical modeling of craniofacial form and
growth.
3. General Growth Standards
The evaluation of the physical growth of the total child is a
large field of science in itself. Many methods have been devised
to appraise height, weight, skeletal development, muscle strength,
the onset of pubescence, and other factors. Ingenious and com-
plicated formulae of growth have resulted in many clever graphic
methods of portraying growth standards so that the individual may
be compared to norms. Such evaluations of physical growth are
done daily in pediatric and dental practice, but there is always
danger of oversimplification of the complexity of growth by as-
suming that anyone or two measurements truly reveal the progress
of physical growth.
SUMMARY
To the biologist growth and development are the normal
changes from birth to death in an individual organism. Growth
and development are therefore different from random, short-term
biologic alterations and long-term evolutionary trends. Growth is
size change. Differentiation is specialization. Translocation is
change in position. Development = growth + differentiation +
Basic Concepts of Growth and Development 17
translocation. Developmental science includes many fields of in-
terdisciplinary study and highly specialized methods of research
and clinical application.
Growth and development show wide variability of expression
within a population. This variability is the source of many clinical
problems. The expected average or norm is not a good expression
of the wide variability seen and the normal is, unfortunately, often
misused as a goal of treatment or is confused with ideal devel-
opment. The evaluation of the growth and development of the
individual patient is an important part of orthodontics as a basis
of comparison with the normal, as a means of discovering and
diagnosing maldevelopment (malocclusion), and as the foundation
for planning orthodontic treatment.
SUGGESTED READINGS
Baer M: Growth and Maturation, An Introduction to Physical
Development. Cambridge, Mass, Howard A. Doyle Publish-
ing Co, 1973.
Falkner F: Human Development. Philadelphia, WB Saunders,
Co, 1966.
Falkner F, and Tanner JM: Human Growth, New York, Plenum
Publishing Corp, vol I, Developmental Biology and Prenatal
Growth; vol 2, Postnatal Growth and Neurobiology; vol 3,
Methodology, Genetics, and Nutritional Effects on Growth,
1986.
Harrison GA, Weiner JS, Tanner JM, et al. Human Biology,
2nd ed. Oxford, Oxford University Press, 1977.
Lowrey GH: Growth and Development of Children, ed 8. Chi-
cago, Year Book Medical Publishers, 1986.
Young JZ: An Introduction to the Study of Man. Oxford, Ox-
ford University Press, 1971.
CHAPTER 3

Prenatal Facial Growth

lames K. Avery, D.D.S., Ph.D.

The history of man for the nine months preceding his birth
would, probably, be far more interesting and contain events
of greater moment than all the three score and ten years
that follow it.-SAMuEL TAYLORCOLERIDGE, Miscellanies,
Aesthetic and Literary ...

KEY POINTS 9. The bony skeleton of the medial face develops from
cartilage, while the lateral face develops from
1. Critical events leading to normal facial growth occur connective tissue or membrane.
in the first 4 weeks of life. 10. The hyoid (2nd) arch muscles migrate over the face
2. Precursor cells migrate into the facial region as the during formation, whereas the muscles of mastication
architects of the individual characteristics of facial develop only within the mandibular (first) arch.
growth.
3. Environmental factors play a significant role in
developmental malformations. OUTLlNE
4. Cleft lip/palate is one of the more common
congenital malformations, appearing in one of every A. Period of organization of the face
800 births. I. The branchial arches
5. In the early stages of development the face is ~ 2. Development of the perioral region
segmented by branchial arches which, if they do not 3. Changes in facial proportions
disappear, can result in branchial clefts and related 4. Origin of facial malformations
lateral facial malformations. B. Development of oral structures
6. The face is closely related to brain development, and
I. Development of the tongue
2. Formation alld elevation of the palatal shelves
defects of the anterior brain usually result in facial
deformations. ".3. Factors in ~ormal palatal development
4. Fusion of the palatat shelves
7. The palate initially develops as shelves formed beside 5. Tooth development
and below the tongue. These then elevate above the 6. Salivary gland development
tongue. This complex developmental process may C .. Differentiation of supporting structures
result in cleft palate. I. Development of the chondrocranium
8. The blood supply of the face shifts from the internal 2. Development of the maxillary complex
to external carotid arteries at the time the palatal 3. Development of the bony palate
shelves are maximally developing. 4. Mandible and temporomandibular joint

18

5. Facial muscles
6. Muscles of mastication
D. The fetal period-third to ninth months
I. Craniofacial changes
2. Radiographic changes
An understanding of the events leading to the organization of the
face in its normal form is critical to the understanding of various
factors responsible for abnormal development in that area.
These events take place during the first 4 weeks in prenatal
life as the fundamental plan for an individual's face unfolds. The
first sign of growth is in the expansion of the forebrain. The tissues
ov.erlying the forebrain will differentiate into the nasal areas and
forehead. Other tissues develop soon after, and will migrate and
form the maxillary processes and mandibular arch. All these tissues
will differentiate into the specific facial characteristics of that in-
dividual. The minute proportional differences that occur in each
human face are what make each of us a distinctly recognizable
individual. Each of us is unique (identical twins are a partial
exception).
Environmental factors will play a role in this differentiation.
Prior to the beginning of heartbeats and establishment of the um-
bilical circulation, in the fourth prenatal week, the embryo is
isolated from the extrenal environment, utilizing its yolk sac for
nourishment and growth. This period is one of rapid enlargement
of the embryo. The increase in cellular proliferation enhances the
potential for teratogenic (adverse environmental) factors to alter
development.
This chapter describes the events leading to maturation of the
human face and evaluates the role of normal and adverse factors
that affect the delicate balance of growth.
Branchial Arches
Oral
Cavity
Heart
A
FIG 3-1.
Sketches of human embryos at 5 (A) and 7 weeks (B) illustrate
appearance of human face during the 2-week time period in which
the face develops.
Prenatal Facial Growth 19
A. PERIOD OF ORGANIZATION OF THE
FACE
1. The Branchial Arches
Differentiation of the human face takes place early in prenatal
life, specifically between the fifth and seventh weeks after fertil-
ization occurs.]4 During this short period, a number of important
events occur that determine the formation of the human face.
In the fourth week after conception, the future face and neck
region located under the fore brain of the human embryo becomes
segmented (Fig 3-I,A). Five branchial arches are formed, ap-
pearing as rounded, tubular enlargements, and are bounded by
clefts and grooves that help define each arch. They are numbered
beginning anteriorly. The mid and lower facial regions develop,
in part, from the first two, named the mandibular and hyoid arches.
The third also contributes to the base of the tongue. Within each
of these branchial arches arise skeletal, muscular, vascular, con-
nective tissue, epithelial, and neural elements that develop into
the systems supplying the face and neck. Most of the structures
of the adult face thus develop from the first and second branchial
arches and from tissues surrounding the forebrain. In the early
period of development (i.e., the fourth week), it is difficult to
distinguish the primary craniofacial features of the human embryo
from those of other mammales (Fig 3-1 ,A and B).
The human face is first characterized by an invagination or
dimple in the surface ectoderm layer appearing just below the
forebrain. As this pit deepens, it forms the outline of the oral
cavity (Figs 3-1 ,A and 3-2,A). The tissue masses immediately
surrounding this oral pit will form the human face. In the fourth
week, the posterior boundary of the oral pit comes into contact
with the developing foregut. As the ectodermal oral plate meets
.i.
20 Growth and Development

the entodermal lining of the gut, the membranes disintegrate, and
continuity between the oral cavity and the gastrointestinal tract is
first gained. At 5 weeks (Fig 3 - I ,A), the "face" appears crowded
between the rapidly growing forebrain and the heart, which oc-
cupies much of the chest cavity at this stage. The nonfunctioning,
developing lungs are still quite small, composed mainly of con-
ducting bronchi until the respiratory bronchioles begin to form in
the fourth month.17 As the lungs do not function in respiration
until after birth, the oxygen needs are supplied from the placenta
through the umbilical veins to the heart. The heart, however, must
function very early. It becomes conspicuous by its size in the third
week and initiates a beat in the fourth week of embryonic life.'9
During the prenatal period, the heart not only pumps blood
thr~ughout the body of the embryo but also conducts blood to,
through, and from the placental system back to the heart. The
heart is proportionately much larger at this time than it will be in
the adult body and, therefore, requires much space for its proper
development. The growth of the heart affects the development of
the face, not only because of the importance of the blood supply
to its development but also because the face during its early period
of rapid growth and organization is crowded between the enlarging
forebrain and the pulsating heart. Even at this early stage, the
growth pattern of the face is downward and forward as it grows
out from between these two organs. Important related occurrences
are the flexures that occur during the fourth week in the region of
the future neck. The brain flexes ventrally, then dorsally and, as
a result, the head becomes more erect.
2. Development of the Perioral Region
The "face" at the fifth week is about as thick as the sheet
of paper from which you are reading, and the whole face is only
about I 1/2 mm wide. At this time, the oral pit is bounded above
by the frontal area and below by the mandibular arch, which
appears shovel shaped (Fig 3-2, A and B). A midline groove is
apparent, disappearing during the sixth week. At this time, two
small, oval, raised areas appear just above the lateral aspects of
the future mouth. In the next 48 hours, the centers of these raised
areas become depressions as the tissues around them continue to
grow anteriorly (Fig 3-2,B and C). The depressions deepen into
pits that will become the future nostrils and the masses surrounding
them-the bridge and the sides of the external nose. The tissue
between the nasal pits is termed the medial nasal process and those
lateral to the pits are called lateral nasal processes. These tissues
originate from the superficial epithelial and connective tissues of
the frontal area as they all grow downward and forward together
(Fig 3-2,C). Figure 3-2,D shows fusion taking place between
the median nasal processes and the lateral nasal processes, which

FIG 3-2.
Anterior view of the developing face in the human embryo
from the fourth to the eighth prenatal weeks. (Remainder of
body was removed to reveal face.) At 4 weeks (A), the future
face is indicated by the bulging forebrain and the first bran-
chial arch immediately below it. By 6 weeks (B), the oral slit
is noted, with nasal pits appearing above it. The eyes appear
on the sides of the head. The mandibular arch bounds the
oral slit below. At 6'/2 weeks (C), the eyes are nearer the
front of the face. The nose is defined, and the developing
ears appear at the corners of the mouth. At 8 weeks (D),
the masses comprising the face have fused together to bound
the oral cavity, and the forebrain has begun its forward growth,
leaving the ears behind.

will be described later. Before this fusion occurs, however, the
nasal pits undergo further elongation. The raised anterior edges of
these pits form the shape of minute horseshoes, with the open
sides below (Fig 3-3). As they grow forward, the inferior ends
of the horseshoes come into contact with each other (Fig 3-4).
The distance between these two nasal pits does not increase during
this important period of facial development, although the pits them-
selves increase in both height and length.24
Since the tissue underlying each nostril represents the first
separation of the nasal cavity from the oral cavity, it has been
designated as the primary palate by some authors.]9 The mode of
formation of these pits is important, since a failure in any of the
steps in their development may result in a cleft lip. The steps in
A B
-.
Prenatal Facial Growth 21
FIG 3-3.
Development of the upper lip. The maxillary processes
(MP) fuse with the medial nasal processes (MN) to form
the floor of the nostril. The lateral nasal processes (LN)
enlarge to form the sides of the nose. The slit below
the nostrils is the nasal fin (NF), which is the potential
site of cleft lip. The mandible (MD) is below the oral
pit. NP = nasal pit.
FIG 3-4.
Frontal section of upper face in fetus shows the nasal
pits (NP) and forming nasal fins (NF). LN = lateral
nasal process; MN = medial nasal process; MP
maxillary processes; MD = mandible.
fusion of the upper lip are illustrated in Figure 3 - 5. Step I can
be defined as the contact between the epithelium covering the
medial border of the maxillary process and the lateral border of
the medial nasal process. These two epithelial-covered processes
together form a lamina termed the "nasal fin" (Fig 3-5). Upon
contact, adhesion of two epithelial sheets occurs; they become
fused into a single sheet. Then, degeneration of this sheet occurs,
resulting in connective tissue penetration through it (Fig 3-5,B
and C). This area of penetration expands rapidly and the nasal fin
is eliminated except at its anterior and posterior limits. In this way,
the lip is unified anteriorly, and separation of the floor of the pits
in' the form of a cleft is prevented. The tissue underlying and
'between the two nasal pits is termed the primary palate since it
FIG 3-5~
Development of the floor of the nostril
and the nasal fin below it. A and B,
·as the nostril elongates, the epithe-
lium of the, maxillary and medial nasal
processes fuse together and an open-
ing appears through which connective
tissue of the lip grows. C, as the tissue
of the lip is unified, it forms the primary
palate, which is a small mass of tissue
bounded by the oral cavity below and
the nostril above. D, posteriorly, the
nasal pit opens into the roof of the oral
cavity by splitting of the two sheets of
epithelium.
22 Growth and Development
forms a separation between the primitive nasal cavity and the oral
cavity. At the posterior limits of the epithelial fin, the same two
epithelial sheets split apart, producing an opening between the
nasal pits and the roof of the oral cavity (personal communication;
H.C. Srivasta and A. Barry) (Fig 3-5,D). This p0sterior opening
of the nasal pit is termed the internal nares and is the posterior
limit of the primary palate. Later, the nasal cavities enlarge pos-
teriorly to form a space overlying the entire oral cavity. The oral
and nasal cavities are then separated by the secondary palatal
shelves. These shelves are termed the "secondary palate," as they
are secondary to the primary palate. The nasal cavity then opens
posteriorly in the nasopharynx (see Fig 3-22). The failure of any
of these rather complex developmental steps to occur in sequence
and a.t the approximate interval of time may result in congenital
defects. This is the reason such defects are most common today.
One in every 800 births results in either cleft lip, cleft palate, or
the combined defect.
In summary, lip development is a three-stage process, the
first being contact of the two epithelial sheets covering the adjacent
processes; the second, fusion of the epithelium into a single sheet;
and, finally, degeneration of this sheet, followed by invasion by
connective tissue of the lip growing through it. The developing
eyelids are an example of two epithelial laminae that come into
tight contact but do not fuse or undergo connective tissue pene-
tration. They simply remain closed, with their surfaces fused, until
the seventh prenatal month, at which time they open, exposing
the eyes.
In the sixth week, the upper face appears flat and broad, with
the nasal pits positioned on the lateral corners of the face. The
distance between the nasal pits represents approximately 90% of
the width of the face. Lateral to this region are the maxillary
processes, which appear at this stage as triangular or wedge-shaped
masses located at the superior lateral aspects of the oral cavity
(see Fig 3-3). At 6 weeks, the mandibular arch appears broad and
flat and comprises the lower border of the oral cavity. In the
midline, a slight constriction still can be seen, and laterally the
auricle of the ear will arise from six small hillocks of tissue that
appear to circumscribe the branchial cleft positioned between the
mandibular and hyoid arches (see Fig 3-1 ,A and B). Three of the
hillocks arise from the mandibular arch and the three below the
cleft arise from the hyoid arch. The first branchial slit later will
become the external auditory canal (see Fig 3-2,C and D).
MP
MA
A BeD
FIG 3-6.
The period of maximal facial development occurs from the fifth to
the seventh weeks. The frontonasal process (FNP), maxillary pro-
cess (MP), mandibular (MA), and hyoid arch (HY) contribute tissues
to facial growth. Observe the changes in facial proportions as nasal
".
3. Changes in Facial Proportions
Three or 4 days later, at 6 '/2 weeks, the facial proportions
appear to have changed greatly, due to an increase in dimension
laterally to the nasal pits. There has been, in this short span of
time, an expansion of the anterior region of the brain, causing the
lateral maxillary regions to move to the front of the face. Thus,
the eyes and adjacent cheek tissues are rotated 90 degrees from
the sides to the front of the face because of this differential growth.
The medial nasal area now makes up only the relatively small
medial segment of the upper lip. The medial nasal tissue interposes
between the maxillary wedges at this stage and will become the
site of the future philtrum of the upper lip* (see Fig 3-2,D).
Early in the seventh week, the face appears recognizably
human as a result of the frontal location of the eyes, differentiation
of the nose, and enlargement of the mandible (see Fig 3-2,D).
Later, as the face increases in height, the nostrils will no longer
be on the same horizontal plane as the eyes. At the seventh week,
the furrows separating the mandibular, maxillary, and nasal areas
are less marked. The external ears are now visible, having dif-
ferentiated from the auricular hillocks. It is of interest that such
complex structures as our external ears can arise from six small
and initially uniform enlargements. The ear will appear well dif-
ferentiated by the sixteenth prenatal week. 19
4. Origin of Facial Malformations
During the period of organization of the face, the mandibular
processes and maxillae emerge from the first branchial arch while
the forehead and nasal area arise from tissues overlying the fore-
brain. These different origins, each with its own very precise set
of activities and timetables, create the primary cause of facial
variability, both within and outside normal limits of growth.
During the fourth to sixth week the forebrain undergoes lateral
expansion as the prosencephalon forms the lateral ventricles. As
*The medial nasal process does not occur in the rabbit, which has
a shallow cleft at the midline, hence the term "harelip." It is a misno-
mer, however, to define the human cleft as a "harelip," since a cleft
rarely occurs in the midline; rather, it appears laterally between the me-
dial nasal and maxillary processes. The rare midline cleft occurs when
the globular or medial nasal processes do not merge properly (see Fig
3-4) ..
E F
pits (NP) appear in (B). The space between them then remains
constant while growth lateral to them causes the nose to appear
smaller. The maxillary (MP) and medial nasal process (MNP) fuse
to form the upper lip. LNP = lateral nasal process; AH = auricular
block.

FIG 3-7.
The neural crest cells arise from the neural folds and migrate onto
the face. During migration they lie under the skin, then proliferate
and contribute to all facial structures.
a result the face broadens and the eyes appear to migrate from
their position on the lateral head to the front of the face. This
change is a result of the general widening of the face with growth
of the tissues behind and underlying the eyes (Fig 3-6). The face
FIG 3-8.
Ethmocephalic complex with lack of development of anterior brain,
nasal, and midlip tissue.
Prenatal Facial Growth 23
is thus shaped by the forebrain, and the tissues that overlay it
contain the neural crest cells which migrate from their origin in
the dorsal neural tube down into the prospective face. A deficiency
in crest cells, for example, may cause a lack of olfactory nerve
development and in turn a lack of nasal placode formation. An
absence of nasal pit and ethmoidal sense capsule follows (Fig 3-
7). The resulting anterior medial facial defect may be classified
as ethmocephaly, which by name indicates both brain tissue and
nasal deficiency (Fig 3-8). The severe forms of these facial mal-
formations clearly reveal the relationship of neural facial devel-
opment. Lack of anterior brain development usually leads to neural
crest and olfactory nerve deficiency and lack of induction of the
nasal field. A partial deficiency will lead to ethmocephaly simplex,
which may result in a median cleft lip and/or nose (Fig 3-9).
A unilateral or bilateral cleft lip is a more common deficiency
of the lip than the midline cleft. These clefts are the result of a
localized growth fault in the floor of the nostril. This may be due
to a lack of development of the nasal fin in which the two halves
may not fuse, which results in an oronasal cleft (Fig 3-5), or there
may be a lack of penetration of the epithelial fin by connective
tissue, which could allow the fin to split apart after initial closure
and a cleft to appear (Figs 3-10 and 3-11). Other defects of the
anterior face may rise from the lack of "merging" along facial
grooves. Merging is defined as the filling in of grooves by tissue
growth underlying the groove (Fig 3-6). Grooves appear between
the nose and eye, (naso-optic) or at the angles of the mouth
(macrostomia) (see Fig 3-14). The sixth to seventh prenatal week
is an important period in development of these types of defects
because these grooves are most apparent at that time, as seen in
Fig 3-2,C.
Defects of the lateral face are usually associated with the
branchial arches. These defects may again arise from neural crest
cell deficiencies as these cells migrate into the branchial arches in
early development when the anterior neuropore is closing, similar
to the way they do anteriorly in the face (Figs 3-7 and 3-8).
Alteration of the external ear is the most common defect found in
FIG 3-9.
Ethmocephaly simplex showing a median cleft lip and nose. This is
an example of a "harelip" and is rare compared with a common cleft
of the lip and nostril.
24 Growth and Development

FIG 3-10.
Views of nasal pits at 6 and 6'/2 weeks. Initially they are a blind
pocket connected to the oral cavity anteriorly by a slit-like opening.
The covering of the maxillary (MP) and medial nasal process (MNP)
form these epithelial sheets which later fuse and are penetrated by
connective tissue, as seen on the right. Meanwhile the posterior
aspect of the pit opens into the roof of the mouth. The lateral nasal
process (LNP) supports the lateral aspect of the nostril.
FIG 3-12.
Lack of improper auricular development. One or several of the orig-
inal auricular hillocks did not merge together (refer to Fig 3-2,C. In
addition to a lack of auricle development, there is also a lack of a
functional external auditory canal; thus, the first branchial groove did
not develop properly and, likely, middle ear development was also
affected.

the branchial arch syndrome (Fig 3-12), but it also includes al-
a short mandible, enlarged tongue, and possible cleft palate (Fig
terations of the facial skeleton and/or muscular development, tongue
3-14). Those with Treacher Coli ins syndrome exhibit lack of
defects, and clefts of the branchial grooves (Fig 3-13). Branchial
development of the malar arches, a shortened curved mandible,
clefts or cysts appear most often along the anterior border of the
and lack of middle ear development which results in loss of hearing
sternocleidomastoid muscle (Fig 3-13). Pierre Robin and Treacher
(Fig 3-15).
Col/ins (mandibulofacial dysostosis) syndromes are both defects
Midline defects also occur in the mandible, although they are
of the branchial arches. The former condition is characterized by
rare (Fig 3-16). They result from a lack of development of the
midline of the first branchial arch, resulting in both skeletal and
soft-tissue deficiency at that site. Thryoglossal duct cysts and fis-
tulas are also seen in the midline of the neck, which are due to
persistence of the cord of epithelial cells from which the thyroid
gland developed (Fig 3-17) .

. ..

FIG 3-11.
Bilateral complete cleft lip. The philtrum or medial nasal process is
FIG 3-13.
isolated as a mass suspended from the nose. Observe the wedge- Failure of complete obliteration of the cervical sinus results in a
shaped maxillary processes which did not contact the medial nasal cervical cyst and branchial fistula. They may be found on the neck
process at the proper time to effect closure. along the anterior border of the sternocleidomastoid muscle.
 Prenatal Facial Growth 25

FIG 3-14.
A case of Pierre Robin syndrome with malformed ear, macrostomia,
and short lower jaw. Note the auricular tag on the right side of the
face.

Treacher Collins Syndrome

(mandibulofacial dysostosis)
f7r"
I :~
--: "\
... ,
"

.2;f~
1'; ...
'~
...
'... " / ;.
coloboma rr~1:,> /
of lower Iid " ~~-,1",<
..,
cilia absent
med ial to coloboma

ptosis
of upper
abnormal hair growth
eyelid
on cheek
micrognathism

malformed ear

hypoplastic zygomatic arches

. ;;.

FIG 3-15.
Diagram of Treacher Collins syndrome shows the facial features of phonse R. Burdi, Department of Anatomy, University of Michigan
this condition. Most usual is the lack of zygoma development, anti- Medical School, Ann Arbor.)
mongoloid slant of the eyes, and short lower jaw. (Courtesy of AI-
26 Growth and Development

FIG 3-17.
This thryoglossal cyst and fistula developed from the epithelial cord,
which descends down the anterior neck to form the thyroid gland.

FIG 3-16.
A mandibular cleft. This defect stems from the fifth prenatal week
when a midline constriction in the mandibular arch is apparent. Lack
of unity of the mandibular processes at the midline results in loss of
soft-tissue and bony union. There is also a lack of development of
mandibular anterior teeth.
B. DEVELOPMENT OF ORAL STRUCTURES
1. Development of the Tongue
The tongue musculature originates from the occipital my-
otomes at the beginning of the fourth week.' As it grows anteriorly
into the floor of the mouth, it carries forward its nerve and blood
supply from more posterior regions and develops into an oral part
(the body) and into a pharyngeal part (the base). The body arises,
in part, from contributions of the first branchial arch, and the base
arises from the second, third, and fourth arches. The body of the
tongue is indicated by three primodia, the paired lateral lingual
swellings, and a centrally located tuberculum impar (Fig 3-18,A).
At the fifth week, the base of the tongue is indicated by a median
elevation, the copula. Between the copula and the tuberculum
impar a small pit appears, termed the foramen caecum, which
gives origin to the thyroid gland tissue. During the sixth and
seventh weeks, the lateral lingual swellings enlarge and relatively
reduce the size of the tuberculum impar. A furrow appears along
the lateral borders of the tongue, separating it from the developing
alveolar ridges (Fig 3-18,B). The two lateral lingual swellings
then merge, and the body of the tongue appears as a more unified
structure (Fig 3-18,C). The tongue grows so rapidly that it pushes
into the nasal cavity above and between the two palatine shelves
(Fig 3-19,B), and by 8 '/2 or 9 weeks the muscles of the body of
the tongue appear clearly differentiated (Fig 3-19,C). Thus, the
oral and nasal cavities originate from the single stomodeal cavity
and become separated as the palatal shelves elevate and grow
between them.
"

D
A B
c
lateral lingual swellings body of tongue
tuberculum impor fungiform papilla
foremen caecum filiform papillo

copulo vallate popillo

sulcus terminalis
glottis
lingual ton;ii
bose of tong ue
epiglottis
FIG 3-18.
Diagram of the developing tongue. A, 5th; B, sixth; and C, seventh
prenatal week; D, adult.
 Prenatal Facial Growth 27

FIG 3-19.
A, removal of the front of the face reveals the relationship of the shelves (PS) are beside the tongue. At 8'/2 weeks (D), the palatal
developing tongue to the palate. At 6 weeks (B), the tongue is a shelves appear above the tongue. At 10 weeks (E), the palatal shelves
small mass of undifferentiated tissue. NC = nasal cavity; NS = fuse together to delimit the nasal and oral cavities. P = palate. (From
nasal septum; QC = oral cavity. At 7 weeks (C), the enlarged and Shapiro M (ed): The Scientific Bases of Dentistry. Philadelphia, WB
differentiated tongue extends up into the nasal cavities. The palatal Saunders Co, 1966, p TT.; Reproduced by permission.)
,. -# -

t ;.

2. Formation and Elevation of the Palatal Shelves

sition probably involves movement of both the tongue and palatal
As the enlarging tongue pushes dorsally into the nasal cavity, shelves (Fig 3-20).26 As the shelves roll over the tongl!e poster-
the palatal shelves develop in a wedge shape and, because of the oanteriorly, the tongue may glide anteriorly to offer less resistance
presence of the tongue, grow downward into the floor of the mouth to the shelf movement. 25 Closure of the palatal shelves over the
along either side of the tongue (Fig 3-19,C). The next critical tongue separates the oral and nasal cavities (Fig 3-19,C and D).
step in palatal development results in the movement of the palatal The tongue may press upward against the palatal shelves, helping
shelves from a vertical position beside the tongue to a horizontal to bring them into closer approximation to facilitate their contact
position overlying the tongue (Fig 3-19,D). This change in po- in the midline. These movements of palatal closure may be quite
28 Growth and Development
FIG 3-20.
Movements of the palatal shelves and tongue during palate
closure. The tongue moves anteriorly (C), depressing
downward (D) and laterally (E) as the palatal shelves slide
from B to A over the tongue.
rapid, possibly occurring with about the same speed as when one
swallows (Fig 3-20). This process occurs between the eighth and
ninth weeks after conception in the human, when, as investigators
have shown, the paraoral structures of the human respond to stim-
ulation.'2 It is possible that the nerve supply to the tongue and
cheeks is thus sufficiently developed to provide some neuromus-
cular guidance to the intricate activity of palatal closure.
3. Factors in Normal Palatal Development
Other activities, such as bringing the head to an erect position,
may be related to the elevation of the palatal shelves26 As the
head elevates, the neck becomes recognizable and the face is no
longer pressed against the thoracic cavity, due partially to settling
of the heart more inferiorly in the thorax. At this time, spontaneous
movements of the head, elevation of the lower jaw, opening of
the mouth, and movement of the tongue occur for the first time]2
(see Chapter 5). Deficiencies of oxygen, various foodstuffs, or
vitamins have been reported experimentally to cause cleft lip and
palate and other types of facial defects in mice and rats.6.27 On the
other hand, excesses of certain endocrine substances, a number of
drugs, and irradiation will have teratogenic effects on the devel-
oping face and palate, as shown in the embryos of experimental
animals.22·27 In regard to vascularity, which, of course, controls
the amount of oxygen and nutritional elements, the face and palate
seem unique in development. There is a most important shift in
circulation in this region during the critical time period of the
seventh and eighth weeks.18 The vessels of the branchial arches
give rise to the external and internal carotid arteries, which provide
the vascular supply to the face and palate when the first and second
branchial arch vessels begin to disappear. During the sixth week,
the stapedial artery arising from the internal carotid supplies most
of the midfacial region (Fig 3-21,A and B). Then, during the
seventh week, the stapedial artery severs its contact with the in-
ternal carotid. At the same time, its branches to the maxilla and
mandible become attached and confluent with the adjacent facial
branches of the external carotid (Fig 3-21,B and C). If, for any
reason, this important shift of the blood supply of the face and
palate from the internal to the external carotid is delayed, the effect
on the developing tissues undoubtedly would be notable. It is a
coincidence that this important shift occurs at this critical time in
the palatofacial development.
4. Fusion of the Palatal Shelves
By 8]/2 prenatal weeks, the palatal shelves appear above the
tongue and in near contact with each other (see Fig 3-19 ,C). Then,
during the ninth and tenth weeks, they come into contact and fusion
begins (Figs 3-19,D and 3-22,C). First, the epithelial coverings
of the shelves join to form a single layer of cells. Next, degen-
eration occurs as the connective tissue of the shelves penetrates
this midline epithelial barrier and intermingles across the area (see
Fig 3-19,D). Thus, the process is similar to that occurring in the
lip (see Fig 3-10). In a few cases, the two shelves have been
repdrted to separate after initial fusion, with resulting epithelially
covered connective tissue bands stretching across the palate be-
tween the shelves.]O As bone forms· in the p~late, the area along
the midline anteroposteriorly will become a suture where important
expansive growth of the palate occurs. The entire palate does not
contllct and fuse at the same time. Initial contact occurs in the
centrarregion of the secondary palaty just posterior to the anterior
or primary palatine process (Fig 3-22,B) and closure continues
both anteriorly and posteriorly from this point (Fig 3-22,C). After
initial contact and fusion, further closure occurs by a process of
"merging," which results in the medial space between the two
processes being eliminated (Fig 3-22,D). The anterior palatine
foramen and a suture between the premaxilla and the palatal pro-
cesses of the maxilla remain in the postnatal period as evidence
of the early existence of the primary and secondary palate (Fig 3-
22,C and D).
 Prenatal Facial Growth 29

A
\
Stapedial a.
Int. carotid a.
Exl. carotid a.
Corn. carotid a.
Aortic Arch

FIG 3-21.
Three stages of shift in blood supply from the in-
ternal to the external carotid arteries in the fetus. At
6 weeks (A), the blood supply to the face is from
Max. Mand. div. of
Stapedial a. the stapedial branch of the internal carotid. At 6'/2
Max. a. weeks (B), the stapedial has expanded into the
Int. Carotid a.
Ext. Carotid a. maxillary and mandibular divisions. At 7 weeks (C),
lingual a. the stapedial detaches from the internal carotid and
Facial a.
Corn. Carotid its terminal branches join the maxillary artery of the
Aortic Arch external carotid. This shift occurs during the vital
stages of development of the face and palate. (After
Padget OH: The development of the cranial arteries
in the human embryo. Contrib Embryo/1948; 32:212.
Reproduced with permission.)

degenerating Stop. a.
Max. a.
1nl. Carotid a.
Ext. Carotid a.
lingual a.
Facial '0.
Corn. Carotid a.

Aortic Arch \

\
'"
r· ;.

-,
30 Growth and Development

FIG 3-22.
View of the roof of the mouth showing closure
and fusion of the palate. Bony development
is shown on the right side of the palate. At 8
weeks (A), the shelves are horizontal and
grow toward the midline. At 9 weeks (B), the
shelves are in near contact and the premax-
illary-maxillary ossification centers appear.
At 10 weeks (C), the soft tissue of the palate
has fused and ossification centers of the pre-
maxilla-maxilla grow medially. At 14 weeks
(D), the premaxillary bone supports the in-
cisors and the maxillary bone supports the
cuspids and first molars. The palatine bone
supports the second molars.

5. Tooth Development 6. Salivary Gland Development

By the seventh week, the epithelial labial lamina becomes
apparent along the perimeter of the maxillary and mandibular pro-
cesses (Fig 3-23). This wedge of epithelial cells penetrates the
underlying connective tissue to separate the tissue of the future
alveolar ridge from the lip. At the same time, a second lamina,
lingual to the labial lamina, appears and grows into the alveolar
ridge. This is the dental lamina, which, at regular intervals, will
give rise to the epithelial enamel organs (Fig 3-23). These organs,
along with adjacent dental papillae of connective tissue origin,
rapidly differentiate to form the enamel and dentin of the teeth.
As the developing crowns enlarge and the roots elongate, the jaws
increase in anterior and lateral dimension, as well as height, to
provide space for the teeth and growing alveolar processes.
The parotid and submandibular salivary glands appear in the
connective tissue of the developing cheek in the sixth week. The
third set of major salivary glands, the sublingual, appears in the
eighth week. All of the major, as well as minor, salivary glands
follow the same pattern of development in which proliferation of
epithelial cells initially occurs from the oral mucosa, followed by
growth of a solid cord of cells into the underlying connective tissue.
This cord of cells then continues to proliferate, growing toward
the region of future gland location. At this site, the epithelial cords
branch repeatedly and the twig-like ends of the cords form berry-
like secretory acini. Gradually, the entire system of epithelial cords
becomes hollow and forms the duct system of the gland.24 The
site of origin of each major gland, as revealed by the initial epi-

alveolar ridge

FIG 3-23.
Diagram of the developing right side
enamel
of the mandibular arch illlustrating the
division of the tissue of the lip and jaw dental organs
by the developing labial lamina. The lamina
dental lamina, tooth germs, and Meckel's
Meckel's cartilage are shown. (From
labial cartilage
Steele P: Dimensions of Dental Hy-
lamina
giene. Philadelphia, Lea & Febiger,
1966, p 280. Reproduced by
permission.) developing
mandible

thelial growth, thus later will be the orifice of the main duct of
the gland, ejecting its secretion to the oral cavity. The connective
tissue adjacent to the developing glands grows around them, en-
capsulates them, and grows into the glands to subdivide them into
lobules (see Fig 3-27). This organization is complete by the third
month, and the differentiation of the terminally located acinar cells
and canalization of the ducts occurs at about the sixth prenatal
month. The acini of the mucous glands become functional during
the sixth month, whereas the serous glands become functional by
birth.8
C. DIFFERENTIATION OF SUPPORTING
STRUCTURES
1. Development of the Chondrocranium
The skeletal elements that form the skull develop initially in
support of the brain, yet others appear very early in the rapidly
developing face as well. The brain is given support by cartilages
forming along its base, the chondrocranial elements, whereas the
. flat bones of the skull, the neurocranial elements, surround the
brain. The chondrocranium also is important to the growing face
and supports both areas through the development of a bar of car-
tilage extending uninterrupted along the midline from the anterior
nasal region ot the foramen magnum (Fig 3-24). The cartilaginous
septum may function in anterior facial growth as well as in support.
Its early fibrous attachment to the premaxilla has been demon-
strated.]5 According to Scott,z] it doubles its length from the tenth
to the fourteenth prenatal week, trebles it by 17 weeks, and is six
times as large by 36 weeks. Anteriorly, this cartilage forms a
Prenatal Facial Growth 31
ST
FIG 3-24.
Sagitttal view of the cartilaginous cranial base at 9
weeks. The bar of cartilage extends uninterrupted pos-
teriorly from the foramen magnum (FM) anteriorly to
the tip of the nasal septum on the left. The location of
FM the sella turcica (ST) is seen.
FIG 3-25.
Sagittal view of the cartilaginous cranial base showing
the positional relationship of the ethmoid (E), the vomer
(V), the sphenoid (SP), and the basioccipital (Ba) bones.
The dotted lines containing (SE) and (SO) indicate the
sites of the future sphenoethmoidal and spheno-occip-
ital synchondrosis. S = nasal septum.
capsule related to the olfactory nerve endings-the nasal capsule.
More posteriorly, the cartilage supports the pituitary; laterally, the
otic capsules develop around the middle and internal ear structures;
and most posteriorly, it forms the occipital cartilages around the
foramen magnum. These cartilages establish the cranial base as
early as the eighth week and will be transformed mostly into bone,
with the future ethmoid bone arising from the nasal capsule, al)d
parts of the sphenoid, temporal, and occipital from the more po's-
terior cartilage. As each of these bones develops, cartilagenous
centers remain between them, forming the cranial base synchon-
droses (Fig 3-25). These centers will provide for further growth
and expansion of the cranial base. The anteriorly located nasal
capsule is a large and important cartilage to the developing face
and consists of a medial septum component, the mesethmoid, and
two lateral cartilaginous wings (Fig 3-26,A).
2. Development of the Maxillary ComIilex
Until bone formation occurs, the nasal capsule is the only
ske.letal support of the upper face. Lateral and inferior to the cranial
base cartilages, ossification centers appear in support of these parts
of the face as it begins to develop in width during the prenatal
period15 (Fig 3-26,B and C). The nasal, premaxillary, maxillary,
lacrimal, zygomatic, palatine, and temporal ossification centers
appear and expand until they appear as bones separated only by
sutures (Fig 3-26,D).
3. Development of the Bony Palate
The bones of the palate arise from several ossification centers.
 32 Growth and Development
A
FIG 3-26.
A, diagram of cartilaginous skeleton of the
face at 9 weeks. The nasal capsule repre-
sents the maxillary skeleton, and Meckel's
cartilage represents the mandibular skeleton
at this age. B, diagram of the mandible at 16
weeks, illustrating the developing body of the
mandible and condyle. Meckel's cartilage still
persists. C, diagram of the mandible at 24
weeks. The coronoid process is evident, as
is the appearance of the temporomandibular
joint. 0, diagram of the skeleton of the face
at 30 weeks. The membrane bones of the
nasomaxillary complex develop externally to
the endochondral bones, replacing the car-
tilages of the middle of the face.
In the eighth week, bilaterally located bony centers in the anterior
palate give rise to the premaxilla and maxilla; they may arise in
common but then develop medially in an independent fashion (see
Fig 3-22,B and C). The premaxillary bone supports the maxillary
incisor teeth, whereas the maxillary bone supports the cuspid and
molar teeth. 28 PosteriorIy, the horizontal plates of the palatine bone
grow medially from single bilateral ossification centers (see Fig
3-22,C). By the fourteenth week, the bony palate is well estab-
lished, with a midline suture extending its length between the
premaxillary, maxillary, and palatine bones. A bilateral suture also
appears between the palatal aspects of the premaxilla and the
maxilla (see Fig 3-22,D).
4. Mandible and Temporomandibular Joint
The lower part of the face is supported by a rod-shaped bar
known as Meckel's cartilage (Fig 3-26,A). This bar extends from
near the midline of the mandibular arch posteriorIy into the otic
capsule, where the two posterior elements later become the malleus
and incus bones of the middle ear (Fig 3-26,A). These two bones
function in the articulation of the mandible in lower animals and
are known as the articular and quadrate.9 There is some evidence
in man that the malleus and incus function to provide a movable
joint until the mandibular condyle develops in relation to the
glenoid fossa of the temporal bone (Fig 3-27). Thus, from ap-
proximately the eighth to the eighteenth week, this joint may
function in jaw movement until an anterior shift in temporoman-
dibular articulation occurs. Then, these two cartilages ossify and
function as middle ear bones. The bony mandible develops laterally
to Meckel's cartilage as a thin, flat, rectangular bar, except for a
small region near its anterior extremity, where the cartilage ossifies
and is fused to the mandible. Since the body of the mandible is
attached to Meckel's cartilage, it could function and be carried
R
\
forward in growth until regression of this cartilage, at which time
the condyle becomes functional. The condyle arises independently
initially as a carrot-shaped cartilage and is enclosed by the de-
veloping bone of the posterior part of the mandible (see Fig 3-
26,B). The condylar cartilage is transformed rapidly into bone
except at its proximal end, where it forms an articulation with the
temporal bone in the glenoid fossa (see Fig 3-26,C). This carti-
laginous head of the condyle, enveloped in a fibrous covering that
is continuous with the joint capsule, persists and functions as a
growth center until about the twenty-fifth year of postnatal life.
The two condylar heads function similarly to the epiphyses of long
bones. The cartilage of the condylar head gradually is replaced by
bone (Fig 3-28). The condylar head is separated from the temporal
bone by a thin disk of connective tissue, which appears as a result
of two clefts in the fibrous tissue that form the upper and lower
compartments of the joint cavity. Gradually, this collagenous disk
thickens, as does the bone forming the joint cavity, until the com-
plete jojnt is developed (Fig 3-28).
Bone forms rapidly along the superior surface of the body of
the mandible between the developing teeth. As the bony mandible
continues to grow during the prenatal·period, fibrous connective
tissue and what is known as symphyseal cartilage unite the two
halves of the mandible, and serve as a growth site until the first
year after birth, by which ti,me it is calcified. The angle of the
mandible by birth is about 130 degrees with the condyle, thus
nearly in a line with the body, wherea~ the large coronoid process
projects above the head of the condyle (see Fig 3-26,D).
S. Facial Muscles
The facial muscle mass, termed the subcutaneous colli, ap-
pears in the fourth week in the ventral lateral portion of the hyoid
arch just beneath the surface of the skin. Gradually, in the fifth
week, it spreads out, unfolding liS the head elevates from the chest

~ .. ~'~ .. ~~~~,.
lateral
pterygoid
muscle
Iower
head ofco~
wall.? This muscle mass fans out and stylohyoid, digastric, and
stapedial muscle masses appear. The seventh nerve travels along
with the facial muscle,8 which now migrates up the side of the
neck and over the face and cranium to meet the sheet of muscle
from the opposite side. During the fifth to ninth weeks, the muscles
of the human face differentiate and become functional to some
extent, since stimulation of the perioral region in this latter period
may result in reflexogenic responses, such as neck flexion and
head turning. 11 The ear causes the muscle to split into the anterior
and posterior auricular parts. The advancing sheet then separates
into a superficial and a deep layer in the seventh week. I The
superficial fibers form the spread of the platysma muscle over the
mandible to the cheek, forehead, and temporal region (Fig 3-29).
The sphincter colli is the deep layer and gives rise to several
muscles, including the occipitalis. Degeneration of intermediate
Prenatal Facial Growth 33
FIG 3-27.
Sagittal section through the developing temporo-
mandibular joint and middle ear at 16 weeks. Note
the forming upper and lower compartments of the
joint and the ossifying condyle, middle ear bones,
developing muscles, and salivary glands. C = con-
dyle; I = incus; SG = salivary glands .
., ...•._--.,
FIG 3-28.
"-...
Diagram of the postnatal temporoman-
.external dibular joint, illustrating the dense, fibrous
auditory canal
articular disk with the adjacent superior
and inferior articular spaces. Underlying
,~~~) W i,
f the fibrous covering of the condyle is a
band of hyaline cartilage, below which is
1 the developing bone of the condyle. (From
Steele P: Dimensions of Dental Hygiene.
"'.& f
Philadelphia, Lea & Febiger, 1966, p 316.
synovial ."
cavit/ Reproduced by permission.)
parts gives rise to the anterior, superior, and postauricular frontalis
and occipitalis muscles. Between the seventh and ninth weeks, the
superficial and deeper muscles differentiate rapidly. The sphincter
colli also forms the orbicularis, the caninus, and the incisivus labii
superioris muscles as the fibers of the more superficial platysma
fac~i attach to the mandible. The quadratus labii inferioris and
mentalis muscles of the lower face appear in the eighth to ninth
week but are not well defined until the thirteenth week. At this
time, the orbicularis oculi and the buccinator muscles appear from
the deep fibers of the sphincter colli, whereas the triangularis and
platysma arise from the superficial facei. Overlying the buccinator
muscle, the buccal fat pad develops (Fig 3-30). It enlarges sig-
nificantly during prenatal life, extending deep between the mas-
seter and temporalis muscles. It functions in sucking and causes
the cheek to appear plump in the newborn. By the fourteenth week,
34 Growth and Development
FIG 3-29 (left).
Diagram of the developing facial muscles at
9 weeks. This sheet of muscle grows cra-
nially from the hyoid arch and splits at the
ear into the anterior and posterior auricular
parts. Deep and superficial facial muscles
arise from this mass.
FIG 3-30 (right).
Diagram of the developing masticatory mus-
cles at 9 weeks. These muscles develop in
the mandibular arch before the skeletal ele-
ments on which they insert.
all the facial muscles are in their definitive positions and the young
muscle fibers are differentiating.
6. Muscles of Mastication
At this same time, the muscles of mastication are developing
in the mesenchyme of the mandibular arch. These muscles begin
differentiation in the seventh week, and nerve fibers are apparent
in them by the eighth week. Although the muscles of mastication
develop at first in close relationship to Meckel's cartilage and the
cranial base cartilages, they are independent and only later attach
to the bony skeleton (Fig 3-30). The temporal is muscle begins
lateral development in the eighth week, occupying the space an-
terior to the otic capsule. As the temporal bone begins to ossify
in the thirteenth week, the muscle attaches along a broad front.
At about this time, the masseter muscle begins attachment to the
zygomatic arch as it undergoes lateral growth, providing space for
muscle development. 19 The pterygoid muscles differentiate in the
seventh week and early are related to the cartilages of the cranial
base and the condyle (see Fig 3-27). Later, as the bony skull
appears and increases in width and length, these muscles expand
rapidly. Typically the fetal histologic structure of the muscles of
mastication appears by the twenty-second week.
D. THE FETAL PERIOD-THIRD TO NINTH
MONTH
1. Craniofacial Changes
By the third month, the face assumes a more human appear-
ance. The eyes are now directed forward and the eyelids have
grown together and are fused. The head is erect and the bridge of
the nose becomes somewhat more prominent. As the face grows
downward and forward, the ears appear on a horizontal plane with
the eyes instead of at the lower corners of the face, as in the
embryonic period. During the fetal period, from the twelfth to the
thirty-sixth week, the head increases in length from approximately
18 mm to 120 mm, in width from about 12 mm to 74 mm, and
in height from 20 mm to 100 mm, thus maintaining a fairly constant
ratio of width to length but not to height. Prior to the fifth month,
the height increase is greatest, whereas width and length increases
are proportional. At birth, the cranial vault is proportionally about
eight times larger than the face. In the embryonic period, the
cranium-to-face ratio may be as high as 40: I ,dropping at 4 months
to 5: I because of the differentially more rapid facial growth during
the period. The cranium then grows faster in the late prenatal
months to attain the 8: I ratio at birth. Postnatal facial growth will
reduce the adult ratio to approximately 2: I.
2. Radiographic Changes
The radiographic appearance of the mandible at the beginning
of the fetal period is that of a slightly curved bone, but, by the
fifteenth week, the condyle, coronoid process, and the angle be-
come evident. 9 Radiographically, the incisor teeth in the lower
jaw make their appearance in the fifth month and the molar crypts
are evident in the sixth month. During the fetal period, the man-
dible increases in length five times, whereas the intercondylar
width increases six times. The gonial angle, which was virtually
nonexistent at the beginning of this period, increases to about 130
degrees at birth. Although these increases follow closely the overall
growth of the face, the lower jaw appears retrognathic at birth.
The palate increases in length fourfold and the maxillary region
about fivefold (Fig 3-31). At the beginning of the fetal period,
the frontal bones are apparent. The nasal bones appear at 3 months
and the first signs of cranial base bone appear at 10 1/2 weeks. The
sella turcica is clearly visible at 4 1/2 months and attains its char-
acteristic shape at 5 months. The sphenoethmoidal and spheno-
occipital synchondroses are evident at 6 months (Fig 3-31).
, At birth, the intervening connective tissue that separates the
bones of the cranial vault is still wide. At six sites located at each
corner of the parietal bones they form the fontanelles (Fig 3-32).
Synchondroses between the ethmoid, sphenoid, and occiptal bones
are still actively growing at birth. The skull contains 45 separate
bom;s.at birth, which will be-reduced by fusions and consolidations
to 22 in the adult. For example, th~ frontal bones at birth are still
paired and separated by the metopic suture. Similarly, the paired
halves of the mandible are separated by the symphyseal suture.
The occipital is in four parts, with synchondroses between them,
and the tympanic annulus is still separate from the temporal'bone.
Some of these sutures, such as the midline mandibular suture,
disappear shortly after birth. The maxillary midpalatal suture, how-
ever, does not close until the sixth to seventh year, although it
may be orthopedically activated until the late teens (see Chapter
15).
 Prenatal Facial Growth 35

Premaxillary

Maxillary

Palatine

FIG 3-31.
Cleared human specimen illustrating the bones of the cranial base by arrows. Premaxillary, maxillary, and palatine processes can
at 21 weeks. The synchondroses of the cranial base are indicated be seen forming the palate.

Anh~piop
fontanel

FIG 3-32.
The cranium at birth. Note the fontanelles,
one at each corner of the parietal bones (From
Caffey J: Pediatric X-ray Diagnosis, ed 6.
Chicago, Year Book Medical Publishers,
1972. Reproduced by permission.)

Postet'iop latet'al
fontanel
A

SUMMARY ·'B. Development of Oral Structures

A. Organization of the Face The tongue undergoes a growth spurt during the fourth to
seventh embryonic weeks and is so large it fills the combined
The face develops from four tissue masses which surround
oronasal cavity. At this same time this cavity proceeds to divide
the oral pit. Above it is the frontal area, laterally binding it to the
into two, the nasal and. oral, by growth of three tissue wedges:
maxillary processes, and below it the mandibular and hyoid masses.
6rre. anterior and two lateral. As they enlarge, the lateral wedges
In the neck, tubular branchial arches add further complexity to
grow down on either side of the tongue. As the shelves continue
development. The face is complex because of the numbers of
to grow they depress the tongue, sliding over it to form a roof to
masses that fuse and merge to develop it. It is no wonder that the
the oral cavity. They finally contact in the midline by the eighth
face and the associated roof of the mouth are two of the most
week, by which time other oral tissues such as teeth and salivary
common areas of congenital defects in the body. Also, the face glands are apparent.
develops very early in prenatal life, during the fifth to seventh
weeks, and in the short span of time of 2 weeks. Facial proportions
change rapidly as the eyes move from a lateral position to the front C. Differentiation of Supporting Structures
of the face. The brain and face are closely allied, and anterior The facial skeleton is initially comprised of two types of
brain deficiencies usually result in facial defects. tissue: cartilage and bone. The cartilage develops in the midline
36 Growth and Development
to form the chondrocranium. It gradually transforms into bone. In
the lateral face, bones originate in the connective tissue (mem-
brane) to develop the bony skeleton of the maxilla and mandible.
The bones of the midline form the cranial base and soon merge
with the lateral bones in support of the brain and faCe. The mandible
is a complex bone, developing its condyle in cartilage and its body
in membrane. The facial muscles grow from the neck (hyoid arch)
and spread over the front, sides, and back of the head. The muscles
of mastication (mandibular) develop within the first arch.
D. The Fetal Period-Third to Ninth Months
During the third to ninth months the embryo increases in size
and develops body proportions. The head lengthens and increases
in width by about six times and in height by five times. The
cranium-to-face ratio decreases from 40: I during the first 12 weeks
to 5: I at 4 months and increases slightly at term to 8: I. The
cranium-face size ratio again decreases after birth to 2: I. At the
same time the number of skull bones is reduced from 45 separate
bones at birth to 22 in the adult.
REFERENCES
I. Bates MN: Early hypoglossae musculature. Am J Anat
1948; 83:329.
2. Burdi AR: Sagittal growth of the naso-maxillary complex
during the second trimester of human prenatal development.
J Dent Res; 1965; 112-125.
3. Burdi AR: Section I. Epidemiology, etiology, and patho-
genesis of cleft lip and palate. Cleft Palate J 1977;
14(4):262-269.
4. Dickson DR, Grant JCB, Sicher Het al: Status of research
in cleft palate anatomy and physiology: July, 1973-Part I.
Cleft Palate J 1974; 11(4):471-492, 1974.
5. Eisbach KJ, Bardach J, Klausner EC: The influence of pri-
mary unilateral cleft lip repair on facial growth. Part II: Di-
rect cephalometry of the skull. Cleft Palate J 1978;
15(2):109-117.
6. Fraser FC, Walker BE, Trasler DG: Experimental produc-
tion of congenital cleft palate, genetic and environment fac-
tors. Pediatrics 19(4): 1957.
7. Gasser RF: The development of the facial muscles in man.
Am J Anat 1967; 120:257.
8. Gasser RF: The development of the facial nerve in man.
Ann Otol Rhinol Laryngol 1967; 76:37.
9. Gerrie J: The phylogeny of the mammalian tympanic cavity
and auditory ossicles. J Laryngol Otol 1948; 62:339.
10. Hayward JR, Avery JK: A variation in cleft palate. J Oral
Surg 1957; 15:320.
11. Hooker D: The Prenatal Origin of Behavior. Porter Lecture
Series XVIII, March 12-13, 1951. Lawrence, University of
Kansas Press, 1952, 136 pp.
12. Humphrey T: The development of mouth opening and re-
lated reflexes involving the oral area of human fetuses. Ala
J Med Sci 1968; 5: 126.
13. Iregbulem FRCS: Median cleft of the lower lip. Plast Re-
constr Surg 1978; 61(5):777-789.
14. Langman J: Medical Embryology, 4th ed. Baltimore, Wil-
liams & Wilkins Co, 1981, pp 268-306.
15. Latham DA: Maxillary development and growth: The septo
premaxillary ligament, J Anat 1970; 107:471.
16. Lowry RB, Trimble BK: Incidence rates for cleft lip and
palate in British Columbia 1952-1971 for North American
Indian, Japanese, Chinese and total populations: Secular
trends over twenty years. Teratology 1977; 16(3):277-283.
17. Moore KL: The Developing Human, 2nd ed, Philadelphia,
WB Saunders Co, 1977.
18. Pad get DH: The development of the cranial arteries in the
human embryo. Contrib Embryol 1948; 32:212.
19. Patten BM: Human Embryology, 3rd ed. New York, Blak-
iston Division, McGraw-Hill Book Co, 1968.
20. Ross RB, Johnston MC: Cleft Lip and Palate. Baltimore,
Williams & Wilkins Co, 1972.
21. Scott JH: Dento-facial Development and Growth: Facial
Growth during the Foetal Life. New York, Pergamon
Press, 1967, P 79.
22. Spriestersbach DC, Dickson DR, Fraser FC, et al: Clinical
research in cleft lip and cleft palate: The state of the art.
Cleft Palate J 1973; 10(2):113-165.
23. Steele P: Dimensions of Dental Hygiene. Philadelphia, Lea
& Febiger, 1966.
24. Streeter GL: Developmental horizons in human embryos:
Age groups XI to XXII. Contrib Embryol 1951; 2: 197,
191.
25. Trasler DG, and Fraser FC: Role of the tongue in produc-
ing cleft palate in mice with spontaneous cleft lip. Dev Bioi
1963; 6:45.
26. Verrusio AC: A mechanism for closure of the secondary
palate. Teratology 1970; 3:17.
27. Warkany J, Kalter H: Congenital malformations. N Engl J
Med 1961; 265:993, 1046.
28.'Woo JK: Ossification and growth of human maxilla, pre-
maxilla, and palate bone. Anat Rec 1949; 105:737-761.
CHAPTER 4

Growth of the Craniofacial

Skeleton

Robert E. Moyers, D.D.S., Ph.D.

Donald H. Enlow, Ph.D.

Those who are enamoured of practice without science are like

a pilot who goes into a ship without rudder or compass and
never has any certainty where he is going. Practice should
always be based upon a sound knowledge of theory.
-LEONARDO DA VINeI. The Notebooks of Leonardo da Vinci,
Vol 11, Chapter XXIX (translated by Edward MacCurdy)

KEY POINTS 8. Growth of the cranial vault is paced largely by

1. Variations in cranofacial morphology are a primary
source of serious malocclusions.
2. Planned changes of bone growth and morphology are
a fundamental basis of orthodontic treatment.
3. Bone forms in two basic modes, endochondral and
intramembranous, named after the site of appearance.
4. All bone growth is a mixture of two basic processes,
deposition and resorption, which are carried out by
investing growth fields. Shape changes are produced
by remodeling, and enlargement may result in growth
movements.
5. The assumption of tight genetic control of
craniofacial bone growth has yielded to a structural-
functional approach, largely in response to Moss'
"functional matrix" hypothesis.
6. Natural controlling factors of craniofacial bone
growth include genetics, "function," general bodily
growth, and neurotrophism.
7. Disruptive factors of facial bone growth may be
elective (e.g., orthodontic treatment), environmental
(e.g., altered nasorespiratory function), or congenital
(e. g., gross craniofacial anomalies).
growth of the enclosed brain.
9. Basicranium growth is effected by a complex
combination of synchondrosal elongation, sutural
growth, and extensive cortical drift and remodeling.
10.' Nasomaxillary growth mechanisms involve the
sutures, endosteal and periosteal surfaces, and
alveolar processes. Alveolar remodeling contributes
" significantly to height, width, and length increases
correlated with eruption.
11. Mandibular growth modes and mechanisms are much
argued but it is agreed that a greater part is
intramembranously rather than endochondrally
determined. Areas, of muscle and tooth attachment
" ;'.ilre important parts of growth and shape change. The
condylar region plays a special role in mandibular
growth and translation.
12. Mandibular growth coincides roughly with growth in
stature and may display coincident periods of .
accelerated growth.
13. An important clinical issue is the extent to which
clinicians can alter mandibular growth.
14. The temporal component of the temporomandibular
joint.is less studied but it grows significantly by both

37
38 Growth and Development

intramembranous and endochondral mechanisms. 2) Timing

3) Compensatory mechanisms
15. There are important sexual differences in overall
c) Theoretical and clinical issues
craniofacial growth-boys grow more, over a longer
2. Basicranium
time, and are more apt to show "spurts" in growth.
a) Functions
16. Racial and ethnic differences in craniofacial
b) Growth
morphology are well documented but little is known I) Mechanisms and sites
about growth differences among racial, ethnic, or 2) Timing
national groups. 3) Compensatory mechanisms
c) Theoretical and clinical issues
OUTLINE 3. Nasomaxillary complex
a) Functions
A. The role of craniofacial skeletal growth in orthodontics b) Growth
B., Rudiments of bone growth I) Mechanisms and sites
I. Osteogenesis 2) Amounts and directions
/ a) Endochondral bone formation (a) Maxillary height
. b) Intramembranous bone formation (b) Maxillary width
2. Methods of studying bone growth (c) Maxillary length
a) Vital staining 3) Timing
b) Radioisotopes 4) Compensatory mechanisms
~' c) Implants 5) Effects on dentition and occlusion
d) Comparative anatomy c) Theoretical problems
e) Roentgenographic cephalometrics d) Clinical issues
f) Natural markers 4. Mandible
3. Mechanisms of bone growth a) Functions
a) Deposition and resorption b) Growth
b) Growth fields I) Mechanisms and sites
c) Remodeling (a) Role of the condylar cartilage
d) Growth movements (b) Ramus and corpus
I) Drift (c) Alveolar process
2) Displacement 2) Amounts and directions
C. Changing concepts and hypotheses of craniofacial growth (a) Height
I. The genetic concept (b) Width
2. The functional concept (c) Length
3. Hypotheses of craniofacial growth (d) "Rotation"
a) The genetic "theory" 3) Timing
b) Sicher's hypothesis (sutural dominance) 4) Compensating mechanisms
c) Scott's hypothesis (nasal septum) 5) Effects on dentition and occlusion
d) Moss' hypothesis (functional matrix) c) Theoretical problems
e) Petrovic's hypothesis (cybernetics) d) Clinical issues
4. Current concepts 5. Temporomandibular joint
D. Controlling factors in craniofacial growth a) Functions and growth
I. Natural b) Mechanisms and sites
a) Genetics c) Effects on dentition and occlusion
b) "Function" d) Clinical and theoretic ab issues
c) General body growth F. Overall pattern of craniofacial growth
d) Neurotrophism G. Racial and ethnic differences
2. Disruptive factors Ut ". "Adult" craniofa'tial growth
a) Orthodontic forces
b) Surgery
c) Malnutrition A. THE ROLE OF CRANIOFACIAL
d) Malfunctions SKELET AL GROWTH IN ORTHODONTICS
e) Gross craniofacial anomalies
E. Regional development In orthodontics skeletal growth is emphasized more than other
I. Cranial vault aspects of craniofacial development, perhaps because the methods
a) Functions for its study were developed earlier. Knowledge of skeletal mor-
b) Growth phology and growth is routinely applied in clinical practice; these
I) Mechanisms and sites can be visualized easily in the cephalogram: but there are problems.

Measurements in the cephalogram show the results of growth of
something, somewhere, at some time, but of what? Why? And in
response to which biologic stimuli or energies?
The craniofacial bony skeleton is a composite structure which
supports and protects a series of vital functions-but it is more
the place of the action than the action itself. We may measure a
football stadium, carefully noting its external dimensions, seating
capacity, location of principal components (i.e., playing field,
spectators' seats, press box, entrances, aisles, restrooms, and so
forth, even observing remodeled additions of parts and enlargement
of stadium size), but from this information we may deduce only
secondary information about the game of football itself. The sta-
dium tells us nothing of the rules, purpose, or strategies of the
ga!TIe, its tactical development, skills required of the players, its
impact on those who watch, or how the game is won or lost. In
fact, we cannot even be sure which of several particular football
games are played in the stadium.
This chapter deals with changes in the structures of the cran-
iofacial skeleton, where much of the action of craniofacial growth
takes place. Craniofacial growth differs from the football stadium
analogy in an important respect-there are significant interactions
constantly between the game of growth and the structure where it
takes place. Further, there is a mutual biologic dependency of
growth, function, and structure on one another. Football can be
played without a stadium but craniofacial growth and its structure,
the skull, are inseparable. But like the analogy of the stadium,
study of skeletal dimensions alone doesn't tell us much about
growth itself, only the results of that growth. Study of the cran-
iofacial skeleton tells us what has happened, not why, and only
from inference and deduction can we predict what may happen
later.
Nonetheless, craniofacial skeletal growth is very important
in orthodontics, since variations in craniofacial morphology are
the source of most serious malocclusions, and clinical changes of
bony growth and morphology are a fundamental basis of ortho-
dontic treatment.
B. RUDIMENTS OF BONE GROWTH*
1. Osteogenesis
Bone forms in two basic modes named after the site of ap-
pearance: cartilage or membranous connective tissue.
a) Endochondral Bone Formation
During endochondral bone formation, the original mesen-
chymal tissue first becomes cartilage. Endochondral bone for-
mation is a morphogenetic adaptation providing continued
production of bone in special regions that involve relatively high
levels of compression. Thus, it is found in the bones associated
*In sections Band E we have drawn heavily on the classic work of
my colleague and collaborator for this chapter, Professor Donald H. En-
low. It is impossible to note every sentence herein which might be cited
as an Enlow reference. The reader is urged to read Suggested Readings
at the end of this chapter for more detailed study of his writings and
those of other principal workers in the field. Note, too, that Enlow's
methods provide vivid descriptions of what has taken place during bony
growth. Why it takes place is another matter for the theoreticians (see
Section C)-R.E.M.
Growth of the Craniofacial Skeleton 39
with movable joints and some parts of the basicranium. Cartilage
cells hypertrophy, their matrix becomes calcified, the cells de-
generate, and osteogenic tissues invade the dying and disinte-
grating cartilage and replace it (Fig 4-1). Endochondral bone is
not formed directly from cartilage; it invades cartilage and replaces
it. The "epiphyseal mechanism" of bone growth (or its equivalent)
does not exert a direct regulatory influence over the growth changes
that occur in all of the other portions of an enlarging bone. Rather,
it is concerned essentially with its own local production of bone
tissue in particular areas served by the specialized cartilaginous
plate. Growth in all other regions of a bone, however, proceeds
in a closely interrelated manner, although the control and coor-
dinating mechanisms are poorly understood at present.
At least four fundamental ideas summarize the importance of
the cartilage-bone interface seen in endochondral bone formation.
Cartilage is rigid and firm, but not ordinarily calcified, thus
providing three basic growth functions: (I) flexibility yet
support for appropriate structures (e.g., the nose); (2) pres-
sure tolerance in specific sites where compression occurs
(e.g., the articular cartilages and epiphyseal growth in long
bones); and (3) a growth site in conjunction with enlarging
bones (e.g., the synchondroses of the cranial base and the
condylar cartilage).
Cartilage grows both appositionally, by the activity of its
chondrogenic membrane, and interstitially, by cell divisions
of chondrocytes and by additions to its intercellular matrix.
Interstitial growth of bone with its calcified matrix is, of
course, impossible.
Bone, unlike cartilage, is tension adapted and cannot grow
directly in heavy-pressure areas because its growth is de-
pendent upon its vascular osteogenic covering membrane.
"Growth cartilages" appear where linear growth is neces-
sary toward the direction of pressure, allowing the bone to
lengthen toward the force area and yet grow elsewhere by
membranous ossification in conjunction with all periosteal
and endosteal surfaces.
b) Intramembranous Bone Formation
In intramembranous bone formation, the undifferentiated
mesenchymal cells of the membranous connective tissue change
to osteoblasts and elaborate osteoid matrix. The matrix or inter-
cellular substance becomes calcified, and bone results.
Bone tissues laid down by tbe periosteum, endosteum, su-
tures, and the periodontal membrane (ligament)* are all intra-
membranous in formation (Fig 4-2). Intramembranous ossification
" *The term periodontal-"-ligament" is used in other chapters. How-
ever.::'it i.s felt by one of this chapter's authors (D.E.) that "membrane"
is much more appropriate for the subject of facial growth since this
word emphasizes the important processes of "membranous" and endo-
chondral bone growth and the role of the various osteogenic membranes
(periosteum, endosteum, sutures, periodontal membrane) in carrying out
growth and remodeling. "Ligament" implies a primary binding or at-
taching function. "Membrane," however, better connotes the multiple
and dynamic functions during childhood craniofacial growth of one of
the most remarkable connective tissue membranes anywhere in the
body. In addition to its ligamentous role, it contributes directly to (I)
tooth formation, (2) tooth eruption, (3) drifting of teech, (4) sensory
nerve reception, (5) vascular pathways, (6) growth of alveolar bone, and
(7) extensive alveolar remodeling associated with orthodontic tooth
movements.
40 Growth and Development
==c::>
oQGC)
000 000
000 000
000
o
FIG 4-1.
Endochondral bone growth. In A, the zones of the growth cartilage
are schematized. Zone a, the reserve cartilage, feeds new cells into
b, the zone of cell division. The cells in zone b undergo rapid division,
forming columns of flattened chondrocytes. This growth process is
responsible for elongation of the bone. In succession, the daughter
cells undergo hypertrophy (zone c), the matrix calcifies (zone d), and
this calcified matrix becomes partially resorbed and invaded by ves-
sels (zone e). Undifferentiated cells carried in by vascular sprouts
provide osteoblasts, which in turn deposit a thin crust of bone on the
remnants of the calcified cartilage matrix (zone f). The entire process
is continuous and repetitive, one zone transferring into the next. Note
that zone b becomes changed directly into zone c (arrow 1), zone d
into zone e (arrow 2), and zone e into zone f (arrow 3). As the entire
c:::> c:::>
cartilage grows in a linear direction toward the top of the illustration,
bone replacement follows. In B, the growth of a cranial synchondrosis
is schematized. Note that proliferation in bone formation occurs on
both sides of the plate, in contrast to the epiphyseal plate pictured
in D. C represents the growth cartilage of the mandibular condyle.
A zone of prechondrocyte proliferation occurs just beneath a covering
lay'er;.of fibrous capsule. Note that columns of prechondrocytes are
poorly' represented. A trypical longobone epiphysis showing a sec-
ondary center, articular cartilage, epiphyseal (growth) plate, and
medullary endochondral bone is represented in D. (From Enlow DH:
The Human Face. New York, Hoeber Medical Division, Harper &
Row, 1968. Reproduced by permission.)

FIG 4-2.
Intramembranous bone formation. In a center of ossification (A), the
cells and matrix of the undifferentiated connective tissue (late mes-
enchyme) undergo a series of changes that produce small spicules
of bone. Some cells (1) remain relatively undifferentiated, but others
(2) develop into osteoblasts that lay down the first fibrous bone matrix
(osteoid), which subsequently becomes mineralized, as in stage B.
Original blood vessels are retained in close proximity to the formative
bony trabeculae (3). As bone deposition by osteoblasts continues,
some of these cells are enclosed by their own deposits and become
osteocytes (4). Some undifferentiated cells develop into new os-
teoblasts (6), and other remaining osteoblasts undergo cell division
to accommodate enlargement of the trabeculae. The outline of an
f
Growth of the Craniofacial Skeleton 41
E}arly bone spicule (5) is shown in the enlarged trabeculae for ref-
erence. Blood vessels (3) have now become enclosed in the fine,
cancellous spaces (C). These spaces also contain a scattering of
fibers, undifferentiated connective tissue cells, and osteoblasts. At
lower magnification (D), the characteristic fine, cancellous nature of
the cortex is seen. This bone tissue type is widely distributed in the
p(e~§Ital as well as the young postnatal skeleton. It is a particularly
fast-growing variety of bone tissue. Note that the periosteum (also
formed from undifferentiated cells in the ossification center) has be-
come arranged into inner (cellular) and outer (fibrous) layers. (From
Enlow OH: The Human Face. New York, Hoeber Medical Division,
Harper & Row, 1968. Reproduced by permission.)
42 Growth and Development

is the predominant mode of growth in the skull, even in composite Alizarin, the essential dye of the madder plant, has subsequently
"endochondral" elements, such as the sphenoid and mandible, been identified and synthesized, and this and other vital dyes (e.g.,
where endochondral and intramembranous growth occur in the procion and tetracycline) are used extensively in bone research.
same bone. The basic modes of formation (or resorption) are sim- The primary value of such vital dyes lies in depicting the
ilar, regardless of the kind of membrane involved. pattern of postnatal bone deposition over an extended period in
Bone tissue sometimes is classified as "periosteal" or "en- one animal. A series of injections will leave layers of dyed bone
dosteal" according to its site of formation. Periosteal bone always alternating with unstained bone (Fig 4-3). The method reveals the
is of intramembranous origin, but endosteal bone may be either manner in which bone is laid down, the sites of growth, the di-
intramembranous or endochondral in origin, depending on the site rection and amounts of growth, and the timing and relative duration
and mode of formation. of growth at different sites. It does not, however, provide direct
Intramembranous bone growth may be summarized by means evidence of bone resorption; resorptive activity must be inferred.
of several basic ideas:
b) Radioisotopes
, Intramembranous bone growth occurs in areas of tension. Radioisotopes of certain elements or compounds often are
The membranes (periosteum, sutures, periodontium) have used as in vivo markers for studying bone growth. Such labeled
their own internal deposition and remodeling processes. material is injected and, after a time, located within the growing
The membrane grows outward rather than just backing off bones by means of Geiger counters or autoradiographic techniques.
as bone is laid down behind it. As it does so it undergoes In the latter method, the bones or sections of bones are placed
extensive fibrous changes in order to maintain continuity
among the periosteum, muscle insertions, and the bone it-
self. Therefore, there is constant deposition and resorption
on the bone surfaces as part of membranous remodeling
and relinking processes.
The periodontal membrane converts the pressures exerted
against the teeth during occlusal functions into tension on
the collagenous fibers attaching the tooth to the alveolar
bone. The positions of teeth within the alveolar process are
altered during eruption, during mesial drifting, and as they
adapt to facial growth or orthodontic forces. These changes
are made possible by constant remodeling and relinkage
processes of the fibrous attachments between the tooth and
the bone.

2. Methods of Studying Bone Growth

The face always has intrigued man, and there is a rich and
lengthy heritage of exciting cooperative research among archae-
ologists, physical anthropologists, anatomists, and orthodontic sci-
entists. Often the only human remains found by the archaeologist
are fragments of the craniofacial skeleton and a few teeth. From
these slender clues the anthropologist has constructed workable
hypotheses concerning the evolution of the human face. In few
fields are there so many and varied workers from human biology
because of the importance of the face's developmental complexities
to clinicians. Knowledge of facial growth is absolutely necessary
to clinical orthodontic practice. Each field brings its own methods
of study, goals, biases, and traditions. The reader is cautioned to
remember that no one method is sufficient, and conclusions based
on one approach must be balanced by the findings derived from
other techniques to provide a synthesis of understanding.

a) Vital Staining* FIG 4-3.

In 1736, BeIchier' reported that the bones of animals who
had eaten the madder plant were stained a red color. The bones
contained a band of red stain followed by an unstained band.
*For a good survey of in vivo staining and marking methods, see
the article by Baer and Gavan.1
The use of tetracycline HCI as a vital bone marker in monkeys. A,
cutaneous resorption: external resorption in nuchal region (a); dep-
osition peripheral to nuchal region (b). Two fluorescent tetracycline
HCllabels are visible. B, meningeal depository surface of the anterior
cranial floor with contralateral resorption. (B courtesy of Or. Mi(;hael
Riolo.)

against photographic emulsions that are then exposed by emission
of radiation from the radioactive substance.
c) Implants
Bjork7 devised an ingenious method of Implanting tiny bits
of tantalum or biologically inert alloys into growing bone. These
serve as radiographic reference markers for serial cephalometric
analysis. The method allows precise orientation of serial cephal-
ograms and information on the amount and sites of bone growth
(Fig 4-4). This method is useful because bone does not grow
interstitially and therefore implants placed inside a bone are stable.
d) Comparative Anatomy
Significant contributions to our knowledge of human facial
growth have been provided through comparisons with other spe-
cies. Not only can experimental work be done more readily on
animals but often basic principles common to growth in all species
are first recognized and defined by studies in comparative anatomy.
Much of our knowledge of the phylogeny of the anatomic com-
B
Growth of the Craniofacial Skeleton 43
ponents comprising the head has been derived from comparative
studies of fossil and present-day species.
e) Roentgenographic Cephalometry
Physical anthropologists and anatomists have measured the
head with calipers to provide standards of both living and dry
skulls (craniometry). From these methods evolved a branch of
anthropometry, roentgenographic cephalometry. The joining of
craniometry and radiology made possible standardized serial stud-
ies of the living, growing craniofacial skeleton and associated
features. Cephalometry has contributed significantly to our knowl-
edge of human craniofacial skeletal growth, and cephalometric
methods are used routinely, not only for the study of facial growth
but also for orthodontic diagnosis, treatment planning, and the
assessment of therapeutic results (see Chapter 12).
f) Natural Markers
The persistence of certain developmental features of bone has
led to their use as natural markers. By means of serial radiography,
FIG 4-4.
Use of implants to study craniofacial growth. A,
cephalogram of a rhesus monkey showing the use
of implants.68 Note specifically the use of implants
in the cranial base region. B, studying mandibular
growth in a rhesus monkey by superimposition over
the mandibular implants. Note the change of the
landmarks (e.g., c to c', pc to pc') with growth.
44 Growth and Development
trabeculae, nutrient canals, and lines of arrested growth can be
used for reference to study deposition, resorption, and remodeling.
Erilow23-25 has developed and used extensively methods for
studying bone deposition, resorption, and remodeling in decalci-
fied and ground sections (Fig 4-5). By relating the findings to
other methods, for example, cephalometrics or vital dyes, our
knowledge of bone growth has been extended greatly. Many of
the illustrations in this chapter are based on information derived
by these methods of study. Certain natural markers are also used
as cephalometric landmarks,o-12 (see Chapter 12).
o in the bone's investing soft tissues~muscles,
FIG 4-5.
Enlow's method of studying ground bone sections. The sequence of
remodeling changes that produced the cortical arrangement seen in
photomicrograph A is shown schematically in S, C, and D. Prior to
the lateral drift, stage S, the cortex is composed of inner (endosteal)
and outer (periosteal) zones. Simultaneously, new bone is added at
surface 1, removed from side 2, added to surface 3, and resorbed
on side 4 as shown in C. The composite result is drift of this entire
region of the bone in the direction indicated by the arrows in C. The
final stage schematized in D is comparable with the actual photomi-
crograph shown in A. (From Enlow DH: The Human Face. New York,
Hoeber Medical Division, Harper & Row, 1968. Reproduced by
permission. )
3. Mechanisms of Bone Growth
Although the reader has studied the histology of bone, the
practical aspects of such study are often not appreciated until the
need arises to understand what can be expected from bone growth
and how it might be altered to the patient's advantage. What
follows in this section is a simple presentation of a complicated
subject of much important current research: Many factors are still
unknown; many issues are still unresolved. More detailed infor-
mation can be gained from the Suggested Readings listed at the
end of the chapter.
All bone growth is a complicated mixture of two basic proc-
esses, deposition and resorption, which are carried out by growth
fields comprised of the soft tissues investing the bone. 59. 60 Because
the fields grow and function differently on different parts of the
bone, the bone undergoes remodeling (i.e, shape change). When
the amount of deposition is greater than the resorption, enlargement
of the bone necessitates its displacement (i.e., its physical relo-
cation) in concert with other bone displacement.
a) Deposition and Resorption
On one side of a bony cortex new bone is added, on the other
side, bone is taken away. Deposition occurs on the surface facing
the direction of growth, while resorption is seen on the surface
facing away (see Fig 4-5). The result is a process termed cortical
drift. a gradual movement of the growing area of the bone.
Bone does not add even accretions on its outside surfaces as
in the concentric rings of a tree (see Fig 4-7 A). The complex
morphologies of facial bones make uniform enlargement impos-
sible and differential growth a necessity; thus, some areas grow
more rapidly and some outside surfaces show resorption (see Fig
4-5).
Enlow's "V" principle is useful in understanding deposition
and resorption in complicated remodeling during growth in length
(e.g .• the ends of long bones or the neck of the mandible) (Fig
4_6).23
b) Growth Fields
All surfaces, inside and outside, of every bone are covered
by an irregular pattern of "growth fields" comprised of various
soft-tissue osteogenic membranes or cartilages. Bone does not
grow itself, it is grown by this environment of soft-tissue growth
fields. The genetic program for bone growth is not contained within
the hard bone tissue; rather, the determinants of bone growth reside
integument, mucosa,
-owod vessels, nerves, connective tissue, the brain, etc63 Any bone
has both resorptiye and depository fields over all its inside and
out~jde cortical surfaces~ The varying activities and rates of growth
of these fields are the basis for the differential growth processes
that produce bones of irregular shapes. The irregularity is a re-
sponse to the varied functions imposed on the bone by attachments
of muscle, sutural articulations with other bones, insertions of
teeth, and other processes.
About one-half the total amount of cortical bone is periosteal
in origin (from the covering membrane)' and half is endosteal
(formed by the lining membrane). Approximately half of both
periosteal and endosteal surfaces are resorptive and half are
depository.
 Growth of the Craniofacial Skeleton 45

B
B
C
\ o

B
B

-0-
C

+
FIG 4-6.
The "V" principle (top left). Many facial bones or parts of bones surface of the cortex. At C, endosteal new bone produces an inward
have a "V" shape. Note that deposition ( + ) occurs on the inner side growth phase. A section at 0 shows a cortex composed entirely of
and resorption ( - ) on the outer. The "V" moves from A to B as the periosteal bone following outward reversal as this part of the bone
overall dimension increases (Le., movement is toward the wide end now increases its diameter. Now the outer surface is depository and
of the "V"). Thus, simultaneous growth movement and enlargement the endosteal resorptive. If markers were placed at X, Y, and Z, note
occur. (Bottom left) note that the diameter at A is reduced as the that X will eventually be freed, Y moves from periosteal cortex to
broad part of the bone is relocated to B. Wider parts become narrower endosteal, and Z is also released, by endosteal resorption. (From
by periosteal resorption and endosteal deposition. (Right) a trans- ,Enlow DH: Handbook of Facial Growth, 2nd ed. Philadelphia, WB
verse section at A shows why the periosteal surface is resorptive. Saunders Co, 1982. Reproduced by permission.)
The section at B shows new endosteal bone added onto the inner
t
Some growth fields having special roles in the growth of one considers the epiphyseal plates of long bones which continue
particular bones are called growth sites (Fig 4-7B). These include. their growth against the large forces of gravity, muscle contrac-
the mandibular condyle, the maxillary tuberosity, the synchon- ·.tLons, etc. By and large, the concept of growth centers in the
droses of the basicranium, the sutures, and the alveolar processes. craniofacial region seems less·,important now, although it is still
These special growth sites do not cause all of the growth in their argued whether or not the mandib\llar condyle and the synchon-
bone, or carry out even most of the growth process of a particular droses in the cranial base are growth centers (see Section E, Re-
bone, for all other inside and outside surfaces must actively par- gional Development).
ticipate as well in the overall growth process.
Some growth sites have been called" growth centers," a term c) Remodeling
which implies that a special area somehow controls the overall Facial bones are not enlarged by generalized surface accretion
growth of the bone. The term "growth center" also implies that that merely follows existing contours (see Fig 4-7 A): they do not
the "force," "energy," or "motor" for a bone resides primarily get bigger as a balloon enlarges, for their shape changes. The
or solely within its growth center. This concept finds support when required differential growth activity necessary for bone shaping,
46 Growth and Development

termed remodeling, involves simultaneous deposition and resorp-' modeling, the constant replacement of bone during childhood; (3)
tion on all inner and outer surfaces of the entire bone. Remodeling, Haversian remodeling, the secondary process of cortical recon-
a basic 'part of the growth process, not only provides regional struction as primary vascular bone is replaced; and (4) the regen-
changes in shape, dimensions, and proportions, it also produces eration and reconstruction of bone during and following pathology
regional adjustments that adapt to the developing-function of the or trauma, Growth remodeling during childhood and adolescent
bone and its various growing soft tissues, growth involves the formation of a highly vascular bone because
There are four kinds of remodeling in bone tissues:27 (I) of the rapid rates of deposition. This original bone is gradually
biochemical remodeling, involving continuous deposition and re- replaced, as the child matures, with slower growing types of bone
moval of ions to maintain mineral homeostasis; (2) growth re- which are less vascular and even nonvascular in some areas. Thus,

•••
v=

/,-~p--
-,/,1-
.- --

--x

FIG 4-7.
Diagrammatic representation of the principles of craniofacial growth,
Explanations of craniofacial growth have often been oversimplified
in the literature. The various bones of the craniofacial skeleton do
not enlarge by a process of generalized surface accretion following
'existing contours, as in A. Facial growth has been presented as a
process occurring largely in facial sutures (1, 2, 3, and 4 in B) and
by additions to the alveolar margin and maxillary tuberosity (5). This
oversimplification does not take into account the extensive remod-
eling growth that occurs in virtually all parts of craniofacial bones, A
bone may move by two means: it can grow (cortical drift) by selective
deposition and resorption (C) or it can become displaced (D) from
one position to another. Relocation is shown by schematized seg-
ments (E), In E, the black segment at the left occupies the number
.1 position, As longitudinal growth (addition of neW segments) con-
tinue,Sc however, the black segment becomes relocated in a position
to number 2, 3, 4, etc. Although its r~lative position with respect to
the other segment constantly changes, note that it does not move;
rather, it becomes relocated because of growth taking place in other
areas, Relocation (F) underlies most .of the remodeling that takes
place during growth in the mandible. For example, portions of the
condyle become converted into the neck. In these superimposed
growth stages, sections of a and b show the local changes that occur
as the bone enlarges. Remodeling is a process of reshaping and
resizing as a consequence of progressive continuous relocation, (From
Enlow OH: The Human Face. New York, Hoeber Medical Division,
Harper & Row, 1968, Reproduced by permission,)
 Growth of the Craniofacial Skeleton 47

the rate of remodeling is intensive during childhood and adoles- d) Growth Movements
cence and slows down considerably but persists to a much lesser Two kinds of growth movements are seen during the enlarge-
extent during adulthood. ment of craniofacial bones: cortical drift and displacement (Figs
To summarize, growth remodeling is paced by the growth 4-7 and 4-8). Drift is growth movement (relocation or shifting)
and functions of the soft tissues which surround the bones. As of an enlarging portion of a bone by the remodeling action of its
these soft tissues grow and function they (I) shape the bone, which osteogenic tissues, while displacement is a physical movement of
adapts to the changing functional actions exerted on it; (2) relocate the whole bone as it remodels.
parts of the bone producing, as a result, a progressively larger
whole bone; and (3) carry out regional adjustments to maintain 1) Drift.-Combinations of deposition and resorption result
continuous fitting together of the separate bones within their grow- in growth movement toward the depository surface-drift (see Fig
ing soft ·tissue environment. 4-7C). Drift is seen with remodeling enlargement and is produced

z x

m \\
-.......• ••• 1.

o ."
z x

,.
FIG 4-8.
Cortical drift and displacement. In A, the model has been positioned
from Pto P'. It may do this b.y either of two basic processes: direct
cortical growth (drift) (B) or displacement (C). These two processes
frequently produce movement in divergent directions simultaneously.
In D, for example, the model itself is growing to the right (arrow) but
is being carried to the left at the same time. In E, the model drifts
(deposition in conjunction with resorption on contralateral surfaces)
from Pto P' for a distance designated as d'. The carrier moves in
an opposite course from X to Z for the distance d2. In F, the original
relationship prior to these movements is indicated by X and I. The
relative position of the model if drift alone occurred would be at m.
The carrier, however, has moved from X to Z. If displacement alone
occurred, the relative position of the model would be at j. The com-
bination of both drift and displacement, however, results in the final
positional relationship seen between Z and k. (From Enlow OH: The
Human Face. New York, Hoeber Medical Division, Harper & Row,
1968. Reproduced by permission.)

",
 48 Growth and Development
by the deposition of the new bone on one side of the cortical plate,
while resorption occurs on the opposite side. If an implant is placed
on the surface of the depository side of a bony cortex, it becomes
gradually embedded in the cortex as new bone .continues to form
over that surface and as resorption occurs on the opposite surface.
In time the implant becomes relocated from one side of the cortex
to the other, not because of its own movement (the implant is
immobile), but because of the drift of the bone around it (see Fig
4-7E).
2) Displacement.-Displacement, on the other hand, is
movement of the whole bone as a unit (see Fig 4-7D). As a bone
is carried away from its articulation with other bones, growth
remodeling simultaneously maintains relationships of the bones to
each other. For example, as the entire mandible is displaced from
its articulation in the glenoid fossa, it is necessary for the condyle
and ramus to grow upward and backward to maintain relationships.
As the condylar neck, coronoid process, and ramus remodel to
accommodate the displacement, they also grow in size and sustain
basic shape (see Fig 4-7F). This entire process is called primary
displacement, that is, displacement associated with the bone's own
enlargement. Secondary displacement is movement of a bone re-
lated to enlargement of other bones.
Drift and displacement occur together and complement each
other (i .e., they move in the same direction) or they may take
place in contrasting directions (see Fig 4-8), making it difficult .
to determine the separate contributions of remodeling and dis-
placement during cephalometric analyses (see Chapter 12); how-
ever, they are separate processes.
C. CHANGING CONCEPTS AND
HYPOTHESES OF CRANIOFACIAL GROWTH
Anyone beginning study in a field wrestles first with the
current conventional wisdom but often has difficulty understanding
how colleagues arrived at the understanding they hold. Kuhn45 has
written wisely about what he terms "scientific revolutions," and
Carlsonl7 has applied Kuhn's concepts to the field of craniofacial
I SC'ENTIFIC I .-. .-.
REVOLUTION
PARADIGM
2
iY
PARADIGM 1 ~ NORMAL
PARADIGM
SCIENC~
I!)I__________ J>I ;,ARADIGM2
FIG 4-9.
Representation of how changes in "normal science" are wrought by the introduction of new paradigms during
scientific revolution. (From Carlson DS: Craniofacial biology as normal science, in Johnson LE Jr (ed): New
Vistas in Orthodontics. Philadelphia, Lea & Febiger, 1985. Reproduced by permission.)
biology. Kuhn45 defines "normal science" as the research findings
generally agreed to be basic to a scientific field. Therefore, a
normal science is that which new students must grasp if they are
to understand the basic concepts of their new discipline. Kuhn45
invents a new term (by distorting the meaning of a classic Greek
word)-"paradigm"-by which he means the current conceptual
framework of a scientific field. Kuhn's "paradigm" is closely
related to his ideas of "normal science," but paradigms change,
new paradigms are suggested, and paradigms may be out of step
with the normal science of the time. The result is conflict within
a field-Kuhn's "scientific revolution." Gradually, a new para-
digm assumes dominance, and a new normal science for the field
emerges (Fig 4-9).
For some time there have been attempts to provide an ov-
erriding conceptual framework for all craniofacial growth or, fail-
ing that, a neat synthesis of several "theories." These efforts have
generally not yet been successful because of the varied aspects
and complicated nature of craniofacial growth. It is, however,
useful for us to review the evolution of the governing concepts in
the field of facial growth through the years. Kuhn45 and Carlsonl7
would call these "paradigms."
1. The Genetic Concept
For many years craniofacial growth research was dominated
by interest in skeletal morphology, an interest which began in
archaeology, physical anthropology, and anatomy. The tempo in-
creased when the craniostat was converted into the radiographic
cephalometer and the field of cephalometrics emerged, making
possible serial study of the growing human craniofacial skeleton.
Brodie,15. 16noting the persistent pattern of facial configuration,
assumed it was under tight genetic control. Research focused on
the growth sites for this control: the sutures, craniofacial cartilages,
and periosteum. The assumption was made that the cartilages and
facial sutures were under genetic control and that the brain deter-
mined the vault dimensions (which meant vault sutures were pas-
sive while facial sutures were actively forcing bones apart). Wendell
Wylie termed this thinking "Orthodontic Calvinism" (see Section
D-l-a, Controlling Factors in Craniofacial Growth, Genetics). Since
PARADIGM
1
NORMAL SCIENCE
 Growth of the Craniofacial Skeleton 49

the concept was one of an invariant, predetermined pattern of
craniofacial growth, there began an interest in prediction, which
was assumed to be easy (see Chapter 12).
In the 1940s two events reflected changing ideas about the
dominant genetic concepts: (l) a marked ilfcrease in the use of
animals in craniofacial research; and (2) the introduction of jaw
and facial electromyography. 65.66 Moss' 1960 formulation of the
functional matrix hypothesis later provided a logical framework
for an emerging new concept. 64Through the distance of time, it
may be thought that each of these events precipitated new thinking.
We believe the reverse is true. Just as it was the need to quantify
and study the head serially which prompted the development of
the cephalometer, so the desire to see beyond the craniofacial
~keleton heightened interest in the experimental model and neu-
romuscular function. One of us (R.E.M.) began the first work in
craniofacial electromyography in 1946 (just 5 years after the pub-
lication of Brodie's classic paper in 1941) and within a year su-
pervised 'a thesis research project involving the effects on skeletal
growth of extirpation of the temporal muscle in neonate rats.82
Scientific historians dependent alone on the literature of a period
are always some years out of phase with the origin and development
of the ideas which resulted in that literature.
Moss,59. 60.64 adopting van der Klaauw's93 concepts, sug-
gested that skeletal tissues were passive and under the control of
functional components to which the craniofacial skeleton adapted.
First he demonstrated that the sutures of the cranial vault were
passive. 58 Then his ideas, which obviously had been fermenting
in his mind for some time, were somewhat inprecisely stated in a
watershed paper whose importance was difficult to appreciate at
that time.59 He called this new concept the "functional matrix
hypothesis. "
2. The Functional Concept
It was some time after Moss' first paper before the functional
matrix concept came to influence thinking in craniofacial growth
(Fig 4-10).64 The concept gradually was clarified by several re-
phrasings, but perhaps its best statement appeared in 1981: " ... in
summary form, the functional matrix hypothesis explicitly claims
that the origin, growth and maintenance of all skeletal tissue and
organs are always secondary, compensatory, and obligatory re-
sponses to temporally and operationally prior events for processes
that occur in specifically related non-skeletal tissues, organs for
functioning spaces (functional matrices)."63 Some have misun-
derstood and misstated or misapplied Moss' ideas. His own writing
is more conservative and careful than some others on the same
topic. It is a theory difficult to prove or disprove, but it has been
provocatively useful and probably has done more in modern times
than any other single new idea to alter the thinking of those in-
terested in craniofacial growth.
3. Hypotheses of Craniofacial Growth
Through the years, a number of hypotheses of craniofacial
development have been formulated which are often encountered
in textbooks and the periodical literature, where they are sometimes

1940 1950 1960 1970 1900

GENETIC GENETIC GENETIC

PREDETERMINATION PREDETERMINATION
PREDETERMINATION
NASAL SEPTU'-4, CRANIAL BASE, NASAL SEPTU'-4, CRANIAL BASE,
'-4ANOIBULAR CONDYLE '-4ANOIBULAR CONDYLE \71

ANTHROPOLOGICAL

CRANIOLOGY

STRUCTURO- CRANIOFACIAL COMPLEX

FUNCTIONAL AS HIGHLY ADAPTABLE,

APPROACH
ONTOGENETICALLY a
PHYLOGENETICALLY

'FUNCTIONAL
EPIGENESIS
MATfm( (SENSU STRICTOJ
,-----------~-_._---~ HYPOTHESIS
I I
l COMPARATIVE WNCTlONAL :

i--1
:
ANATOMY,
EMBRYOLOGY CLASSICAL
(EP/GENETlCS),
PALEONTOLOGY
:-If
f7'11j
:
L l
FIG 4-10.
Changing concepts of craniofacial growth acting as paradigms to alter the normal science of craniofacial biology. (From Carlson DS:
Craniofacial biology as normal science, in Johnson LE Jr (ed): New Vistas in Orthodontics. Philadelphia, Lea & Febiger, 1985. Reproduced
by permission.)

I
50 Growth and Development
called "theories." Theory requires a basis of sound evidence;
while hypothesis is thoughtful conjecture of the meaning of in-
complete evidence. In the long run the most useful hypotheses are
those which can be rigorously tested. It is interesting to place them
in the historical evolution of overriding conceptS' ("paradigms")
discussed earlier (Fig 4-10).
a) The Genetic "Theory"
The genetic theory simply said that genes determine all. Al-
though called a theory it was more assumed than proven. A brief
summary of its current pertinency follows in Section 0-1. After
the general assumptions were found to be flawed, some said "per-
haps this part is genetically controlled while that is not," or "this
part,is more controlled by heredity than that." Such statements
showed uneasiness with the all-embracing aspects of the' 'theory. "
b) Sicher's Hypothesis (Sutural Dominance)
Sicher'9' deduced from the many studies using vital dyes that
the sutures were causing most of the growth; in fact, he said" ...
the primary event in sutural growth is the proliferation of the
connective tissue between the two bones. If the sutural connective
tissue proliferates il creates the space for oppositional growth at
the borders of the two bones." Replacement of the proliferating
connective tissue was necessary for functional maintenance of the
bones. He felt that the connective tissue in sutures of both the
nasomaxillary complex and vault produced forces which separated
the bones, just as the synchondroses expanded the cranial base
and the epiphyseal plates lengthened long bones. Sicher'8 viewed
the cartilage of the mandible somewhat differently, stating that it
grew both interstitially, as epiphyseal plates, and appositionally,
as bone grows under periosteum. His ideas came to be called the
"sutural dominance theory," but it would seem he held sutures,
cartilage, and periosteum all responsible for facial growth and
assumed all were under tight intrinsic genetic control.
c) Scott's Hypothesis (Nasal Septum)
Scott,85-87 noting the prenatal importance of cartilaginous por-
tions of the head, nasal capsule, mandible, and cranial base, and
feeling that this development was under intrinsic genetic control,
held that they continued to dominate facial growth postnatally. He
specifically emphasized how the cartilage of the nasal septum
during its growth paced the growth of the maxilla.85 Sutural growth,
Scott felt, came in response to the growth of other structures
including cartilaginous elements, brain, the eyes, and so forth87
Latham46 elaborated on Scott's ideas about the nasal septum
and maxillary growth, emphasizing the role of the septo-premax-
illary ligament beginning in the later part of the fetal period. He
felt the maxillary sutures began as sliding joints adapting to ini-
tiating growth forces elsewhere, but later manifest increasing os-
teogenesis, contributing to the main displacing force at the free
surfaces. Thus, he combines ideas of Scott, Sicher, and Moss.
d) Moss' Hypothesis (Functional Matrix)
As noted elsewhere, Moss feels that bone and cartilage lack
growth determination and grow in response to intrinsic growth of
associated tissues, noting that the genetic coding for craniofacial
skeletal growth is outside the bony skeleton.63 He terms the as-
sociated tissues "functional matrices. "59 Each component of a
functional matrix performs a necessary service-such as respira-
tion, mastication, speech-while the skeletal tissues support and
protect the associated functional matrices. Moss divides the skull
into a series of discrete functional components each comprised of
a functional matrix and an associated skeletal unit, c(esignating
functional matrices as either periosteal or capsular.60 A periosteal
functional matrix affects deposition and resorption of adjacent bony
tissue; therefore, the matrix controls remodeling and the size and
shape of a bone (e. g., the interaction between the temporal muscle
and the coronoid process of the mandible). Moss identifies two
large, enveloping capsular matrices: the cerebral and the facial.60
Each contains specific tissues and structures and spaces, spaces
which must remain open to fulfill their functions. As each capsular
matrix and its associated elements expand, all of the bones, en-
dochondral and intramembranous, grow to maintain the physio-
logic spaces. Thus, Moss argues, the skeletal tissues grow only
in response to soft-tissue growth. The effect is a passive translation
of skeletal components in space.
e) Petrovic's Hypothesis (Servosystem)
Using the language of cybernetics, Petrovic73 reasoned that
it is the interaction of a series of causal change and feedback
mechanisms which determines the growth of the variouscrani-
ofacial regions. According to this servosystem theory of facial
growth, control of primary (see E-4, Mandible, later in this chap-
ter) cartilages takes a cybernetic form of a "command" whereas,
in contrast, control of secondary cartilage (e.g., the mandibular
condyle) is comprised not only of a direct effect of cell multipli-
cation but also of indirect effects.76 In his experiments Petrovic
detected no genetically predetermined final length for the man-
dible79 Rather, the direction and magnitude of condylar growth
variation are perceived as quantitative responses to the lengthening
of the maxilla.75. 77.78 Petrovic's provocative ideasc are ~specially
useful in understanding the role of functional appliances in man-
dibular growth. 74.80For a more detailed study see Suggested Read-
ings and, especially, his 1984 paper.74
4. Current Concepts
Where are we now? What do we do now? What is true (now)?
We have been, in Kuhnian terms, in the midst of a scientific
revolution. Carlson17 calls it moving from the genetic paradigm to
th€ structural-functional approach (see Fig 4-10). Everything is
not yet known and much research is yet to be done, but clinicians
must treat patients with working hypothes1s of growth in mind
while issues are being resolved by craniofacial biologists in their
minds and laboratories.
':. While we may no longer seek a synthesizing single theory
for aft. of craniofacial growth, w~ may now have, because of
Petrovic's work, a convenient model and a "language" by which
to describe and relate growth activities to one another, thus ob-
viating any need for another "paradigm."
It is very important to remember that old ideas persist in the
literature, in the thinking of some teachers, and the treatment
planning of some clinicians long after they have been disproven
and abandoned by craniofacial research biologists. It is also es-
sential to realize that while fresh, exciting, new ideas may be
revealing and useful, only time can attest to their truth and their

place in understanding the complicated mosaic of craniofacial
growth.
" What follows in the rest of this chapter is as clear and direct
a statement of conventional wisdom as we can write at this time.
Others would write it differently, and scientific reports regularly
will alter parts of the overall picture of craniofacial development
as new concepts, hypotheses, and theories emerge and are applied.
D. CONTROLLING FACTORS IN
CRANIOFACIAL GROWTH
1. Natural
Van Limborgh94~96 has divided the factors controlling skeletal
morphogenesis into five groups, namely, intrinsic genetic factors,
local and general epigenetic factors, and local and general envi-
ronmental influences. It is the proportional importance of these
various groups of factors in the control of later craniofacial skeletal
development that we must try to understand.
a) Genetics*
One can often conclude immediately that all resemblances in
families are genetic and structural. But such similarities as facial
expressions, mode of laughter, and way of speaking may be learned
as a result of living together. Garn et al. 28 report similarities in
fatness in families as a cohabit:ltional effect, suggesting that living
together and consuming the same food result in measurable sim-
ilarities in some structural dimensions. What we sometimes assume
to be genetic may be acquired and superimposed on a genetic
foundation common to parents and progeny. The old argument
about heredity versus environment has changed from the question
of which is more important to how, when, and in what way does
environment alter the original form laid down by heredity.
When we think of inheritance, we remember such things as
the fact that by examination of the parents we can predict precisely
the ABO blood types of the progeny, for blood types are dis-
tributed discontinuously (i.e., in any sample, everyone falls into
one of the four blood types). Such a discontinuous distribution is
evidence for simple Mendelian inheritance. A continuous distri-
bution of a variable, with most values grouped around a mean, is
evidence for inheritance from several or many genes. There are
no craniofacial skeletal measures which are discontinuous in their
distribution. In ,addition to multiple genes there are the effects of
the environment on the product of the genetic contro~ during
formation.
Undoubtedly there are primary controls for initiation and for-
mation of facial structures. Van Limborgh96 reports experimental
studies on chick embryos indicating that the intrinsic genetic in-
formation necessary for the differentiation of cranial cartilages and
bones is supplied by neural crest cells. He feels that the importance
o! intrinsic genetic factors for control of craniofaci~] differentia-
tion, perhaps even intramembranous bone growth, is considerably
*In writing this section on genetics we have borrowed heavily from
a splendid summarizing paper by Professor W. S. Hunter. 37 Because he
is a geneticist, an active research worker, and an orthodontist, he is able
to place these matters in sound, useful perspective.
-.
Growth of the Craniofacial Skeleton 51
greater than has been thought in recent years. Primary genetic
control determines certain initial features (e.g., tooth buds calcify
in the jaws, and mandibles form in faces, not legs). Secondarily,
there are inductive local feedback and inner communication mech-
anisms between cells and tissues-the teeth "talk to" the bone,
the muscles "talk to" the bone, and the bone "talks back" to the
muscles. As a result, the genes for muscles have a modifying
effect on the products of bony initiation and formation. Although
it is argued whether or not there is simple gene control of formation
of facial bones, the end result after tooth formation and muscle
development appears to be polygenic or multifactorial. What is
environment to the bone is genetic to the muscles and the teeth:
van Limbourgh's "epigenetic factors." There is also some kind
of an overriding sizing mechanism, far more precisely seen in the
dentition than the bones. Although the upper and lower teeth are
never perfectly matched, all of the teeth in an individual tend to
be proportionately large or small (see Chapter 6).
If the face were under rigid genetic control, it would be
possible to predict features of children from cephalometric data of
the parents. A number of studies illuminate this particular point:
the best involve parents whose children have achieved maturity,
so that little growth is yet expected from them.38 Given multifac-
torial controls, it can be shown that the highest correlation between
parents and progeny can only be a correlation of r = .5. This can
be compared to the correlation for blood type, namely, r = 1.0
between parents and progeny. Squaring the correlation coefficient
enables one to arrive at the amount of variation explained or pre-
dicted for one variable in the correlation by the other. Thus a
correlation of 0.5 enables one to predict only 25% of a child's
mandibular size from knowledge about the parents' mandibular
sizes. Since the usual correlation between parents' and children's
dimensions is about 0.3, something less than 15% of children's
dimensions are predictable or explained by parents' dimensions.
If we wish to apply genetics clinically, we must ask what other
alternatives than predicting size are available to us. Johnston noted
that 30% to 54% of the variability of a patient's Class II maloc-
clusion features can be explained by using data from the patient
himself or herself. 42Hunter et al. 38 obtained a slightly higher amount,
60%. These facts are utilized in the cephalometric diagnoses de-
taileq in Chapter 12, particularly in "prediction"; however, the
examination of parents for the purpose of forecasting size in chil-
dren is not likely to be clinically very useful.
, Some investigators, feeling that heritability in the face is not
entirely polygenic, have undertaken investigations to study the
matter. However, from the investigations thus far, two conclusions
seen inescapable: (I) inheritance of facial dimensions is polygenic84
and (2) no more than one-fourth of the variability of any dimension
in .~hildren can be explained by consideration of that dimension
in parentS . 37
To summarize, it is highly unlikely that any component of
the facial skeleton is inherited in the Mendelian fashion. Rather,
the evidence strongly supports polygenic inheritance, greatly lim-
iting our ability to explain facial dimensions from study of parents.
Even if the size of facial bones were inherited in a Mendelian
fashion, that inherited pattern is altered by environmental influ-
ences, some epigenetic and some general, to such an extent that
in the patient the underlying genetic features cannot be easily
detected.
52 Growth and Development

FIG 4-11.
Relationship of times of emergence of certaif}
teeth and the onset and end of peak height ve-
locity (PHV). (From Hagg U, Taranger J: Dental
development assessed by tooth counts and its
GIRLS

1 2
1l,;.,
11 2
2
2.z;
2
3
:z l
ONSET

{'..

3
~ ~~
PHV

(
END

5
~
5

ONSET PHV END

correlation to somatic development during pu- BOYS
berty. Eur J Orthod 1984; 6:55-64. Reproduced
by permission.) T T ,............, ! T ! ,............,

6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
YEARS

DESv DES M'"

b) "Function"
Normal function plays a role in skeletal growth, for its ab-
sence, as in temporomandibular ankylosis, aglossia, and neuro-
muscular disorders, results in gross distortion of bony morphology.
The role of ftmction as the primary factor in control of craniofacial
growth is the essence of Moss' "functional matrix hypothesis"
(see Section C). The role of malfunction in causing compensatory
abnormal growth is appreciated (see D-2-d. Disruptive Factors,
Malfunction, later in this section). Read carefully the sections on
compensatory mechanisms for each region in Section E, Regional
Development, for an understanding of the sites of compensatory
growth and their adaptive responses to altered function.
c) General Body Growth
Biological maturity plays a general role in all aspects of ma-
turation of the individual.44 All maturational events are influenced
in individuals by a combination of factors including genetic, cli-
matic, racial, nutritional, and socioeconomic. For this reason there
has been considerable interest in the relationship between the ma-
turation and timing of somatic growth and dimensional growth in
the craniofacial complex'"' 9. 11.14.21.72.97.98The most obvious di-
mension in growth of the child's body, and that studied most
frequently, is height, which is measured easily and reliably. The·
velocity curve for height diminishes continuously from birth except
for two spurts, the first a small and inconsistent one at about 6 or
7 years of age and the second at the time of puberty (Fig 4_11).29
During the pubertal spurt in stature, the velocity of growth is apt
to be greater than at any other time when orthodontic treatment is
ordinarily undertaken. Therefore it would seem to be of great
benefit if aspects of orthodontic treatment depending on growth
could be undertaken during this time. It would be especially ben-
eficial if one could predict any craniofacial spurts from earlier
developmental events.
All facial dimensions do not undergo a spurt, nor is the rate
of increased velocity, the onset, the duration, or the cessation
similar in all people. Generally, however, those facial dimensions
which do spurt do so at about the same time as stature. On the
average, the peak of the growth spurt in stature is about 12 years
in girls and 14 years in boys, but the standard deviation is nearly
I year for each sex."7 It would be most advantageous to predict
the onset of spurts in facial growth. However, this is exceedingly
difficult and it is hard to identify the growth spurt until it is well
under way. Therefore, most studies have concentrated on the Max-
imum Height Velocity (also known as Peak Height Velocity). It
is well known that several other maturational events are related to
the overall height growth curve; for example, skeletal age, derived
from hand-wrist radiographs, is an established method of esti-
mating physical maturity and has value in predicting adult height.
Orthodontists, however, have tried to use the hand-wrist radi-
ograph not to predict ultimate adult height or even facial dimension
but, rather, the time of the Peak Height Velocity in growth. Many
have attempted to derive clinical precision from this general bio-
logic relationship, however. Houston,'6 in one of the most thorough
and best designed studies, concludes that' 'the practical difficulties
of timing ossification events and the need for serial observations
before an estimate of age at Peak Height Velocity can be made,
. will preclude their use in most clinical situations." Lewis et al.:7
after studying mandibular spurts, flatly stated: "It can be desirable
to determine whether a spurt has occurred in an individual patient.
For this purpose, skeletal age, as determined from carpal radi-
ographs, may be only slightly more meaningful than chronolog-
ical age, and neither is sufficiently precise for many clinical
applications. "
The use of population means to predict developmental events
in the individual provides very little help because of the extent of
normal variation. Even if one were able to predict the Peak Height
Velocity, approximately one-half of the advantage would be lost
since it occurs before the peak. Dental development has also been
tried as an indicator of the timing of the pubertal growth spurt,
but it too has not been very helpful. 22.30
To summarize, somatic growth and craniofacial growth are
generally related, but that relationship is difficult to utilize in
precise, practical prediction of facial dimensional change. This is
not to say that the general information is not useful clinically, it
is;'but its practical, quantified application has sometimes been
overstated.
d) Neurotrophism
It is known that neural activity controls muscle activity and
gro}V~h. Nervous controL of skeletal growth, assumedly by trans-
missibn of a substance through th~ axons of the nerves, has been
hypothesized for years and is called neurotrophism. The history
of this idea, the arguments for and against it, and its relationships
to current theories of craniofacial growth have been reviewed in
articles by Behrents3 and by Moss.62
Theoretically, a direct neurotrophic effect on osteogenesis is
possible, but, logical as it seems, it has not been demonstrated
experimentally. Neurotrophism could act indirectly by the nerves
inducing and affecting soft-tissue growth and function, which in
turn would control or modify skeletal growth and morphology-the

basic idea in Moss' functional matrix hypothesis, which holds bone
growth to be mostly in response to the surrounding soft tissues.
But'neurotrophism, even within Moss' view, 6' has an element of
primary cause and control. Such evidence as we have (Behrents,'
Piminides,"' and others) seems to say that neurotrophic mecha-
nisms exist and may have some primary impact, but the overall
effect is slight. Nor can we yet, by this evidence, separate clearly
any direct neurotrophic effects on bone from neurotrophic effects
on muscle or their varying functions.
2. Disruptive Factors
Disruptive factors in facial growth are those which do not
rQutinely contribute to normal variation but when they appear in
the individual may be important. They may be elective, environ-
mental, or congenital in origin.
a) Orthodontic Forces
Orthodontic forces are utilized to affect growth and alter tooth
positions. The general biologic responses to orthodontic forces are
discussed in Chapter 13, and specific local effects of orthodontic
force systems on growth are discussed in Section E. Regional
Development.
b) Surgery
Orthognathic or plastic surgery is undertaken for two reasons:
to correct a craniofacial anamoly (e.g., cleft palate) or to improve
craniofacial esthetics in non anomalous faces deviating significantly
from the norm (see Chapter 17). Modem surgical techniques have
improved the surgeon's ability to reposition parts of the face, but
there remain two problems much studied yet still not thoroughly
understood: (1) relapse of the surgical result, even in "nongrowing
adults;" and (2) the effects of surgery on subsequent growth. The
latter problem is particularly important when the surgery has been
performed on young patients. Carlson et al. 's point out that these
two factors are closely interrelated since growth itself is largely a
process of adaptation of parts. Data on the effects of surgery on
"normal," healthy children and adults are quite incomplete (see
Suggested Readings). The effects of surgery on craniofacial an-
amolies and their subsequent growth is even less understood be-
cause of the magnitude of the necessary surgical correction and
lack of understanding of the basic abnormal growth which created
and maintains the syndromal anomaly.
c) Malnutrition
Although it is presumed that gross malnutrition affects cran-
iofacial growth in humans (it has been studied some in animals),
there is little specific information available.
d) Malfunctions
That altered malfunction can play a role in craniofacial mor-
phology is well documented in the experimental laboratory by the
classic research of Harvold, 31-34Petrovic,73-so McNamara,5'-55 and
Carlson.1s-2o Clinical studies of the effects of altered nasorespir-
atory function on growth and morphology (Linder-Aronson)4S-50
and posture (Solow and Tallgren)9" 92support the long-held biases
of orthodontists and physicians that craniofacial growth is deter-
mined to some extent by the functional environment of the cran-
Growth of the Craniofacial Skeleton 53
iofacial skeleton. The enunciation of the functional matrix theory
by Moss59 and the well-documented research noted above give
solid support to the idea that function helps determine morphology
during normal growth and that altered function can produce altered
morphology.
The role of nasorespiratory malfunction (e.g., "mouth-
breathing") is discussed in Chapter 7, as is altered occlusal func-
tion-the so-called "functional mal occlusions . " The idea that
function plays a controlling factor in craniofacial morphology not
only has a theoretical base and etiologic credibility but is clinically
attractive, for if the environment plays an important role in con-
trolling morphology, surely then the orthodontist can find thera-
peutic help in contriving ways to alter that environment. This latter
point, of course, is the basis for the entire concept of functional
appliance therapy.
The Suggested Readings at the end of this chapter include
several items on the role of nasorespiratory function and crani-
ofacial growth, muscle adaptation in the craniofacial region, de-
terminants of mandibular form and growth, and clinical alteration
of the growing face. This will be an exciting and active area for
research for some time in the future. The clinician who wishes to
apply the principles being clarified by this research must guard
against the overly enthusiastic advocacy by some clinical col-
leagues, tempering their optimism with the sound findings from
basic and clinical research.
e) Gross Craniofacial Anomalies
Patients with a gross craniofacial anomaly present a head and
face markedly altered during early organogenesis in ways hard to
discern postnatally. It is difficult to note all of the primary sites
and the nature and extent of the dysmorphogenesis except in the
crudest of terms (e.g., what is seen in the radiograph). Further,
it is nearly impossible to separate original dysplasia from later
adaptive growth. We attempt to understand this grossly dysplastic
growth from our knowledge of variable normative growth, which
is not very helpful since there is more variation within a single
syndrome (e.g., Apert's) than in the random nonaffected popu-
lation. Our knowledge of postnatal growth of some of the more
common syndromes (e.g., cleft palate) has become better in recent
years, but much fundamental work is still needed. Fortunately a
number of fine research centers are dedicated to the understanding
and treatment of these problems. Detailed discussion of anomalous
craniofacial growth is impossible in a volume of this type; there-
fore, readers interested in broadening their knowledge should see
the Suggested Readings at the end of this chapter. A few references
are listed which give overviews of this important area.
"
,.,c.
E. REGIONAL DEVELOPMENT
The same outline will be used in each of the regions to be
discussed in this section. Note the four subsections titled "Com-
pensatory Mechanisms," for therein are described those areas best
able to compensate and adapt when usual growth has failed or is
in any way abnormal. The regions most able to adapt and com-
pensate naturally are also those most able to respond to clinically
imposed forces (see Chapter 13).
54 Growth and Development
FIG 4-12.
Distribution of resorptive and depository
periosteal surfaces in the cranial vault,
cranial base, and nasomaxillary complex
as seen in a lateral internal view. Re-
sorptive regions are shown in black and
depository regions in light gray.
1. Cranial Vauft
a) Functions
The primary function of the bony cranial vault is protection
of the brain. The vault's growth is paced by the growth of the
brain itself.
b) Growth
1) Mechanisms and Sites.- The growth of the bones of the
calvaria utilizes a suture system plus relatively small surface de-·
posits on both the ectocranial and endocranial sides. Remodeling
adjustments are minor, primarily adjacent to sutures. Extensive
remodeling changes do not take place. The calvaria encloses the
brain; all major arteries, veins, nerves and the spinal cord enter
or leave by way of the cranial floor. The continued positioning of
the foramina associated with them thus is not a factor in the growth
of the skull roof.
The bones of the cranial vault are joined with one another by
sutures, and the bones of the nasomaxillary complex are linked
together and to the cranial vault by a system of sutural junctions
providing sites for growth and adjustment (Fig 4-12).
2) Timing.- The growth of the skull roof is provided by
sutural responses to the expansion of the enclosed brain; thus,
vault growth is paced by brain growth. Since brain growth is largely
completed in early childhood, the cranial vault is one of the first
regions of the craniofacial skeleton to achieve full size, though
the vault sutures are patent for some time after growth is mostly
over.
3) Compensatory Mechanisms.- The sutural system of the
cranial vault provides extensive adaptive capability for such path-
ologies as hydrocephalus or cultural practices as head binding.
However, when cranial stenosis occurs almost all of the adaptive
compensatory possibilities are lost and a very serious clinical prob-
lem prevails.
c. Theoretical and Clinical Issues
There is general agreement on the mechanisms and methods
of vault growth, but there is little understanding of the control of
cessation of sutural growth potential. What determines when a
suture closes? Why do some close before others? Why do they
not all close approximately togetheras brain growth is diminished?
The principal clinical issues are those seen with grossly ab-
normal and anomalous growth (e.g., cranial stenosis, hydroce-
phaly). In almost every serious instance the clinical problem requires
surgical rather than orthodontic intervention.
2. Basicranium
a) Functions
The human cranial floor and calvaria are adapted to upright
boQ,y.posture and the development of relatively large cerebral hem-
ispheres. These factors are assoc(ated with a midventrally posi-
tioned foramen magnum and a marked flexure of the cranial base
because of the huge forward expansion of the frontal lobes in man
and the backward and downward enlargement of the occipital and
cerebellar lobes (see Fig 4-12). Cranial base flexure places the
foramen magnum directly over the vertical spinal cord and achieves
a forward alignment of the face and orbits because of human
bipedal posture.
The basicranium not only supports and protects the brain and
spinal cord but also articulates the skull with the vertebral column,
 Growth of the Craniofacial Skeleton 55

FIG 4-13.
Growth sites in the cranial base. The
sphenoid bone is at b. The left arrow
points to the sphenoethmoidal syn-
chondrosis; the right arrow, to the
spheno-occipital synchondrosis.

mandible: and maxillary region. One of its important functions is at synchondroses, and extensive cortical drift and remodeling (Figs
as an adaptive or buffer zone between the brain, face, and pha- 4-13 and 4-14). This combination provides (I) differential growth
ryngeal region, whose growths are paced differently. enlargement between the cranial floor and the calvaria, (2) ex-
pansion of confined contours in the various endocranial fossae,
b) Growth and (3) maintenance of passages and housing for vessels and nerves
1) Mechanisms and Sites.-Growth of the basicranium is and such appendages as the hypophysis. Elongation of the cranial
carried out by a complex balance among sutural growth, elongation . base is provided by growth at the synchondroses and direct cortical

FIG 4-14.
The distribution of resorptive and
depository periosteal surfaces in
the cranial floor. Resorptive re-
gions are shown in black and de-
pository areas in gray.

-.
56 Growth and Development

growth (see Fig 4-13). The process of cortical drift in the cranial cranial base growth are buffered by the complicated articulations
floor produces regionally variable growth movements in a gen- of cranial base structures with other bones.83
erally ectocranial direction by surface resorption (see Fig 4-14)
from the endocranial site, with proportionate deposition on external 3) Compensatory Mechanisms.- The basicranium is gen-
surfaces. - erally considered to be the most stable of all portions of the cran-
Growth of the cranial floor has a direct effect on placement iofacial skeleton and the least affected by such external influences
of the midface and mandible. As the anterior cranial fossae and as altered neuromuscular function or orthodontic treatment. There-
cranial floor elongate, the underlying space occupied by the en- fore, the cranial floor displays less compensatory growth relative
larging nasomaxillary complex, pharynx, and ramus increases cor- to the viscerocranium than is seen in other craniofacial structures.
respondingly. The spheno-occipital complex elongates, displacing
the entire middle face anteriorly, producing an enlargement of the c) Theoretical and Clinical Issues
pharyngeal region. Correspondingly, the ramus enlarges as the The various hypotheses about craniofacial growth are less
mandible is displaced anteriorly in conjunction with the forward clear in explaining neurocranial growth than any other part. How
displacement of the maxilla. Thus, the anteroposterior growth of much basicranium change, for example, is due to the influence of
the basicranium has an important role in both nasomaxillary and the functioning growth fields, and how much to the inherent growth
mandibular growth. potential residing within the cartilages?
It is frustrating for the orthodontist to discover, during.the
2) Timing.- The cranial fossae show reduced rates of re- cephalometric analysis, that neurocranial structures make a sig-
mode ling with the completion of brain growth. The cranial syn- nificant contribution to the malocclusion. Skeletal base dysplasia,
chondroses, however, are paced differently, and the fossae continue of course, affects the midfacial and mandibular regions, but neither
to grow somewhat in length for an extended period of time. Al- the orthodontist's nor surgeon's efforts ordinarily alter the cranial
though they must be under similar control to that of the other floor itself. Treatment must consist of compensatory alteration of
growth cartilages in the body, pubescent' 'spurts" in endochondral maxillary and mandibular growth of form and tooth positioning.

FIG 4-15.
The sutural and periosteal membranes. In the upper diagram, the
edges of two adjacent bones (A) are joined by the connective tissue
of the suture. Note the position of markers (x). The border zone (B)
inserts directly into the surface of the bone. At its other end, each
fiber of zone B continues into the labile linkage fibrils of the inter-
mediate zone (C). These fibrils are more delicate than the heavy,
coarse fibers of the capsular zone (0). This layer contains the vessels
(b) and may become regionally subdivided into separate capsular
zones for each side of the suture junction. The periosteum is similarly
composed of a border zone (B), an intermediate zone (C), and a
dense outer fibrous zone (0).
In the lower diagram, an arbitrary increment of new zone has
been added (+ arrows) to each sutural bone surface (A'). The old
bones (A) have become displaced away from each other (oISPL
arrows). Note the changed positions of the markers (x). The fibers
of the former zone B have now become embedded in the new bone
(A'). A new border zone has formed from the old intermediate zone
(C). As its fibrils lengthen in a direction away from bone surfaces,
they undergo differentiation into coarse, mature collaganous fibers.
The bone simultaneously increases in thickness by subperiosteal
(and also endosteal) deposition (+ arrows). The coarse fibers of the
border zone become embedded attachment fibers as the linkage
fibrils of the continuous intermediate zone differentiate into the fibers
of a new border zone. As the entire periosteum "drifts" in an outward
course, the linkage fibrils lengthen in a direction toward zone 0 and
increase in number to accommodate the expanded coverage. (From
Enlow OH: The Human Face. New York, Hoeber Medical Division,
Harper & Row, 1968. Reproduced by permission.)

Several of the craniofacial syndromes involve gross dysplasia
of the basicranium with resultant imposed abnormal adaptive growth
else'where in the face and cranial vault.
3. Nasomaxillary Complex
a) Functions
Dentists appreciate the important role of the nasomaxillary
region in mastication (attachment of teeth and muscles), but it has
other important functions as well. The nasomaxillary complex
provides a significant portion of the airway, contains the phys-
iologically important nasal mucosae with their glands and tem-
perature-adjusting vascular components, separates nasal from oral
cavities, houses the olfactory nerve endings, encloses the eyes,
and adds resonance to the voice because of the sinuses contained
within the region. Its growth must adapt to that of the basicranium
to which it is attached and to the mandible with which it functions
Growth of the Craniofacial Skeleton 57
in mastication, speech, facial expression, respiration, etc. Its func-
tions are as complex as its growth and adaptations.
b) Growth
1) Mechanisms and Sites.- The mechanisms for growth in
the nasomaxillary complex are the sutures, the nasal septum, the
periosteal and endosteal surfaces, and the alveolar processes. As
Mills56 points out, the maxilla is increased in size by subperiosteal
activity during postnatal growth, although the periosteum has dif-
ferent names in different sites. Over most surfaces it is simply
periosteum; in some areas, mucoperiosteum; where the periosteum
of one bone meets another, it is termed a suture; and where the
two bones become one bone (alveolar process) and interface with
the modified bone of the tooth's root (cementum), the periosteum
is called the periodontal membrane. Despite the different names
on different body surfaces, all carry out the essential role of re-
modeling (Figs 4-15 and 4-16). The entire nasomaxillary complex
FIG 4-16.
Sections of the nasofrontal suture from a young, rapidly growing
kitten prepared according to the differential polychrome proce-
dure. All three zones in both A and B can be seen. The coarse
fibers of the border zone (a) and the delicate linkage fibrils of trhe
intermediate zone (b) are indicated in photomicrograph B. The
heavy, coarse fiber bundles of the capsular zone (c) are labeled
in photomicrograph A. (From Enlow DH: The Human Face. New
York, Hoeber Medical Division, Harper & Row, 1968. Reproduced
" by permission.)
;;.
58 Growth and Development

FIG 4-17.
Regional depository and resorptive perios-
teal surfaces in the nasomaxillary complex.
The resorptive surfaces are shown in black
and depository surfaces in light gray. The
white zones (t) are areas in which normal
variation occurs in the reversal line between
resorptive and depository surfaces.

is joined together and to the cranial vault and cranial base by the
most complicated sutural system of all, a primary mechanism for
the region's growth and adaptation (see Figs 4-14 and 4-15).
An endochondral mechanism for bone growth, as is seen in
long bones, the mandible, and the cranial base, is not widespread
in the midface, although the midfacial extensions of the ethmoid
are of endochondrial origin. The embryonic nasal capsule does not
simply ossify to become the bones of the nasomaxillary complex:
The growth of the cartilaginous part of the nasal septum, however,
has been regarded as a souce of the force that displaces the maxilla
anteroinferiorly, although this theory has been largely modified
by many researchers. Growth and remodeling of most of the mid-
facial complex accompanies and follows this displacement by the
familiar intramembranous bone process.
Sometimes too much emphasis is still placed on the nasal
septum in midface growth, suggesting almost a dominant role. It
must be remembered that virtually all of the inner and outer sur-
faces of each bone within the midface complex are actively in-
volved in the total growth remode!ing process (see Figs 4-14, 4-
15, 4-17, 4-18, and 4-19). All the endosteal and periosteal sur- .
faces are blanketed by localized growth fields which operate es-
sentially independently but somehow harmoniously with one
another. Thus, surface growth remodeling is very active, providing
much regional increase and remodeling which accompany and
adapt to the additions taking place in sutures, synchondroses, con-
dyles, and so forth. The variety of growth processes is nowhere
more elaborate or complicated in the head and face than in the
nasomaxillary region.
2) Amounts and Directions.-
(a) Maxillary Height.-The classic implant studies of Bjork
al)d Skiellerlo confirm that maxillary height increases because .of
sutural growth toward the frontal and zygomatic bones and ap-
positional growth in the alveolar process. Apposition also occurs
on the floor of the orbits with resorptive modeling of the lower
surfaces. Simultaneously the nasal floor is lowered by resorption
while apposition occurs on the hard palate. The relative portions
of vertical increases at different growth sites is important. The
orbits do not increase in height in childhood through adolescence
to the same degree as does the nasal cavity, so that the sutural
lowering of the maxillary corpus is compensated for some\Vhat by
apposition of the floor of the orbit. The lowering of the floor pf
the orbit from the age of four onward is somewhat less· than half
the sutural lowering of the maxillary corpus ..
Growth at the median suture produces more millimeters of
width increase than appositional remodeling, but surface remod-
eling must everywhere accompany sutural additions.lo Alveolar
remodeling contributing to significant early vertical growth is also

FIG 4-18.
Growth and displacement in the nasomaxil-
lary complex. Left, the resorption and dep-
osition necessary to produce the adult
nasomaxillary complex are clearly shown.
Right, the displacement necessary to ac-
company the adult nasomaxillary remodeling
configuration is depicted.

B +
+
c from its opposite surface (A and B). At
important in the attainment of width because of the divergence of
the alveolar processes. As they grow vertically, their divergence
increases the width. Up to the time that the mandibular condyles
have ceased their most active growth (late adolescence), maxillary
alveolar process increases constitute nearly 40% of the total max-
illary height increases. IQ
, (b) Maxillary Width.-Growth in the median suture is more
important thJln appositional remodeling in the development of max-
illary width.'O Growth increases at the median suture mimic the
general growth. curve for body height, and maximum pubertal
.growth in the median suture coincides with the time for maximum
growth iri the facil\J sutures as seen in the profile radiograph.'o
:; - How~ver, there is 'not a correlation between growth in width at
.: the mt;?ian suture and the sutural growth contributing to height of
, the maxilla. Mutual transverse rotation of the two maxillae'results
. in separation of the halves more posteriorly than anteriorly.
(c) Maxillary Length.-Length increases in the maxilla after
about the second year occur by apposition on the maxillary tub-
erosity and by sutural growth toward the palatine bone. Surface
resorption occurs anteriorly on the bony maxillary arch. Bjork and
Skieller's implant studies show th'is anterior surface to be rather
stable sagittally, IQ but the maxillary arch is remodeling as it grows
downward, which is why the anterior region is resorptive.27 Its
labial surface moves away from the largely inferior direction of
growth. The maxilla rotates forward in relation to the anterior
cranial base.
3) Timing.-Alveolar process increases are closely corre-
lated with the eruption of teeth. Increases in' overall maxillary
height coincide nicely with vertical growth in the mandible. There
Growth of the Craniofacial Skeleton 59
+
FIG 4-19.
Vertical growth and displacement in the
nasomaxillary complex. The palate grows
in an inferior direction by subperiosteal
bone deposition on its entire oral surface,
with corresponding resorptive removal
the same time, the nasomaxillary com-
plex is increasing its overall size (C) while
being displaced inferiorly by growth of
parts above and behind it (D).
is some general pacing of overall maxillary and mandibular growth,
for both are roughly coincident with general bodily growth.
4) Compensatory Mechanisms.-All mechanisms of na-
somaxillary growth are well designed for adaptive and compen-
satory growth, but adaptation is most dramatically seen in the
alveolar process. When the palate is narrow, for example, the
alveolar process compensates in both height and width. The plane
of occlusion is coordinated during growth with the overall mor-
phologic pattern, alveolar process deposition and resorption com-
pensating nicely for palatal displacement. Thus, in skeletal deep
bite, where the gonial angle is more nearly orthogonal, the occlusal
plane (established by alveolar process growth) is nearly parallel
to the mandibular plane. On the other hand, when anterior face
height is disproportibnately long, anterior alveolar growth com-
~nsates and the occlusal plane is steep .
Because of the adaptive and compensatory nature of alveolar
growth the occlusion is sometimes at variance with the skeletal
relationship and one finds a CIllss I mollIT relationship, for ex-
ample, in a retrognathic(Class II) skeleton. Predicting skeletal
growth does not predict precisely the future occlusal relationship.70
Orthodontic treatment, >irrespective of the appliance, depends, to
a g;eat extent, on the adaptive capacity of alveolar process growth
and remodeling.
5) Effects on Dentition and OccIusion* .-Bimolar width
in the first molar region correlates nicely with vertical growth of
the maxilla, growth in the midpalatal suture, and growth in height.
The dental arch in the maxilla drifts forward on an average of 5
mm by late adolescence in the molar region and 2.5 mm in the
*See also Chapter 6.
60 Growth and Development
incisors. 10 The dental arch perimeter is thus shortened (see Chapter
6). The important point to note here, however, is that crowding
is not due simply to the differences in tooth size between the
primary and permanent dentition, or even to mesial drifting, for
Bjork and Skieller showed that the lateral segments, though drifting
mesially, were unchanged in length while the incisor segments
were shortened. 10 The shortening of the maxillary dental arch pe-
rimeter continues at least through the termination of growth in the
mandibular condyles, and its greatest association is with the erup-
tion of the maxillary second molar, not the third as is commonly
assumed. Further, the root development of the third molars, and
thus the initiation of eruption, occurs after the greatest shortening
of length in the maxillary dental arch. The crowding in the frontal
segments In the maxilla, therefore, seems to be due to mesial
drifting of all the teeth and to shortening of the anterior segments,
probably the result of the convergence of the dental arch anteriorly
as the sagittal shift of the teeth is directed inward over a narrowing
bone base.
c) Theoretical Problems
Previously the principal theoretical problem seemed to be
whether or not the expanding nasal septum is the principal ener-
gizing force in nasomaxillary. growth movements, or whether' it
operates in conjunction with other soft tissue displacing forces.
Most authorities now hold the latter view.
d) Clinical Issues
Whether the clinican can alter nasomaxillary morphology and
growth is no longer seriously argued, for the documentation is
overwhelming (see Chapter 15). The biologic principles of such
adaptations to orthodontic forces are discussed in Chapter 13. The
sutural system adapts to posterior forces (extraoral, cranial, and
cervical traction), anterior traction (face masks), and transverse
forces (lingual archwires and rapid palatal expansion devices).
A B
FIG 4-20.
A, endochondrial bone growth in the mandible. One may visualize
the mandible as the central portion of a tubular long bone that has
Variations in maxillary growth and morphology may play
important roles in some skeletal malocclusions, for example, Class
11 (excessive midface growth) and Class III (decreased midface
growth). Altered nasorespiratory function and nasomaxillary growth
are other important clinical issues (see Chapter 7). The region is
the site of the single most common gross craniofacial anomaly,
namely, cleft palate.
4. Mandible
a) Functions
The mandible, the most highly mobile of the craniofacial
bones, is singularly important, for it is involved in the vital func-
tions of mastication, maintenance of the airway, speech, and facial
expression.
b) Growth
The modes, mechanisms, and sites of mandibular growth are
complicated and much argued in the literature. Some of the prob-
lems in interpretation of mandibular growth data are shown i:J
Figure 4-20. Note that the mandible basically is a slender, U-
shaped bone with an endochondral growth mechanism at each end
and intramembranous growth between-just as in long bones. To
it are attached muscles and teeth. Both prenatally and postnatally
only a small percentage of mandibular growth is "endochondrally"
developed; a far greater portion is intramembrously determined.
Growth and shape changes of the areas of muscle attachment and
teeth insertion are controlled more by muscle function and eruption
of the teeth than by intrinsic cartilaginous or osteogenic factors.
The cephalometrist, on whose research we depend greatly, locates
handy landmarks around this odd-shaped bone in sites of easy
visualization (Fig 4-20B), but they are insufficient in number and
imprecise in location, and thus we are unable to segregate cleanly
developmental and adaptive changes of the different regions to
o Growth from intrinsic factors associated c condylar cartilage
• Growth from remodeling associated c muscle attachments
CD Growth from remodeling associated c eruptions
. ;;.
Me
been bent so that half of each epiphyseal plate is in either condylar
position. This bent tube constitutes the corpus mandibularis, to which
are attached areas of bone for muscle insertion and areas for holding
the teeth. (A adapted from Symons NBB: Dental Record 1951; 71 :41.)
8, ultimate portions of the mandible associated with different aspects
of growth on cephalometric landmarks (see Chapter 12). (See Fig
4-15 for explanation of Part 8 elements.)
 Growth of the Craniofacial Skeleton 61

their own controlling mechanisms. It is neat and handy for us to

consider the mandible as a single unit, but its adaptive growth can
be understood only by studying enlargement and change in form
separately in the regions identified in Figure 4-20.

1) Mechanisms and Sites.-

(a) Role of the Condylar Cartilage.- The condyle is of spe-
cial interest because it is a major site of growth, it is involved in
one of the most complicated articulations in the body, and there
have been so many opinions about its role in mandibular growth.
The mandible is really a membrane bone remodeling over all
surfaces, though one part develops in response to a phylogeneti-
cally altered developmental situation and becomes the condylar
region. The condylar cartilage is a secondary cartilage (meaning
that it did not develop by differentiation from embryonic primary
cartilages) which makes an important contribution to the overall
length of the mandible.
Regional adaptive growth in the condylar area is important
because the corpus of the mandible must be maintained in func-
tioning juxtaposition with the base of the skull where it articulates.
The condylar region and the ramus must adapt to the numerous
functional demands placedon it, yet allow the growth displ,!cement
of the mandible away from the skull.
The many arguments about condylar growth focus mostly on
one question: Is the condylar cartilage the principal force that
produces the forward and downward displacement of the mandible?
For many years it was considered the primary "growth center"
of the bone, controlling and pacing its entire growth. Proponents
of the functional matrix· theory, however, claimed that some man-
dibles function adequately and seem to be positioned rather nor-
mally when condyles are absent, so perhaps the condyle did not
FIG 4-21.
play the role of the master growth control center or cause man-
A, hyalinization in the intermaxillary suture of the palate of the Rhesus
dibular displacement. (For a dissenting view see 10hnston42) They
monkey after experimental compression. 8, heavy, rapid expansion
concluded that soft-tissue development carries the mandible for- of the intermaxillary suture of the palate in the Rhesus monkey. (From
ward and downward while condylar growth fills in the resultant Linge L: Tissue Changes in Facial Sutures Incident to Mechanical
space to maintain contact with the basicranium. Influences. An Experimental Study in Macaca mulatta, thesis. Uni-
The growth mechanism of the condylar area is fairly clear versity of Oslo, 1973. Reproduced by permission, courtesy of L.
(Fig 4-21), the main factor being t~e mesenchymal cells (i.e., the Linge.)
periosteum) above the cartilage itself, how they grow, and what
influences them. A significant fact about condylar cartilage is.that, assumption fits neatly with the functional matrix theory. Trans-
compared with other cartilages, it reacts faster with a lower thresh- plantation experiments with the condyles and adjacent tissues also
old to outside mechanical factors. The condyle does not determine ,shed light on this problem. When the condyle is transplanted alone,
how the mandible grows, rather it is the mandible which determines it does not flourish, but when it is transplanted with adjacent bones,
how the condyle grows. Articular function determines condylar it does.26 Other experiments hav.e shown that if the condylar head
growth, and articular function is dependent on how the mandible is transplanted in situations which providejtwith function, it grows
grows. Mandibular growth is determined by factors outside the normally. 10hnston42 and colleagues carried out experiments in
mandible-muscles, maxillary growth, etc. which the condyles of guinea pigs were detached from the body
Cartilage is present because variable levels of surface pressure Of-!he mandible. The diiached condyles continued to grow down-
occur in the joint at the articular contacts. An endochondral growth ward while the ramal portion collapsed upwards because of the
mechanism is required because the condyle grows in the direction influence of the muscles. After the two parts were reunited, normal
of the articulation in the face of pressure, a situation which pure growth continued. In experimental animals, if the condyle is re-
intramembranous bone growth could not tolerate. Cartilage of the moved, the region is diminished in size but the rest of the mandible
mandibular condyle is not like that of an epiphyseal plate or syn- continues to grow through periosteal remodeling. Experimental
chondrosis, for it is, as noted earlier, different in origin and struc- injection of papain, which interferes with chondrogenesis, pro-
ture. Primary cartilages have some degree of intrinsic growth duces quite similar results. Koski43 and colleagues conclude from
potential; but the condylar cartilage is a secondary cartilage and several well-designed studies that periosteal tension in the condylar
is presumed not to have such potential, although Petrovic et al80 neck provides a built-in control for growth of the ramus by way
have noted the role of hormones in condylar cartilage growth. This of the cartilage and that other local factors, such as the lateral
62 Growth and Development
FIG 4-22.
A, comparison of a child's mandible with
an adult's. This frequently used orienta-
tion is very misleading. The child's man-
dible simply could not become the adult
mandible by general overall growth as this
orientation indicates. B, by orienting dif-
ferently, the effects of growth displace-
ment, remodeling, and resorption are
better visualized. On the left, a child's
mandible has been superposed to show
areas of resorption and deposition. Note
the"extensive remodeling, deposition, and
cortical drift necessary to produce the
outline of the adult mandible. On the right,
the orienta\ion and registration on the
condylar region dramatizes the displace-
ment of the mandible with growth.
pterygoid muscle, may introduce outside control. They indicate
that periosteal integrity is important for normal proliferative ac-
tivity of the connective tissue cells of the condyle apart from the
role of the lateral pterygoid muscle. Their work clarifies the roles
of ramal remodeling and condylar growth, reducing a conflict of
theories to understandable integration.
Clear-cut, all-or-none conclusions are hard to make, but the
following seem logical in the face of the evidence. The condylar
region plays an important role in mandibular growth because of
the articular site and because of the extensive regional remodeling
necessary. Though the condylar cartilage is a secondary cartilage,
it probably plays some role in the translation of the mandible. At
the same time animal experimentation and human clinical studies
have shown that the condylar cartilage is highly responsive when
the mandible is repositioned purposefully during growth (see D,
Clinical Issues). In our efforts to find which single theory of
mandibular growth is correct, we may have missed an important
point, namely, that several growth mechanisms may be operating
together and it is simply the proportionate contribution of each
that is at question. Perhaps both the condylar cartilage and the
functioning muscles translate the mandible, and, in the absence
of one, the other does its best to compensate. In either event the
integrity of the periosteum of the condylar neck region is important.
When the environment is radically changed, as during the insertion
of a functional appliance, the compensatory contributions of both
are enhanced.
(b) Ramus and Corpus.- The additions of new bone pro-
vided by the condyle produce a dominant growth movement (trans-
lation) of the mandible as a whole (Fig 4-22). The posterior border
of the ramus, in conjunction with the condyle, also undergoes a
major growth movement (cortical drift) that follows a posterior
and somewhat lateral course (Fig 4-23). The combination of con-
dylar and ramus growth brings about (I) a backward transposition
of the entire ramus (the anterior border is resorptive), thereby
simultaneously elongating the mandibular body; (2) a displacement
of the mandibular corpus in an anterior direction; (3) a vertical
lengthening of the ramus as the mandible is displaced; and (4)
movable articulation during these various growth changes (see Fig
4-22). As the ramus grows and becomes relocated in a posterior
direction, the lingual tuberosity correspondingly grows and moves
posteriorly in a manner comparable to the maxillary tuberosity.
Studies of remodeling, animal experimentation, and the use
of implants have provided the information in the previous para-
graph. It is easy to perceive how difficult it is to study mandibular
growth with cephalometric natural landmarks alone (see Fig 4-
20). For example, corpus length cephalometric ally is usually de-
fined as the distance from gonion to such anterior landmarks as
pogonion, yet gonion is being carried along by ramal changes in
one direction while pogonion moves forward nearly oppositely.
Further, cephalometric definitions of corpus and ramus result in
changes in the ramal-corpal angle (the so-called "gonial" angle)
yet the relationship between the corpus of the mandible and the
posterior cranial base is one of great angular constancy. 71 (See
discussion of "rotation" later.)
The growth movements of the mandible, in general, are com-
plemented by corresponding changes occurring in the maxilla. A
primary function of corpus displacement is the continuous posi-
tionipg of the mandibular arch relative to the complementary growth
moveibents of the maxilla. As the lJIaxilla becomes displaced an-
teriorly and inferiorly, a simultaneous displacement of the man-
dible in equivalent directions and approximate extent occurs.
Muscle attachment areas of the ramus play an important role
in localized remodeling and cortical drift accompanying the down-
ward and forward mandibular displacement. Areas of muscle at-
tahment at the coronoid processes and the gonial regions become
fully differentiated only in response to the development and func-
tioning of the muscles that insert there. It has been shown exper-

imentally that these regions do not develop well if the muscles are
removed'very early or if the nerves and vessels serving these
muscles are severed (see Sections C and D),
The mandible appears to "grow" in a forward and downward
manner when visualized in superimposed serial cephalometric trac-
ings registered on the cranial base, causing an important problem
in the analysis of treatment effects (Chapter 12) (Fig 4-24), Actual
growth, however, takes place in a wide variety of regional direc-
tions, The predominant trend of growth generally is superior and
posterior, but simultaneous displacement of the whole mandible
occurs in an opposite (i ,e" anterior and inferior) course, regardless
of the many varying regional directions of growth, remodeling,
and local drift.
(c) Alveolar Process.- The alveolar process is not present
when teeth are absent. Its formation is controlled by dental eruption
and it resorbs when teeth are exfoliated or extracted, The teeth,
in either arch, are not carried forward and downward exactly as
the mandible and maxilla are by growth and displacement, for
intercuspation restrains the teeth somewhat. Thus the alveolar proc-
esses serve as important buffer zones helping to maintain occlusal
relationships during differential mandibular and midface growth,
Growth of the Craniofacial Skeleton 63
FIG 4-23.
The distribution of resorptive and depo-
sitory periosteal surfaces in the human
mandible is mapped in these drawings,
Periosteal surfaces that undergo pro-
gressive removal during growth are in-
dicated in black; outer surfaces that are
depository in nature are indicated in light
gray,
Alveolar process growth is most active during eruption, plays
an important and unappreciated role during emergence and initial
intercuspation (see Chapter 6), and continues to maintain the oc-
clusal relationships during vertical growth of the mandible and
maxilla, When corpus growth is essentially over, vertical alveolar
growth persists as the occlusal surfaces wear; thus occlusal height
is maintained even in adulthood. Adaptive remodeling of the al-
veolar process makes orthodontic tooth movements possible.
2) Amounts and Directions*-
(a)Height.-Ramus height increases correlate well with cor-
pus length and overall mandibular length, and periods of accel-
erated growth roughly coincide with those in stature.47
Alveolar process height increases are highly correlated with
eruption, Anterior mandibular height (e.g., mandibular line to
incisal edge) is related to dental development and overall man-
dibular growth downward and forward. Therefore, mandibular
anterior height is related to facial type and is quite different in,
for example, a skeletal deep bite and a long anterior face height.
*Tables of mandibular dimensional change will be found at the end
of Chapter 12,
FIG 4-24.
Serial cephalograms superposed on the cranial base.
'. The changes seen adtie chin are the summation of all
growth between the chin and the cranial base, not just
mandibular growth and displacement alone: Compare
with Fig 4-22.
64 Growth and Development
FIG 4-25.
Three types of rotation of the mandible during growth. A, forward
rotation with the center at the incisal edges of the lower incisors. B,
forward rotation with the center at the premolars. C, backward ro-
tation with the center at the occluding molars. (From Bj6rk A: Pre-
diction of mandibular growth rotation. Am J Orthod 1969; 55:585-
599. Reproduced by permission.)
(b) Width.-Bigonial and bicondylar diameter increases are
a function of growth in overall mandibular length and the natural
divergence of the mandible. Most width increases occur simply
because the mandible grows longer, though some periosteal dep-
osition occurs (see Fig 4-23). Mandibular width increases are
generally more evenly acquired than those of overall length or·
height.
(c) Length.-Mandibular length is measured two ways (I)
overall length (e.g., condylion-gnathion) and (2) corpus length
(e.g., pogonion-gonion). Both dimensions show increases corre-
lated with ramus height increases, and "spurts" in mandibular
length occur about the same time as "spurts" in stature.
(d) "Rotation".-Serial cephalometric studies, using cranial
base registrations, imply that normally the mandible is carried away
from the posterior cranial base in a downward and forward direc-
tion. When the mandibular corpus is steeply related to the posterior
cranial base, and anterior face height increases are significantly
greater than those posteriorly, the mandible is sometimes said to
"rotate" posteriorly (Fig 4-25). A significant amount of the ex-
cessive anterior face height in such instances is contributed by
mandibular anterior height. Thus, the alveolar process in the man-
dible under such circumstances is significantly higher anteriorly
than in the molar region. Obversely, when posterior face height
is greater than normal, the bite tends to be deeper and the mandible
is said to display anterior "rotation." Bj6rk8 and others2.41 have
studied this so-called "mandibular growth rotation" by the use of
metallic implants and other methods. However, the nature and the
amount of "rotation" are sometimes misinterpreted through the
use of conventional cephalometric landmarks. Some of the con-
fusion is eliminated by the use of implants or carefully chosen
natural markers in the mandible, for example, the mandibular
canal, the lower rim of the crypt for molars, and the inner contour
of the cortical plate of the lower portion of the symphysis (see
Chapter 12). Bj6rkl2 also makes a clear distinction between what
he terms "matrix rotation" and "intramatrix rotation" (Fig 4-
26). "Matrix rotation" often goes in the form of a pendulum
movement with the rotation point in the condyle." "Intramatrix
rotation" is the "rotation" of the mandibular corpus' inner half
of its matrix within the mandibular corpus and not in the condyle
(Fig 4-26,B). It is important to note that Skieller, Bj6rk et al90
show that the total so-called "rotation" is made up of the sum of
both "matrix" and "intramatrix" rotations (Fig 4-27).12 Appar-
ently in most instances the "intramatrix rotation" accounts for
most of the total, though there is great variability.
, 'Rotation" is an unfortunate choice of terms to explain what
are essentially complex remodeling shape changes difficult to de-
pict and quantify with conventional cephalometric techniques (see
Chapter 12). The mathematics of rotation is appropriate when
studying the kinematics of jaw opening and closing, for the shape
of the mandible does not change during brief periods of time.
During growth over time, as Bj6rkl2 has emphasized and others
studyihg "mandibular rotation" often have not, all parts undergo
a
~ APPOSition
Resorptlon
82
. ;;.
0,,"
-, ~
_
APPOSition
Resorptlon
FIG 4-26.
A, matrix rotation. In both forwards and backwards matrix rotation
the mandible moves as a pendulum with the center of rotation in the
condyles. B, intramatrix rotation. The areas of apposition and re-
sorption change with forward and backward intramatrix rotation: B-
1, forward; B-2, backward intramatrix rotation. (From Bj6rk A, Skieller
V: Normales und anomales Wachstum des Unterkiefers: Einer
Synthese longitudinaler kephalometrischer Implantstudien wahrend
eines Zeitraums van 25 Tahren. Inf Orthod Kieferorthop 1984; 16:9-
54. Reproduced by permission.)
 Growth of the Craniofacial Skeleton 65

A1 A2

~ - Unterkleferrotatlon

'y \ ~ \J\
....

+ 8°
l ruckwarts
7176'4'
R

He
u
Behandlung
I I
Retention
I Total 100%
_

I MatriX 71%
uu_
+ 6°l.
+ 4°l. H,
/" ----
+ 2°
I /~ Intramatrlx 29%

71769 OOL/ 6 146 166 186 206 24 6 306

12"
g6 106 12 Jahre
306

B - 14,0°
FIG 4-27.
A, mandibular rotation backwards. Treatment took place from ap-
proximately age 17 to 19'/2 years. Note that of the total "rotation"
"11% is accounted for by "matrix rotation" and 29% by "intrarTiatrix
rotation." This pattern is typical of patients with disproportionate an-
terior face height growth. 8, serial tracings of a mandible rotating
forwards. Registration is on implants. Note the extensive apposition
and remodeling in the corpus. In such cases "intramatrix rotation"
accounts for the preponderance of the total "rotation," quite the re-
verse of that shown in A. (From Bj6rk A, Skieller V: Normales und
anomales Wachstum des Unterkiefers: Einer Synthese longitudinaler
kephalometrischer Implantstudien wahrend eines Zeitraums von 25
Tahren. Inf Orthod Kieferorthop 1984; 16:9-54. Reproduced by
permission.)

shape changes, altering landmark positions and relationships of clinical import. However, most research shows that such predic-
parts, which makes true rotational analysis a staggeringly difficult tion's are not sufficiently precise for practical clinical application.47
"

procedure both conceptually and mathematically. We agree with

Bookstein 13 that tensor analysis is a better way to study craniofacial
shape change. Much that is reported as mandibular "rotation" is
mostly regional compensatory remodeling (' 'intramatrix rotation")
to corpus translation.
3) Timing.-Spurts in mandibular dimensions are common
but not universal and are more frequently seen in boys than girls,
occurring approximately 1'/2 years earlier in girls.47 The most im-
portant spurt in mandibular growth is that related to puberty; it
usually occurs before Peak Height Velocity, but there is remarkable
variation in this relationship.47. 97 Almost all first pubertal spurts
occur after ulnar sesamoid ossification and before menarchy-two
developmental events which have been used to predict skeletal
growth spurts. The prediction of the timing of mandibular growth
spurts, and whether or not they will occur at all, would be of some
4) Compensating Mechanisms.-As noted above, the areas
of muscle attachment and the alv'eolar process are the most adap-
tive, and hence variable, regions in the mandible. In extremes of
facial type these regions show great morphologic variance. For
e~ample, the shape of the'coronoid process, the amount and place-
melit of the alveolar process, ansl the condylar angle are greatly
different in a skeletal open bite than a skeletal deep bite (see Figs
4-26 and 4-27). Maximal differences in these regions are also
seen between Class II and Class III cases and in skeletal asym-
metry. Precision-bracketed orthodontic appliances mostly take ad-
vantage of the adaptive capacity of the alveolar process as it responds
to tooth movements. Functional appliances change the way that
muscle contractions shape the areas of attachment and guide the
eruption of teeth and hence the shape of the alveolar process. In
addition, repositioning of the mandible with a functional appliance
66 Growth and Development
may change the amounts and directions of growth in the condylar
region.51
5) Effects on Dentition and Occlusion.-Variation in man-
dibular morphology and size contributes more sigllificantly to most
malocclusions than does maxillary variability. The mandible, for
example, is more apt to be at fault in both Class II and Class III
malocclusions than is the maxilla. When there are significant var-
iations in mandibular morphology, both the upper and lower den-
titions must adapt during development. 68 Typical. tooth displacements
in a skeletal Class II or III malocclusion noted early in life help
to predict the ultimate molar and incisor relationship which will
obtain with subsequent growth.
c) Theoretical problems
Currently the two theoretical issues of most interest are (I)
the role of the condylar cartilage in mandibular growth and (2) the
source of the mandibular displacement which occurs during man-
dibular growth. Functional matrix theorists hold that it is the sur-
rounding soft tissues which displace the mandible, while others
feel that the endochondral mechanisms in the condyle push the
mandible downward and forward.
d) Clinical Issues
The principal clinical issue in mandibular growth is the extent
to which the clinician can alter mandibular morphology. 57 The
work of Petrovic, McNamara, and Carlson, particularly, reveals
the mandible as much more amenable to clinical control than
previously thought. Their work provides a theoretical framework
for understanding and planning control of mandibular growth, and
their animal experiments demonstrate the timing of such possi-
bilities and the maturationallimitations. Clinical studies generally
are much more difficult to design and, hence, clinical reports of
altered mandibular growth are less clear in their conclusions. It
seems significant that the more extensive and thoroughly designed
clinical studies are quite consonant with the experimental studies,oB
while many of those which conclude that one cannot alter man-
dibular growth are flawed in their mensurational methodology or
design. This important issue is not fully understood as yet, and
clinicians, while awaiting more detailed and critical reports, must
protect themselves against both the overly enthusiastic claims of
some and the denial of any clinical effects on the mandible by
others, for we are undoubtedly able to affect mandibular growth
and form much more than previously thought, but we have much
to learn about this important clinical advantage.
5. Temporomandibular Joint
The condylar component of the temporomandibular joint is
much studied (see E-4, Mandible), but the temporal component
(eminentia articularis and fossa) is much less so, hence our knowl-
edge about it is quite incomplete. The embryologic development
of the region has received attention (see Chapter 3) but postnatal
changes are less well known.
a) Functions and Growth
In the neonate the temporal articular surfaces are almost flat
since the eminence and fossa are not well differentiated, lacking
the familiar S-shaped profile characteristic of adult joints. During
-.
the development of the primary dentition, fossa depth increases
appreciably and the eminence becomes clearly identified. Later
the articular disc, which at birth is completely vascularized, be-
comes clearly avascular in the mid region. The vascularization of
the superior surface of the condyle disappears at about the same
time. Probably the definition of the joint contours is a result of
the stimulation of beginning masticatory function since both the
form and position of the fossae are different with congenital ab-
sence of a ramus or unilateral condylectomy.
During childhood the mandibular fossa becomes deeper and
the slope of the eminentia steeper as a result of differential dep-
osition and resorption, mostly deposition on the eminence. The
literature contains arguments about the duration of growth of the
articular eminence. Sparse data and logic both indicate that the
region grows and remodels continuously but in a decelerated fash-
ion as bone growth and remodeling occur elsewhere in the body.
b) Mechanisms and Sites
Although the region is clearly one growing by intramem-
branous ossification, a number of researchers have drawn attention
to the role of an endochondral-like mechanism in eminetia growth
in humans and monkeys analogous to the growth mechanisms in
the condyle (e.g., see the works by Hinton in Suggested Readings).
This is not surprising since, as discussed earlier, cartilage appears
in areas where pressure exists but bone growth must proceed.
Studies of altered mandibular function in growing animals
clearly indicate that the temporal portion of the joint is responsive
in concert with the condyle and that maturation plays a similar
role in the duration and extent of the effects of altered function of
the temporomandibular joint (the article by Hinton and McNamara
in Suggested Readings provides a good summary).
c) Effects on Dentition and Occlusion
Much of the research on temporomandibular kinematics and
the relationship of occlusion to joint morphology has been done
on adults needing occlusal rehabilitation. It almost seems that some
believe the joint incapable of adaptation and remodeling. Certainly,
modern occlusal rehabilitation practice involves carefully fitting
the occlusion to some features of the joint morphology, for ex-
ample, the slope of the eminence. Developmentalists studying
occlusion note the interrelationships of occlusion and the joint with
overall craniofacial morphology during growth and emphasize the
interrelationships rather than the dependence of occlusal relation-
ships on unchanging joint morphology. Indeed it can be expected,
as the animal experimental evidence shows, that definitive studies
of orthodontic correction during growth should be expected to show
concomitant changes in temporal joint remodeling.35 There is an
ext~nsive literature evalu(!ting the relationships of mandibular fossa
deptJt -to dental stress factors such as tooth wear, loss of teeth,
periodontal disease, and fractures.' Since some force probably is
delivered to the joints during function, 30. 40 reported adaptative and
compensatory changes are not surprising and provide the rationale
for the establishment of proper occlusal function to promote rea-
sonably normal joint growth and physiologic function.
d) Clinical and Theoretical Issues
While the theoretical issues of the growth and remodeling of
the temporal component of the joint are not much argued, the
clinical aspects are. For example, it is not fully known how tem-

poromandibular growth and adaptation vary with different crani-
ofacial types. Further, there is the question about the "proper"
position of the condyle within the fossa and whether or not slight
variance in condylar positioning affects changes in growth amounts
or directions. We are in a period of intensive study of temporo-
mandibular joint growth and the developmental aspects of tem-
poromandibular joint dysfunction67 It is suggested that the reader
study carefully the Selected Readings at the end of this chapter
(e.g., the monograph by Carlson, McNamara and Ribbens), and
read the new literature carefully as this complicated and fascinating
area of regional craniofacial growth becomes better understood.
F,. OVERALL PATTERN OF CRANIOFACIAL
GROWTH
The gross effects of summarized craniofacial growth are usu-
ally depicted cephalometrically by registration of successive trac-
ings on common cranial base landmarks (see Fig 4-24). The additive
result of displacement, growth, and remodeling appears to be
downward and forward despite local change in many different
directions (see Fig 4-24). As noted in Chapter 12, such orienta-
tions and registrations can be misleading. The usual simplistic
presentations of overall pattern of growth thus often conceal rather
than reveal important regional and sexual differences of great clin-
ical import.
There are sexual differences in overall growth (men grow
more, grow actively over a longer time span, display more "spurts",
and so forth) but such differences are better understood by studying
regional sexual dimorphisms (see Section E). From a clinical stand-
point the most significant overall sexual differences are seen in
the achievement of facial height (see Chapter 12). Total facial
height and some components of it show remarkable sexual di-
morphisms in amount, timing, and pattern of growth, necessitating
sexually different treatment strategies for certain types of open
bite and deep bite (see Chapters 15 and 16).
G. RACIAL AND ETHNIC DIFFERENCES
Morphologic differences among the various human races and
ethnic groups have long been studied. Indeed craniofacial features
are probably used more than any others to typify group charac-
teristics and diversities. There are a very large number of ce-
phalometric studies of craniofacial morphology of widely varying
racial and ethnic groups ranging from Australian aborigines to
Bantu, Lapps, North American whites, Japanese, Swedes, several
North American Indian tribes, Mexicans, Brazilians, French, Ital-
ians, Greeks, Finns, North American blacks, and others. *
The literature on racial morphologic craniofacial diversity is
detailed and extensive but there are few studies on growth differ-
ences among racial, ethnic, and national groups (see, e.g., the
article by Moyers and Miura69). Most extensively reported on are
North American whites and Europeans. Serial cephalometric data
of North American blacks exist but are not yet fully analyzed.
*This is not to suggest that these studies are available in a handy
form for clinical diagnostic use; they are not. It will require an exten-
sive research project in itself to standardize and normalize the various
data sets for practical comparisons.
-.
Growth of the Craniofacial Skeleton 67
It is a great pity we know much about morphologic variation
among ethnic groups and little about the developmental differences
which produce it.69 Even casual reading of the international or-
thodontic clinical literature suggests different distribution of mal-
occlusions among, to name obvious examples, Japanese, Italians,
Swedes, British, and North American whites. Since radiation hy-
giene regulations now restrict serial cephalometric growth studies
in most countries, it will likely be some time before detailed
knowledge of growth differences among races is known.
H. " ADULT" CRANIOFACIAL GROWTH
There exists a general viewpoint that craniofacial growth de-
celerates after pubescence, ceasing sometime in the third decade
of life--earlier in women than in men. The perception that there
is very little adult growth appears as assumptive in many articles
and is reiterated in almost all textbooks, including earlier editions
of The Handbook of Orthodontics! Studies have existed for many
years which present contrary evidence. Though one can criticize
almost any of the reports (e.g., for small sample size, lack of
sufficiently long series, flawed research design, or inappropriate
methods of measurement), when they are taken in toto, the findings
undeniably affirm the presence of continuing changes in craniofa-
cial morphology throughout life. It is true that there has not been
a complete consensus among researchers themselves, but the' con-
trary evidence is less abundant and less sound.
Part of our failure to appreciate the extent of adult skeletal
growth may be due to the restricted use of the word "growth" in
cephalometrics to mean size increase alone (and size frequently
"measured" by changes in an angle whose apex is far removed
from the bone or region under study [e.g., LANB to measure
mandibular length or growth]). A recent monograph by Behrents4
forces us to abandon the old views of minimal adult craniofacial
growth.
Behrents4 did an extensive adult follow-up research of sub-
jects in the original Bolton study, analyzing 163 individuals rang-
ing in age from 17 to 83 years, all of whom had previous
extraordinarily complete serial growth data, including cephalo-
grams, obtained during childhood and adolescence. His findings
provide good evidence of surprising extensive craniofacial changes
throughout life.
" Behrent's results4 may be briefly summarized as follows:
a) Craniofacial size and shape changes continue past 17
years to the oldest ages studied.
. ..
b) Significant sexual dimorphism exists: men are larger at
all ages, they gi6w more, and their adult growth is
more apt to persist along the same vectors of adolescent
growth.
c) Women showed periods of increased rates of craniofa-
cial growth, apparently related to the time of
pregnancies.
d) Skeletal changes resulted from continuous localized re-
modeling, producing differential alterations in size and
shape.
e) The amounts of growth were not sufficient to serve as a
basis for practical adult orthopedic or functional appli-
ance therapy.
68 Growth and Development
f) The amounts of growth were sufficient, however, to
cause significant adaptations in mandibular orientation
'and occlusal relations.
The implications for clinical dentistry of this important work
are not yet fully realized, but it is obvious that treatments (ortho-
dontic, restorative, prosthetic) based on a presumptive "stability"
of occlusion if treated "properly" are challenged, for all occlusions
obviously change. Our treatment goals should not be based on
hoping for static relationships but rather on achieving favorable
adaptations to the inevitable changes of aging.
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32. Harvold EP: Altering craniofacial growth: Force application
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33. Harvold EP, Chierici G, Vargervik K: Experiments on the
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34. Harvold EP, Vargervik K, Chierici G: Primate experiments
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35. Hinton RJ, McNamara JA Jr: Temporal bone adaptations in
response to protrusive function in juvenile and growing
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1984; 6:155-174.
36. Houston WJB: Relationships between skeletal maturity esti-
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37. Hunter WS: Genetics and forecasting. Lecture presented at
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38. Hunter WS, Balbach DR, Lamphier DE: The heritability of
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39. Hylander WL: Patterns of stress and strain in the Macaque
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42. Johnston LE Jr: The functional matrix hypothesis: Reflec-
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43. Koski K, Ronning 0: Condyle neck periostomy and the mi-
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...•
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51. McNamara JA Jr: Neuromuscular and skeletal adaptations
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70 Growth and Development
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81. Piminidis MZ: The Mandibular Trigeminal Nerve of the
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Facial Motor and Growth Changes Following Early Lesion
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82. Rampton FR: Temporal Muscle Dysfunction as a Basis for
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83. Roche AF, Lewis AB: Sex differences in the elongation of
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91. Solow B, Tallgren A: Head posture and craniofacial mor-
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95. van Limborgh J: Factors controlling skeletal morphogenesis
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New York, Alan R. Liss, 1982.
96. van Limborgh J: Morphologic control of craniofacial
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97. Woodside DG: Distance, Velocity and Relative Growth
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SUGGESTED READINGS
B,'''R.UDIMENTS OF BONE GROWTH
Baer 11, Gavan JA: Symposium on bone growth as revealed by
in vivo markers. Am J Phys Anthropol 1968; 29:155.
Dixon AD, Sarnat BG (eds): The International Conference on
Factors and Mechanisms Influencing Bone Growth. New York,
Alan R. Liss, 1982.
Enlow DH: Principles of Bone Remodeling. Springfield, Ill, Charles
C Thomas, 1969.
Enlow DH: The remodeling of bone, in Buettner-James J (ed):
Yearbook of Physical Anthropology Series, Vol 20. Washington
DC, 1976.

Enlow OH: Handbook of Facial Growth, 2nd ed. Philadelphia,
WB Saunders Co, 1982.
C. CHANGING CONCEPTS AND"
HYPOTHESES OF CRANIOFACIAL
GROWTH
Carlson os: Craniofacial biology as normal science, in lohnston
LE lr (ed): New Vistas in Orthodontics. Philadelphia, Lea &
Febiger, 1985.
Moss ML: The functional matrix,in Kraus, BS, Riedel R (eds):
Vistas in Orthodontics. Philadelphia, Lea & Febiger, 1962; pp
85-98.
Moss ML: The primary role of functional matrices in facial growth.
Am J Orthod 1969; 55:566.
Moss ML: Genetics, epigenetics and causation. Am J Orthod 1981;
80:366-375.
Petrovic AG: Experimental and cybernetic approaches to the mech-
anisms of action of functional appliances on mandibular growth,
in McNamara lA lr, Ribbens KA (eds): Malocclusion and Ihe
Periodonlium, monograph 15. Craniofacial Growth Series. Ann
Arbor, Mich, Center for Human Growth and Development,
University of Michigan, 1984, pp 213-268.
D. CONTROLLING FACTORS IN
CRANIOFACIAL GROWTH
Behrents RG: Deja vu: Neurotrophism and the regulation of cran-
iofacial growth, in McNamara lA lr (ed): Faclors Affecling Ihe
Growlh of Ihe Midface, monograph 6. Craniofacial Growth Se-
ries. Ann Arbor, Mich, Center for Human Growth and Devel-
opment, University of Michigan, 1976.
Behrents RG, lohnston LE lr. The influence of the trigeminal
nerve on facial growth and development. Am J Orlhod 1984;
85:199-206.
McNamara lA lr (ed): Conlrol Mechanisms in Craniofacial Growlh,
monograph 3. Craniofacial Growth Series. Ann Arbor, Mich,
Center for Human Growth and Development, University of
Michigan, 1975.
McNamara lA lr (ed): Delerminants of Mandibular Form and
Growlh, monograph 4. Craniofacial Growth Series. Arln Arbor,
Mich, Center for Human Growth and Development, University
of Michigan, 1974.
Dixon AD, Sarnat BG (eds): The Inlernalional Conference on
Faclors and Mechanisms Influencing Bone Growlh. New York,
Alan R. Liss, 1982.
Hagg U, Taranger l: Dental development assessed by tooth counts
and its correlation to somatic development during puberty. Eur
J Orthod 1984; 6:55-64.
Hinton Rl: Form and function in the temporomandib\llar joint, in
Carlson OS (ed): Craniofacial Biology, monograph 10. Crani-
ofacial Growth Series. Ann Arbor, Mich, Center for Human
Growth and Development, University of Michigan, 1981.
Houston WlB: Relationships between skeletal maturity estimated
from hand-wrist radiographs and the timing of the adolescent
growth spurt. EurJ Orthod 1980; 2:81-93.
lohnston LE lr: The functional matrix hypothesis: Reflections in
-..
Growlh of the Craniofacial Skelelon 71
a jaundiced eye, in McNamara lA lr (ed): Faclors Affecling Ihe
Growth oflhe Midface, monograph 6. Craniofacial Growth Se-
ries. Ann Arbor, Mich, Center for Human Growth and Devel-
opment, University of Michigan, 1976.
McNamara lA lr: Functional determinants of craniofacial size and
shape, in Carlson OS (ed): Craniofacial Biology, monograph
10. Craniofacial Growth Series. Ann Arbor, Mich, Center for
Human Growth and Development, University of Michigan, 1981.
Moss ML: The functional matrix, in Kraus BS, Riedel R (eds):
Vistas in Orlhodontics. Philadelphia, Lea & Febiger, ]962; pp
85-98.
Moss ML: The primary role of functional matrices in facial growth.
Am J Orthod 1969; 55:566.
Moss ML: An introduction to the neurobiology of orofacial growth,
ACIa Biomelrica ]972; 21:236-259.
Moss ML: Neurotrophic regulation of craniofacial growth, in
McNamara lA lr (ed): Control Mechanisms in .Craniofacial
Growlh, monograph 3. Craniofacial Growth Series. Ann Arbor,
Mich, Center for Human Growth and Development, University
of Michigan, 1975.
Moss ML: Genetics, epigenetics and causation. Am J Orthod ]981;
80:366-375.
Carlson OS, McNamara lA lr (eds): Muscle Adaplalion in Ihe
Craniofacial Region, monograph 8. Craniofacial Growth Series.
Ann Arbor, Mich, Center for Human Growth and Development,
University of Michigan, 1978.
Disruptive Factors
Orthodontic Forces
McNamara lA lr, Ribbens KA, Howe RP (eds): Clinical Alleralion
of Ihe Growing Face, monograph 14. Craniofacial Growth Se-
ries. Ann Arbor, Mich, Center for Human Growth and Devel-
opment, University of Michigan, 1983.
Surgery
McNamara lA lr, Carlson OS, Ribbens KA (eds): The EffecI of
Surgical Intervention on Craniofacial Growlh, monograph 12.
Craniofacial Growth Series. An'n Arbor, Mich, Center for Hu-
man Growth and Development, University of Michigan, 1982.
Malfunction
¥cNamara lA lr (ed): Naso-Respiralory FunClion and Craniofa-
cial Growlh, monograph 9. Craniofacial Growth Series. Ann
Arbor, Mich, Center for Human Growth and Development,
University of Michigan, 1979."
Gross Craniofacial Anomalies
B;r~sma 0 (ed): Birth Defecls AIlas and Compendium. Baltimore,
Williams & Wilkins, ]973.
Bergsma 0, Langman l, Paul NW: Morphogenesis and Malfor-
mation of Face and Brain. The National Foundation 1975; XI:7.
Converse lM, McCarthy lG, Wood-Smith 0 (eds): Symposium on
Diagnosis and Trealmenl of Craniofacial Anomalies. St Louis,
CV Mosby Co, 1979.
Grabb WC, Rosenstein SW, Bzoch KR (eds): Clefl Lip and Palale.
Boston, Little, Brown Co, 1971.
72 Growth and Development

joint, in lrby WG (ed): Current Concepts in Oral Surgery. St

E. REGIONAL DEVELOPMENT Louis, CV Mosby, 1980.
Cranial Vault Carlson OS, McNamara JA Jr, Ribbens KA (eds): Developmental
Aspects of Temporomandibular Joint Disorders, monograph 16.
Enlow OH: Handbook of Facial Growth, 2nd ed. Philadelphia, Craniofacial Growth Series. Ann Arbor, Mich, Center for Hu-
WB Saunders Co, 1982. man Growth and Development, University of Michigan, 1985.
Hinton RJ: Form and function in the temporomandibular joint, in
Carlson OS (ed): Craniofacial Biology, monograph 10. Crani-
Basicranium
ofacial Growth Series. Ann Arbor, Mich, Center for Human
Bosma JF (ed): Development of the Basicranium, publ NIH 76- Growth and Development, University of Michigan, 1981.
989. US Department of Health, Education and Welfare, .Public Hinton RJ, McNamara JA Jr: Temporal bone adaptations in re-
Health Service, National Institutes of Health, Bethesda, Mary- sponse to protrusive function in juvenile and growing adult
land, 1976. Rhesus monkeys (Macaca mulatta). Eur J Orthod 1984; 6: 155-
Enlow OH: Handbook of Facial Growth, 2nd ed. Philadelphia, 174.
WB Saunders Co, 1982. Moffett BC: The morphogenesis of the temporomandibular joint.
AmJ Orthod 1966; 52:401-415.

Nasomaxillary Complex
Enlow OH: Handbook of Facial Growth, 2nd ed. Philadelphia,
WB Saunders Co, 1982.
McNamara JA Jr (ed): Factors Affecting the Growth of the Mid-
face, monograph 6. Craniofacial Growth Series. Ann Arbor,
Mich, Center for Human Growth and Development, University
of Michigan, 1976.
Mandible
McNamara JA Jr (ed): Determinants of Mandibular Form and
Growth, monograph 4. Craniofacial Growth Series. Ann Arbor,
Mich, Center for Human Growth and Development, University
of Michigan, 1975.
Enlow OH: Handbook of Facial Growth, 2nd ed. Philadelphia,
WB Saunders Co, 1982.
Kantomaa T: The Role of the Mandibular Condyle in the Facial
Growth. Proc Finn Dent Soc 1984; 80:(suppl IX) I-57.
Temporomandibular Joint
Carlson OS, McNamara JA Jr, Graber LW, et al. Experimantal
studies of the growth and adaptation of the temporomandibular
F. OVERALL PATTERN OF CRANIOFACIAL
GROWTH
Enlow OH: Handbook of Facial Growth, 2nd ed. Philadelphia,
WB Saunders, 1982.
Solow B: Factor analysis of craniofacial variables, in Moyers RE,
Krogman WM (eds): Craniofacial Growth in Man. Oxford,
Pergamon Press, 1971.
H. " ADULT" CRANIOFACIAL GROWTH
Behrents RG: Growth in the Aging Craniofacial Skeleton, mon-
ograph 17. Craniofacial Growth Series. Ann Arbor, Mich, Cen-
ter for Human Growth and Development, University of Michigan,
1985.
Behrents RG: An atlas of Growth in the Aging Craniofacial Skel-
eton, monograph 18. Craniofacial Growth Series. Ann Arbor,
Mich, Center for Human Growth and Development, University
of Michigan, 1985.

~"
,'.

,. " :.. ..
CHAPTER 5
Maturation of the Orofacial
Musculature
Arthur T. Storey, D.D.S.,
It is not easy to blow and swallow at the same time.-
PLAUTUS (Mostellaria, Act Ill, Scene ii)
KEY POINTS
1. The facial muscles not only provide expression but
also contribute to the maintenance of facial and
mandibular posture.
2. Posture of the head, mandible, tongue, and hyoid is
interactive.
3. Mandibular movement is best perceived as movement
of a free body manipulated in an intricate web of
orofacial muscles with the teeth and joints acting as
stops and guides .
4. Reflexes of the upper airway and alimentary tract are
interactive. Protective reflexes preempt supportive
reflexes.
5. Sophisticated instruments are available by which to
study movement, force, and pressure resulting from
orofacial muscle activity.
6. Forces exerted by orofacial muscles may arise from
active tension, passive tension, or a combination of
both.
7. The relative contribution of active tension to total
tension in jaw muscles is different while one is
awake or asleep. The ratios differ in facial muscles,
which have no muscle spindles.
8. Reflexes of facial muscles appear to be initiated and
modulated by cutaneous receptors, while reflexes of
Ph.D.
jaw muscles originate in receptors around the teeth
and in muscles and joints.
9. Closure into full intercuspation may be actively or
passively guided. Long-standing active guidances
may lead to alterations in jaw growth or to
dysfunction.
10. Protrusion of the tongue in posture, a reflex response
. to encroachment on the pharyngeal airway, can lead
to altered tooth positions.
11. Forces in mastication normally do not move teeth;
., indeed, vertical forces stabilize the teeth.
12. Swallowing, serving both an alimentary and an
airway function, involves some muscles (obligate)
which are tightly regulated in the~synergy; others
(facultative) may be recruited. Obligate muscles are
insensitive to fee<!~ack, while the facultative muscles
·'·~.regulating anterior oral seal and tongue stability are
responsive to sensory cue's.
13. Deficiencies in velopharyngeal valving produce
speech problems, but defects in articulation involving
the teeth,alveolar process, lips, and tongue may not
appear if neuromuscular adaptability is high.
14. Orofacial reflexes may be both unlearned and
learned. Portions of a reflex, such as swallowing,
may be unlearned and others learned.
15. Postural position is exclusively determined by
73
74 Growth and Development

reflexes, but intercuspal position and retruded
position are in part actively determined.
16. Retruded contact position is passively determined
actively attained. This makes it the most reliable
the registration positions if all passive stops are
attained.
17. There are no longitudinal studies on orofacial muscle
growth. Limited studies on adaptation suggest that
changes in functional length and adaptation in tendon
and in muscle attachment to bone occur in the
growing animal but not in the adult.
18. Ontogenetic in sights into orofacial behavior patterns,
although not well documented, provide useful clues
in assessing normal development.
OUTLINE
contact muscles are often dIscussed by region, a somewhat artificial des-
ignation since orofacial behavior recognizes no regional bounda-
but ries. For exarnple, swallowing entails muscle activities in the facial,
of jaw, and portal regions: at both the sensory and motor level there
is much interaction among regions.21 The facial musculature in-
nervated by the seventh cranial nerve has as a major function that
of expression. The jaw musculature innervated by the fifth cranial
nerve is exemplified by masticatory function. Oral and pharyngeal
muscles innervated by the fifth, ninth, and tenth cranial nerves
collectively serve such important functions as respiration and al-
imentation. The standard anatomic description of a muscle includes
its location, origin and insertion, action, innervation and blood
supply, an approach appropriate for surgery, but in orthodontics,
it is necessary to view the orofacial musculature in a different
context to understand its effects on growth of the face and the
effects of mal relation of jaws and facial structures on muscle ac-
tivity. The emphasis in this section will be on the function of the
orofacial musculature.

A. Orofacial Muscles
I. Facial muscles 1. Facial Muscles
2. Jaw muscles
3. Portal muscles The primary function of the facial muscles is expression of
B. Methods of Study the emotions. Duchenne22 electrically stimulated these muscles in
I. Anatomic the human in an attempt to find the role of the individual muscle
2. Functional in the display of emotions. The expression of emotions in man
a) Movement and animals fascinated Charles Darwin,'8 who wrote one of the
b) Force and pressure first books contending that behavioral patterns are as characteristic
c) Electromyography of a species as are its structural forms. The capacity for expressing
3. Behavioral affective states is highest developed in the human. Coleman17 con-
C. Basic Concepts of Orofacial Neuromuscular Physiology tends the human is capable of 7,000 possible facial expressions.
I. Active and passive tension There is considerable racial and individual variability in the de-
_ 2. Simple orofacial reflexes velopment of these muscles in the human, affording an anatomic
a) Facial reflexes basis for variability in facial expression.37
b) Jaw reflexes In addition to expression of emotions, these muscles are im-
c) Tongue reflexes portant in maintenance of posture of facial structures. Paresis of
3. Complex orofacial reflexes the orbicularis oculi leads to drooping of the lower eyelid and
a) Mastication drying of the conjunctiva with subsequent inflammation. Paralysis
b) Bruxism of the orbicularis oris or muscles inserting into the corner of the
c) Swallowing mouth will lead to drooling and angular cheilosis. According to
d) Gagging Proffitn the lip and buccinator muscles opposed by the tongue
e) Speech contribute to a postural equilibrium of the teeth. The facial muscles
4. Learned and unlearned reflexes also contribute to stabilization of the mandible during infantile
D. ·Reflexdeterminants of mandibular registration positions s~allowing and in chewing and swallowing in the edentulous and
I. Postural position occlusally compromised adult. It is quite possible that postural
2. Intercuspal position (usual occlusal position, centric alterations in the facial muscles may· contribute to structural changes
occlusion) in the jaws, as has been documented for alterations in postural
3. Retruded contact position activity of the mandibular muscles (see Section E).
E. Growth and adaptation of orofacial muscles ., frankeF8 has speculated that the buccinator muscles exert a
I. Structural constraining force on the maxillary, alveolar process as well as the
2. Functional and behavioral teeth. The demonstrated increase in arch width with the appliance
F. Interaction of orofacial muscles with development of the bearing his name (see Chapter 18) is attributed to the buccal shields
craniofacial skeleton and the dentition which hold the cheeks from the alveolar process and teeth. 54 Form
also dictates function: patients with short upper lips or excessively
proclined maxillary incisors compensate by elevation of the lower
A. OROFACIAL MUSCLES lip, through action of the mentalis muscle, to establish an anterior
seal during swallowing (see Fig 10-3). Facial muscles also play
The orofacial muscles may be classified according to region, an important role in both visual and spoken communication: a
cranial nerve innervation, or function. Functions of the various smile or frown is part of a universal language. Lip contact with

opposing lip or teeth provides one-quarter of the articulations of
the English language. Lips and cheeks are essential as well for
bolus control in mastication; patients with facial palsies have prob-
lems with food accumulation in the labial and buccal vestibule of
the affected side.
2. Jaw Muscles
Jaw muscles are often designated as levators and depressors
or protractors and retractors, but this classification of muscles
acting as synergists or antagonists can be a handicap to a better
understanding of their roles in posture and jaw muscle synergies.
The simplest concept of neural control of mandibular posture is
of the mandible maintained against gravity by the stretch reflex in
tfie mandibular elevators. Electromyographic (EMG) studies of
postural position have shown that the inframandibular group of
muscles are more active than the levator muscles.58 (This can be
interpreted as depressors opposing levators in the determination
of posture of the mandible or as an indicator of muscle activity
regulating the posture of the tongue and hyoid.) As will be shown
later, it is wrong to think of posture of the mandible without
thinking of posture of the tongue, hyoid complex, and other struc-
tures because all are intimately related.
This concept of posture of the mandible involving posture of
other structures can be extended to the head. Brodie'o conceived
of head posture as determined by a chain of muscles ventral to the
vertebral column opposed by another chain dorsal to the cervical'
vertebrae. (The ventral chain would include the mandibular lev-
ators, the muscles connecting the mandible to the hyoid bone, and
the muscles connecting the hyoid to the sternum.) Extension of
the head results in an increase in freeway space, while flex ion
results in a decrease'" Changes in head posture also affect the
anteroposterior position of the mandible in postural position'"
While the mandible is capable of a pure rotational movement
early in opening and late in closure, studies have shown that normal
opening and closing are never purely rotational.66. 88. 91The actual
rotation centers are dorsal to the mandibular ramus and shift during
opening and closing. This means that the opening and closing of
the mandible can no longer be conceived as largely an interplay
between levators and depressors. Mandibular movement is more
accurately perceived as that of a free body manipull,lted in an
intricate muscular web, with the teeth and joints acting as stops
and guides. If it were not this way, patients with bilateral con-
dylectomies could never chew.
This concept of the jaw suspended in a web of muscles is
helpful in understanding the mechanisms which bring about sta-
bilization of the mandible in both chewing and swallowing. If
there are marked deflective contacts in the teeth (e.g., "slides in
centric" and "functional malocclusions"), the mandible is shifted
to the position of maximal intercuspation, displacing one or both
condyles from their ideal position. Such a displacement can only
be accomplished by a complex interaction of all the muscles in-
serting onto the mandible. Before teeth arrive in the infant, man-
dibular stabilization is affected by synergistic activity of both levator
and depressor muscles, and the facial muscles may be called upon
to assist in the stabilization, for example, during swallowing.
In this interactive web, muscles serve various functions: but
the superior head of the lateral pterygoid muscle is illustrative of
-..
Maturation of the Orofacial Musculature 75
FIG 5-1.
Moments for the two heads of the lateral pterygoid muscle at rest
(postural position) and open positions computed about the instan-
taneous centers of rotation of the mandible. At postural position (R)
the superior head (5) has a closing moment ( + 176) while the inferior
head (J) has an opening moment ( - 756). At the open position (0)
both heads have opening moments. (From Grant PG: Lateral pter-
ygoid: Two muscles. AmJAnat 1973; 138:1-10. Used by permission.)
a muscle's multiple functions. CaJculationsofthis muscle's vector
about the instantaneous center of rotation (see Fig 5-1) suggest
that its action early in opening and late in closure is to stabilize
the joint. 32 This hypothesis is further supported by EMG st~dies
in both monkey'6. 8' and human (reference 42 and Williamson EI1,
personal communication, March 1980). Through the remainder of,
the mandible's range of motion, the muscle functions to distract
the disc or check its return.'o Thus, the same muscle can act in
two very different ways in a particular synergy.
Probably the most important application of this field concept
of muscle action relates to its effect on development of the jaws.
The effect of postural activity is likely to be, more important than
that of synergies such as mastication and swallowing.72 The al-
teration of mandibular, tongue, and hyoid position in mouth breath-
ing changes the environment of both the mandible and maxilla and
alters the way they grow. The" "long fa,ce syndrome," which
Linder-Aronson45 associates with mouth-breathing, is a good ex-
ample. Early treatment of functional posterior and anterior cross-
bites is advised to preveht eventual perpetuation in bone, yet the
fdnhional protraction of the mandible in posture in Class II mal-
occlusions,39 the so-called "Sunday bites," does not lead to skel-
etal correction. What is the difference in adaptive stimulus between
a naturally occurring protrusive posture and that resulting from a
functional appliance? We do not know, but finding out would have
great clinical consequence. Perhaps it is the frequent return of the
mandible to a more dorsal position during mastication and swal-
lowing which cancels the biologic signals to joint structures to
adapt. Perhaps this is why the functional appliances which are
worn the most hours per day seem to work best. These are tan-
76 Growth and Development

TABLE 5-1. A
Effector Sites Giving Rise to Supportive and Protective Reflexes of 8

the Upper Airway and AlimentarySUPPORTIVE

EFFECTOR Tract PROTECTIVE'>"'" fi'" GENIOGLOSSus
SITE SITES REFLEXES REFLEXES

Upper Nose Sniffing Apnea, sneezing

airway Pharynx Airway Sniffling
maintenance
Larynx Airway Apnea MASSETER
maintenance Glottic closure I Mass
Swallowing
Coughing

Alimentary Mouth Suckling Spitting . ORIS

tract Mastication ,• ORBiCuLARIS 00
Pharynx Swallowing Gagging
Esophagus Swallowing Vomiting •
8

talizing questions for the investigator of control mechanisms on B

condylar growth. B

3. Portal Muscles

The term "portal area" was coined by Bosma7 to denote the

upper alimentary and respiratory tracts. The muscles of the portal
area serve the multiple functions of posture, respiration, and feed-
ing. Portal muscles include the muscles of the tongue (both intrinsic
and extrinsic), the soft palate, the pharyngeal pillars, the pharynx
proper, and the larynx. It is the crossing of these tracts in the
pharynx that requires special reflex controls for maintenance and
protection. Complex neural controls are necessary to allow only
the most important reflex to occupy the portal area at one time.
Reflexes of the oropharynx must support a patent airway during B
respiration and provide a pressure gradient during swallowing. If
FIG 5-2.
foreign substances gain accidental access to either the alimentary·
or the respiratory tract, protective reflexes must be called into Histograms of muscle activity in normal (A) and open bite (B) subjects
on opening to maximum (vertical line B-B). GG, Mass, and 00 in-
play, for example, retching and coughing. A more complete listing
dicate threshold increase in electrical activity (20% of baseline). Note
of portal reflexes if given in Table 5- I. Each effector site is capable
that in the subject with normal occlusion the increase in genioglossus
of giving rise to several reflexes-with some reflexes, such as activity begins late and is small while in the subject with the open
swallowing, engaging more than one site. The two portal.reflexes bite the increased activity occurs early in opening and is very large.
of greatest significance to orthodontics are pharyngeal airway Vertical calibration, 250 mV; horizontal calibration, 1.0 second. (From
maintenance and swallowing. (A discussion of swallowing is found Lowe AA, Johnston WO: Tongue and jaw muscle activity in response
in Section C.) to mandibular rotations in a sample of normal and anterior open-bite
An important anatomic feature of the respiratory pharynx is subjects. Am J Orthod 1979; 76:565-576. Used by permission.)
its ventral wall, which is formed by the base of the tongue. If the
tongue is large for the space enclosing it, the tongue might be
expected to spill into the pharynx. Only in the infantile syndrome open bite, while the tongue activity maintains it (Chapters 7 and
of Robin and in sleep apneas does this happen, with great risJc for 10).;'·
the patient. Otherwise the tongue is postured forWard or bucplly,
leading to anterior or posterior open bites. (It is posture of the
tongue rather than thrusting in swallowing which accounts for this B.METHODSOFSTUDY
kind of open bite when it occurs. See Section C-4). Anterior open
1. Anatomic
bites have also been shown to be associated with large tongue-to-
tongue space ratios. S2 Subjects with anterior open bites have very The oldest method of studying muscle is gross dissection.
active tongue protraction reflexes4s (see Fig 5-2). This finding The shape, boundaries, origin, and insertion provide insight into
explains well the role of the tongue in open bites associated with the possible force vectors of the muscle; but estimated force vectors
a history of thumb-sucking. The thumb-sucking may create an for the whole muscle have limited value in predicting the real force

vl<ctors because the muscles are never fully contractile in normal
function. If the contractile elements of all the mandibular muscles
coul<j be identified in an actual jaw movement the vectors of all
the muscles participating summed jaw loading could be calculated.
Knowing the magnitude of these vectors wOHld permit a better
understanding of their effect on mandibular growth and remodeling.
Another traditional method of studying mus.cle.s i~ thy his-
tologic. Readers are familiar ,with the microstructure of striated
muscle, to which all the orofacial muscles belong, and may be
familiar with techniques to characterize muscle types on the basis
of enzyme histochemistry. The two major classifications are based
on the concentrations of oxidative enzymes and/or adenosinetri-
phosphatase (ATPase) present in the muscle fiber. On the basis
of oxidative enzyme stains, fibers have been designated as oxi-
da'tive or glycolytic and functionally correlated with speed of con-
traction and susceptibility to fatigue. ATPase staining has led to
typing of fibers as either type I or 11, with subcategories of type
11 based on prior incubation at various pH levels. (Not all inves-
tigators have been successful in subclassifying jaw muscles; see
Maxwell et al. SI) These techniques are continually being refined
and new ones being developed, for example, myosin
characterization.
Type I muscle fibers are associated with small, low-tension,
slowly contracting motor units. These units are very resistant to
fatigue and richly supplied with capillaries. (They are the units
most dependent on good circulation.) These units possess excellent
endurance at low forces, which makes them well suited for main-'
tenance of posture of the mandible. Type 11 fibers are associated
with large, high-tension, rapidly contracting units. They may be
fatigue resistant (IIA) or fatigue sensitive (lIB) and possess either
a good (IIA) or poor (lIB) capillary circulation. The type IIA units
are thought to be recruited for maximum effort of long duration
and type lIB for maximum effort of short duration. Transitional
(or intermediate) units (lIe and IM) complete the spectrum of fiber
types.
On the basis of histochemical studies it has been found
(Eriksson25) that the temporalis, the masseter, the anterior medial
pterygoid, and the lateral pterygoid muscles are 75% composed
of type I fibers (based on cross-sectional areas). While this suggests
that these muscles are primarily responsible for posture of the
mandible, it is quite likely that these fibers also perform most of
the modest work entailed in mastication of a modem soft diet.
Type IIA fibers are found in significant proportions (30%) only
in the digastric muscle. Type lIB fibers, which are found in all
jaw muscles, are present in the highest proportion (45%) in the
superior posterior temporalis, posterior medial pterygoid, and an-
terior digastric muscles. The mix of fiber types is quite different
between the digastric and lateral pterygoid muscles, both of which
are jaw depressors, but not between the two heads of the lateral
pterygoid (Eriksson25).
These and other studies on the jaw muscles of man have
shown that the size and proportions of the different types are not
the same as in limb muscles. The jaw muscles display a broad
spectrum of types which are highly adaptive to the functional
demands placed on them. While type 11 fibers are significantly
larger in human subjects with high biting forces (RingqvisC9), there
appears to be no significant adaptation in fiber size or distribution
Maturation of the Orofacial Musculature 77
to the state of the occlusion assessed by numbers of opposing
contacts (Ringqvist8o). The specification of fiber types is not solely
determined by function since differentiation into the two major
fiber types occurs at 20 to 23 weeks gestation (Ringqvist et al.").
One wonders about the effects of functional orthodontic treatment
on fiber types, but this is impossible to state because of the het-
erogenous character of jaw muscles and the obvious technical
difficulties in making such a determination.
2. Functional
a) Movement
The study of movement resulting from muscle action is an
old and respected field designated kinesiology. This scientific dis-
cipline is not to be confused with the chiropractic fad which, sadly,
has adopted the same name but which has as a major goal the
optimizing of muscle performance through various muscle, dental,
and skull manipulations.
Movement of facial structures has been a favorite subject since
the invention of recording on moving film. The technology of
topographic mapping can be adapted to the study of the face in
repose. Observing the movement of a shadow grid projected onto
the face during activity of the facial musculature is an old technique
which has been updated using Moire fringe and computer tech·
nologies.23 Movement of facial structures can also be explored in
three dimensions by holography. One of the first techniques for
movement studies of the mandible was to record on moving film
the movement of a small ball or a light projecting from the man-
dibular incisors. This principle has been updated so that a small
'magnet attached to the lower incisors is tracked by three magne-
tometers and movement displayed in three planes of space on a
storage cathode ray oscilloscope or x-y recorder. 36 Another system
uses clutches on both the jaws and displacement transducers to
simulate movement of models of the teeth.97 Still another uses
light-emitting diodes affixed to the teeth and tracked by two special
cameras with coordinate sensors to display three-dimensional
movement of any point of the mandible, including the condyle.4I
Movement of the mandible and the portal structures can be vis-
ualized in cineradiographs, landmarks can be digitized, and alter-
ations in position or shape quantified. This tool has been most
helpful in understanding the movements associated with
swallowing. 16
b) Force and Pressure
Other parameters which can be used to assess the activities
of orofacial muscles are those of force and pressure. Pressures of
the lips, cheeks, and tongue against the teeth have been measured
by a number of investig';l.tors using strain gauges (e.g., ProffiC3).
Mas!icatory, swallowing, and maximal biting forces have been
recorded on the teeth, for exampl'e by Graf and coworkers.3I Pres-
sure transducers are an important tool in studying pressure gra-
dients in the upper alimentary tract during swallowing. Warren96
has developed an instrument which permits simultaneous recording
of air flow through both the nose and the mouth.
c) Electromyography
The instrument most often used for evaluating the activity of
orofacial muscles is the electromyograph. Although it is possible
78 Growth and Development
to measure other parameters of muscle activity (e.g., change in
tension, heat production), the electrical activity is the easiest to
record .. Electrodes may be placed on the skin over the muscle or
inserted into the body of the muscle. Electrode type can be selected
so as to study a large portion of the muscle or a few motor units
in a specific region. Surface electrodes record from a larger pop-
ulation of muscle fibers than do needle electrodes. Both types of
electrodes record the membrane action potentials from the several
to many fibers in a single motor unit which arrive at the electrode
at different times, giving a unique signature to that unit as long
as the electrode is not moved. This permits the investigator to
study the behavior of individual units and how the units are re-
cruited. Figure 5-3 illustrates the manner in which force is in-
creased by an increase in frequency of firing units (temporal
summation) and by the addition of other units (quantal summation).
As more and more units are added and units fire at greater fre-
quencies, the action potentials from the various units merge to-
gether and' produce the typical electromyogram. At high force
levels, the interaction of both negatively and positively going ac-
tion potentials (the "interference pattern") leads to a leveling off
of the electromyogram so that the linear relationship between force
generated and EMG amplitude in isometric contraction no longer
Unit B provide rigorous procedures for studying orofacial muscle func-
Units A,B&C
I I
~~ ,
... ...•...
FIG 5-3.
A diagrammatic representation of the mechanism whereby tension
(dotted line) is increased in striated muscle, The upper three traces
(Units A, B, and C) represent the action potentials recorded sepa-
rately from three motor units of different thresholds with a needle
electrode in the muscle, At minimal tension, only Unit A fires (at far
left of trace). As activation increases to produce an increase in ten-
sion, Unit A fires at an increasing frequency (temporal summation)
and Unit B, and later Unit C, begin to fire (quantal summation). Units
Band C also demonstrate temporal summation. The bottom trace
illustrates how the three units would appear as usually seen in an
electromyogram recorded from the skin overlying these motor units,
holds. The electromyogram can be quantified by measuring either
the height of the action potentials or the frequency of the individual
action potentials. At high levels of activity, when action potential
spikes are superimposed, frequency counts become inaccurate.
Although electromyography can give useful information on
whether a muscle is active and define when the activity begins
and ends in the muscle fibers sampled, it is impossible to know
how much activity in the muscle is being missed. Movement cannot
be inferred from the electromyograph alone for reasons already
discussed: antagonistic muscles may be working synergistically to
control the movement or provide stabilization. Other instruments
monitoring force, pressure, or position must be used in conjuction
with the electromyograph to correlate muscle activity with effect.
The author of this text was one of the first to use the elec-
tromyogram in the study of the orofacial muscles,63 opening up a
field in which much work has been done and continues. Our
growing knowledge of the role of the orofacial muscles in posture
and movement, of reflexes regulating these muscles, and of muscle
pattern changes in dysfunction becomes increasingly useful to the
clinician. The study by Lowe and 'lohnston48 in which a high
correlation was shown beween early EMG activity in the genio-
glossus muscle and open bite is an example of clinical insights to
be gained from electromyography.
3. Behavioral
Whi1e the experimental methods of anatomy and physiology
tion, there are obvious limitations in applications to humans. Dis-
ciplined observation of behavior can be very useful; it is noninvasive
and examines total muscle activity in the natural state.
The acquisition of complex patterns of behavior may be looked
upon by analogy to a tree. According to the concepts of Windle, 100
discrete reflexes become aggregated into increasingly complicated
patterns of behavior. The branches and twigs are consolidated into
the trunk. An alternative concept is suggested by the development
of behavior in human fetuses, where gross behavior such as head
flexure or jaw opening precedes more discrete behavior such as
tongue and eyelid reflexes38 To the trunk of the tree are added
the branches and the twigs, Mastication can be visualized as a
consolidation of simple elements such as jaw opening, jaw closing,
ja-Y' translation, tongue protraction, and tongue retraction into a
more elaborate synergy according to the model of Windle. Other
behavior, such as swallowing, appears to emerge as a fully de-
veloped reflex to which other elements are aldded. As is often the
case, orofacial behavior cannot be forced into a single mold, and
may fit either concept or ,~ combination of both.
'. In all animals, it appears that some behavior is predetermined
and u~learned. Nest building of birtls is predetermined while sing-
ing is learned from birds of the same species. Life-sustaining
behavior such as ventilation and swallowing are usually considered
predetermined, yet the exclusive cortical control of respiration in
sea mammals and the early "respiratory" movements of the fetus
in utero suggest that ventilation may indeed be learned, The bolus-
propelling component of swallowing appears to be predetermined
while the anterior seal and stabilization components are learned.
 Maturation of the Orofacial Musculature 79

Those elements of behavior which are congenital are less easily

alteredt by training than are those which are learned during de-

;;;
velqpment or through life. Attempts to alter the bolus-propelling
components of swallowing by training will be unsuccessful whereas
the anterior seal and stabilization components can be changed by z
o
;
training as well as by altering the sensory feedback from the struc- ;;;
z
",II'Ii
~ I
.I.,,,
tures modified by orthodontic treatment (see Chapters IQ and 18).
..
..,.
Myofunctional therapy directed at the role of the tongue in bolus I • ,,
handling is likely to be unsuccessful. There are no adequately --- Total Tension
•...••.••.•..•••..
Active Tension ~ ,.' 'f
controlled, reliably measured clinical studies of success of such ._. Passive Tension .....
·1 ~
therapy. MUSClE LENGTH

C. BASIC CONCEPTS OF OROF ACIAL
NEUROMUSCULAR PHYSIOLOGY
1. Active and Passive Tension
~ When a muscle is stretched, the tension in that muscle in-
creases. This increase in tension may be the result of reflex con-
traction of the muscle. If the muscle contains sensory organs called
muscle spindles, the elongation of the spindle excites the spindle
afferents, which synapse on motor neurons innervating the gross
muscle (extnifusal fibers), resulting in their contraction. This is
the classic stretch reflex. The spindle afferents can be segregated
into at least two types (nuclear bag or primary and nuclear chain
or secondary endings) which are preferentially sensitive to a sudden
(phasic) stretch or a prolonged (tonic) stretch. Since all the man-
dibular levator muscles possess spindles,21 this mechanism can
occur with stretch of these muscles. This tension resulting from ~
contraction of muscle tissue is called active tension. In this example
it is the result of reflex activity, but can also be increased by willed
contraction of the muscles as in volitional clenching of the teeth.
Since the facial muscles possess I;lospindles,21 stretching of facial
muscles will not elicit a stretcfi" re"flex. Nevertheless, the tension .-
in these muscles will increase with elongation because of the elastic
properties of muscle and its investing tissues. Tension which results
from the physical properties alone of the tissue is called passive
tension.
FIG 5-4.
The relationship of tension to muscle length in innervated skeletal
muscle. Total tension which increases with length is the sum of active
and passive tensions. Active tension is due to the contraction of
muscle (stretch reflex in the example 'given in the text) while passive
tension is due to the viscoelastic properties of the muscle and its
investing tissues. Note that at short muscle lengths the tension is all
active while at long lengths it is all passive. Vertical dashed line is
optimal length of muscle for generation of maximal active tension.
For the innervated limb in Figure 5-4, the decline in active
tension with increasing muscle length is due to initiate inhibitory
reflexes suppressing the contraction brought about by excitation
of spindle afferents. In limb muscle, this inhibitory reflex may be
the result of excitation of Golgi tendon organs giving rise to the
inverse stretch reflex.
Many treatment procedures in orthodontics result in elonga-
tion of jaw and facial muscles. Expansion of the dental arches
stretches the cheeks or lips and increases tension in the buccinator
and orbicularis oris muscles. Increasing the occlusal vertical di-
1.0
oz
(f) •••.0.5
Z
I&l

~
In many muscles, elongation will result in an increase in both
active and passive tension. The sum of both tensions is appropri- LENGTH
ately called total tension. The curves for all three tensions, as the
length of the muscle is increased, is illustrated in Figure 5-4 for ACTI N

an innervated limb muscle. Below a specific length, all the tensions

are zero. As the muscle is stretched, the active tension increases.
In a muscle containing spindles, this has been attributed to the
stretch reflex. Initially, there is no passive tension, so that total
tension is equal to active tension. As the stretching increases, the
muscle begins to behave elastically: passive tension now begins
to add to total tension. As the muscle is elongated further, active
tension is inhibited while passive tension continues to increase.
On further stretching, active tension is suppressed as passive ten-
sion rises exponentially. At this length, total tension is the same
as passive tension.
The active tension curve may be due In part to the extent to
which the actin and myosin filaments overlap. The generation of
active tension falls off if the overlap is excessive or inadequate.
In Figure 5-5 this relationship between the degree of filament
overlap and tension development is depicted .
z
FIG 5-5.
Diagram to illustrate the'mechanism whereby maximal active tension
is generated at an optimal length, (vertical dashed line). The length
tension curve at the top of the figure is the same as the active tension
curve in Figure 5-4. At this length the active filament in the bottom
of the figure optimally overlaps the myosin filament within a sarco-
mere muscle segment between Z lines. If the muscle is lengthened
the active filament overlaps less of the myosin filament and force
generation is reduced. Ifthe muscle is shortened the active fiber can
be visualized as buckling so that the interface between the filaments
is unable to generate maximal tension. (From Elftman H: Biome-
chanics of muscle with particular application to studies of gait. J Bone
Joint Surg 1966; 48A:363-377. Used by permission.)

•
80 Growth and Development
mension in closed-bite malocclusions will stretch in the levator
muscles. Appliances such as bite planes and activators which in-
crease vertical dimension and/or advance the mandible increase
tensions in both levator and retractor muscles. Habits such as
mouth-breathing, which increase the postural vertical dimension,
increase tension in levator muscles, Surgical procedures which set
back or advance the mandible or impact the maxilla profoundly
affect muscle length and increase or decrease tensions in muscles
of the face, mandible, and the hyoid complex.
Why are treatment procedures which change muscle length
successful in some malocclusions and not in others? Why does
increasing vertical face height in faces with acute gonial angles
tend to cause relapse as does surgical advancement of the mandible
with a closing rotation? Why can contact and postural vertical
dimension be increased with impunity in growing patients but not
in adults? Are the length tension curves different for the levator
muscles in a Iong face compared with those in a short face? Tabary
and coworkers92 have shown that the passive tension curve of limb
muscle does not change following immobilization in a lengthened
position. Following immobilization in a shortened position, ex-
tensibility is decreased, that is, shortened muscles are less elastic.
Only a beginning has been made in characterizing the ac-
tive/passive tension curves for levator muscles in mammals. Ex-
ploratory work on the combined jaw levators in humans confirms
that the active tension rises then falls with increase in length as
with limb muscle, but no data on differences between subjects
with skeletal malrelationships have been reported. Since the stretch
reflex is attenuated or abolished in jaw muscles during sleep,
passive tension is the major motor force generated in these muscles
by functional appliances at night.
On a theoretical basis, it would seem reasonable to expect
that the contribution of active tension to total tension in facial
muscles would be different from that in jaw muscles since facial
muscles contain no spindles. Characterization of the active and
passive tension curves in lips and cheeks might be indicative of
the extent to which expansion could be used in treatment.
2. Simple Orofacial Reflexes
No attempt will be made here to review the basic physiology
of those reflexes which are arbitrarily designated as simple. Only
those aspects of clinical relevance will be discussed.
a) Facial Reflexes
Reference was made in the previous section to the question
of the extent to which passive and active tensions contribute to
the total tension exerted by the lips on the teeth. A perioral reflex,
which can be elicited by brief mechanical or electric~1 stimu'lation
of the lips, has been postulated as playing a role in voluntary lip
motor control in speech.53 This reflex is probably initiated from
cutaneous receptors in the lips. Sustained stretching produces no
reflex response,6' which is not surprising as there are no muscle
spindles in the orbicularis oris muscle.
In a study (M0ller, unpublished data) of upper and lower lip
postural activity and facial form, the only sig!1ificant correlation
was between lower lip EMG and lower face height. This reflex
activity is undoubtedly due to the mentalis muscle acting to effect
an anterior lip seal. Baril and Moyers' demonstrated that the men-
talis reflex is suppressed by contact of the lower lip with an acrylic
projection added to an oral shield at the level of the mandibular
alveolar process (see Fig 18-40). Reflexes of both the orbicularis
oris and the mentalis muscles appear to be largely determined by
excitation of cutaneous receptors.
b) Jaw Reflexes
Simple jaw reflexes can be conveniently divided into vertical
(jaw closing and opening) and horizontal (anteroposterior and lat-
eral) categories. Because of the occlusal consequences, the jaw
closing and lateral reflexes are particularly relevant to orthodontic
treatment. Although it has been known for a long time that re-
ceptors in and around the teeth protect the teeth from excessive
loading (negative feedback), it can be shown that the same recep-
tors may increase occlusal loading (positive feedback).49 EMG
studies 101 and occlusal force studies'o have shown that jaw position
determines whether the jaw closing reflex will be enhanced or
suppressed. Contact on anterior teeth alone suppresses biting force
while contact alone on posterior teeth increases biting force. Con-
tact of teeth on the balancing (nonworking) side suppresses biting
force while contact on the working side enhances biting force. The
forces are attenuated on the side (or sides) where condylar trans-
lation occurs (i.e., heavy biting force is avoided when the joint
has to be stabilized by muscle activity). These jaw position de-
terminants of closing forces have been suggested as a rationale for
cuspid-guided or mutually protected occlusal schemes: the forces
on the "guiding" or "protecting" teeth are less if in the anterior
rather than posterior segments. Williamson and Lundqvist98 have
shown that anterior guidance which discludes posterior teeth sup-
presses levator contractions.
Mechanical stimulation of orofacial as well as other body
sites leads briefly to a cessation of ongoing muscle activity in jaw
levators as well as depressors."" 101 If the stimulus is non-noxious,
the duration of this silent period is about 20 msec. If the stimulus
is painful, the duration is prolonged. Patients suffering from or-
ofacial pain frequently have prolonged silent periods but these
silent periods are not unique to one pain syndrome.'2 The prolonged
silent period may be indicative of a depressed pain threshold.
Useful insight into lateral jaw reflexes comes from studies in
which occlusal interferences are removed from or artificially in-
troduced into the occlusal scheme. When an occlusal interference
is incorporated into the dentition so that it occurs on the working
side, reflex responses to the interference rarely occur."' Closure
from initial contact on the working side during chewing is usually
passively or nonreflexly guided by the tooth inclines. That is, the
occlusal guidance is passive (see Fig 5-6,A). On the other hand,
when a balancing occlusal interference is incorporated into the
demi.tion, nearly half of the closures are actively or reflexly guided
into loll intercuspation. On initial, contact of the balancing inter-
ference, the levator muscles fall silent briefly (silent period), then
asymmetrically contract to shift the mandible laterally to avoid the
interference. That is, the occlusal guidance is active (see Fig 5-
6,B). This lateral reflex initially is unlearned or unconditioned.
Following multiple contacts on the interference, the offending
contact may be avoided through conditioning (Fig 5-6,C). When
the lateral shift on closure from retruded contact position into
intercuspal position is small it is sometimes referred to asa "slide
in centric"; when larger, as a functional posterior crossbite. Some-

A PASSIVE GUIDANCE B ACTIVE GUIDANCE C ACTIVE
a) unconditioned b) conditioned
FIG 5-6.
Occlusal guidances may be active or passive. A, a working side
contact between opposing buccal cusps elicits no reflex response
(straight arrow). The closure to intercuspal position is along cuspal
inclines. B, a balancing side contact elicits a reflex response (zig-
zag arrow). On initial contact muscle activity ceases (silent period)
followed by a lateral jaw reflex avoiding further cuspal contact on
closure into intercuspal position. C, in time the balancing contact may
become avoided on closure into intercuspal position. (From Storey
AT: The neurobiology of occlusion, in Johnston LE Jr (ed): New Vistas
in Orthodontics, Philadelphia, Lea & Febiger, 1985.
permission.)
times the conditioning seems to affect the postural position, since
the path of closure from postural position to intercuspal position
may demonstrate no lateral deviation. Examples of EMG studies
before and after occlusal equilibration are shown in Figures 18-
66 and 18-67, where procedures for equilibrating functional cross-
bites in the primary and early mixed dentition are also discussed.
Lateral jaw reflexes may lead to skeletal asymmetries in the grow-
ing child or to temporomandibular disorders in susceptible patients.
c) Tongue Reflexes
Of the simple tongue reflexes, that of most significance to
orthodontic diagnosis and treatment is tongue posture. Reflex con-
trol of tongue posture is essential for maintenance of the pharyngeal
airway and plays an important role in the position of the teeth. It
is not surprising that the demands of the airway may reflexly alter
tongue po:>ture and consequently tooth positions.
The base of the tongue forms the anterior wall of the pharynx
which serves as the portal for both the alimentary tra):t and the
airway (see Section A-3). Maintenance of the pharyngeal airway
demands that the tongue base not be allowed to intrude into this
airway. This vital function is performed by the genioglossus mus-
cle. EMG studies of this muscle show a small activity in synchrony
with respiration. The genioglossus reflex may be initiated by a
large tongue or large tonsils or it may also be initiated by jaw
opening.48 Sustained jaw opening, as in mouth-breathing, leads to
sustained tongue protraction. Such forward posturing of the tongue
may force incisor teeth labially or prevent eruption of mandibular
incisors if the tongue rests over the incisal edges. Large tongues
may spill over the buccal teeth, preventing their eruption, and may
produce a posterior open bite or a deep overbite.
3. Complex Orofacial Reflexes
a) Mastication
There is little evidence to indicate that the extent of chewing
Maturation of the Orofacial Musculature 81
GUIDANCE has a significant effect on digestion in the human. Studies have
shown that masticatory efficiency makes little difference to the
degree of digestion except for poorly digestible foods such as fried
meat and legumes. 26 What appears of significance to orthodontic
treatment are the magnitude and direction of the occlusal forces
in mastication and the extent to which these forces contribute to
tooth movement or tooth stability .. That the teeth make contact
during chewing has been unequivocally proven21 even though claims
to the contrary still appear in the dental literature.
Position of the teeth is thought to be determined by forces of
occlusion as well as lip or tongue pressures and eruption.72 Since
the teeth are apart most of the time and yet possess the capability
of eruption through life, occlusal contacts, intermittent though they
are, must account for the vertical stability of tooth position. Con-
tinuing vertical movement of a tooth ("passive eruption") follow-
ing loss of antagonists is a clinical observation supporting this
hypothesis. Use of a functional appliance or a maxillary appliance
with a flat anterior bite plane to permit eruption of posterior teeth
offers further validation.
Used by One may ask whether masticatory occlusal forces can move
teeth. If so, orthodontic treatment need only approximate the cor-
rect position of a cusp in a fossa and occlusal forces will' cause
the teeth to settle into the best occlusal relationship possible. The
few experimental studies in animals and man fail to answer this
question because the forces are either interrupted' continuous forces
or have a significant continuous component. 89 Unpublished studies
by the writer of this chapter and coinvestigators in Bern, Switz-
erland, suggest that if the occlusal force on the tooth with an
occlusal interference does not elicit either a lateral jaw refleX or
suppression of the jaw-closing reflex, the intermittent forces of
mastication and swallowing will cause the tooth to move if there
are no constraints on that tooth's ability to move. If the occlusal
force is such that simple jaw reflexes are evoked, the interfering
tooth is avoided and tooth movement does not occur. Since teeth
normally are stable, masticatory occlusal forces ordinarily do not
move teeth, but in some parafunctions, such as bruxism, occlusal
forces may produce tooth mobility and movement. The question
why the protective simple jaw reflexes are inactive in parafunctions
is a tantalizing one.
b) Bruxism
Tooth clenching and grinding (bruxism) are usually consid-
ered parafunctions of the adult and are thought to result from
physiological stress with or without occlusal interferences. Brux-
ism, however, is also found in children and has alleged associations
with allergies, asthma, ")digestive upsets," "nervousness," and
other conditipns (see Chapters 7 and 10). Its signs and symptoms
ci;ln be artificially induced by sustained tooth clenching. 15 While
the"pain is initially of muscle origin, the hyperactivity responsible
for the pain may have a variety of etiologies.21 Genetic factors
have been shown to be important in the genesis and pattern of
bruxism in children46 (see Chapter 6). The relationships, if any,
between bruxism in childhood and later life are not known, nor
are longitudinal studies available.
c) Swallowing
As in the case of mastication, the features of swallowing of
82 Growth and Development

TABLE 5-2.
Requirements of Swallowing
Pressure Gradient Genioglossus

ongue piS on ac Ion Facial muscles

Stab,ilzatton of tongue base L eva tor musc Ies
T . t l' {MUSCles in floor of mouth
Pharyngeal constrictors: stripping action Orbicularis Oris
Esophagus: peristalsis
Prevention of Reflux

Anterior oral seal Incisors Temporalis

fLipS
l Tongue
Tongue palate apposition
Hypopharyngeal sphincter
Masseter
Gastroesophageal sphincter
Protection of Airway
Palate/Pharyngeal wall opposition
Elevation of larynx Mylohyoid
Adduction 'of vocal folds
Apnea
Geniohyoid

most significance to orthodontic treatment are the role of occlusal

and tongue forces in establishing tooth position. Occlusal forces Posterior Tongue

in swallowing have received less attention than those in mastication

but appear to be of the same magnitude as those in chewing2. 30
Palatopharyngeus.
(The implications for tooth position are the same as in chewing.)
As seen in Table 5-1, swallowing is both an alimentary and
a protective reflex. It can be initiated reflexly by mechanical stim-
Superior Constrictor
ulation by a bolus in the pharynx and by chemical stimulation. by
water in the larynx. The swallow evoked in the larynx also protects FIG 5-7.
the airway against further penetration. Abnormalities of swallow- Schematic summary of electromyographic activity in obligate (dark
ing can be differentiated into vagaries of either the alimentary or silhouettes) and facultative (stippled silhouettes) muscles during
airway reflex. Because swallowing serves an airway protective swallowing. The obligate muscles participate rigidly in the synergy
whereas the facultative muscles' participation is variable. Classifi-
role, it is not surprising that it is rigorously programmed.
cation of the genioglossus muscle (open silhouette) has yet to be
There are three essential features of swallowing (Table 5-2):
determined. (From Dubner R, Sessle BJ, Storey AT: The Neural
(I) establishment of a pressure gradient, (2) prevention of reflux, Basis of Oral and Facial Function. New York, Plenum Press, 1978.
and (3) protection of the airway. The muscles responsible for these Used by permission.)
essential features are characterized by an al!-or-none participation
and rigid sequencing of contractions insensitive to feedback-the bring the teeth together in swallowing. When teeth are absent or
obligate muscles. 2\ Once the swallow has begun, all the muscles
create occlusal disharmonies in intercuspation, the facial muscles
participate in their stereotyped way (see Fig 10-15). ' will stabilize the mandible.63 (See Chapter 10 for the clinical sig-
In contrast to the obligate muscles of swallowing are muscles nifjcance of these variants of swallowing.) While the obligate
which participate more loosely in the synergy-the facultative muscles are programmed prior to birth and incapable of condi-
muscles (see Fig 10-15). Facultative muscles serve the function
tioning, the facultative muscles adapt to naturally occurring stimuli
of stabilizing the tongue base and establishing an anterior oral seal.
(e.g., bolus consistency, occlusal interferences) and to training
They mayor may not participate in swallowing, and if they do
procedures.
so, may participate in varying degrees. They are very sensitive to
The action pattern of..the genioglossus, the protractor of the
feedback, especially from the teeth. The extent to which the fa-
ton~u.~, is left unfilled in Figure 5-7 because it is not yet clear
cultative muscles participate depends on the need for stabilization
whether it is obligate or facultative: It may even vary from patient
of the tongue base and the adequacy of lips and teeth to effect an
to patient. Should the muscle be obligate, training programs to
anterior oral seal. When one is swallowing liquids or saliva, the
correct tongue-thrust swallows would not be indicated; should the
tongue requires less stabilization than when one is swallowing
muscle be facultative, the rationale for tongue training to correct
solid boluses; there may be little or no contraction of facial and
a tongue-thrust would seem more logical (but see Section C-4).
mandibular levator muscles.
When one is swallowing a solid bolus, stabilization of the d) Gagging
mandible as well as the tongue base may be required. When teeth Gagging is a reflex initiated from the oropharynx and may
are present and in acceptable occlusion, the levator muscles will be regarded as protective of either the upper alimentary tract or

the airway. The afferent arm of the reflex is not exclusively in .the
glossopharyngeal nerve4: the trigeminal nerve would appear also
be to involved in troublesome gaggers. The reflexogenic sites (e.g.,
faucial pillars, base of tongue, soft palate, and posterior pharyngeal
wall) are normally in contact with each other .ilnd the food bolus
but do not give rise to gagging under these conditions. An expla-
nation for this refractoriness might suggest new strategies for
suppression of gagging. Since central vagal stimulation has been
shown to suppress pharyngeal motor activity in dogs thought to
be gagging,13 maneuvers increasing central vagal discharge, for
example, holding the breath in deep inspiration, might be expected
to suppress gagging during the taking of dental impres·sions. Gag-
ging is readily conditioned: a previously neutral stimulus, such as
the sight of a loaded dental impression tray approaching the mouth,
can lead to gagging in the problem gagger.
e) Speech
Speech problems which may be improved by orthodontics are
those of faulty articulation. The articulatory valves most likely to
be drawn to the attention of the dentist for correction are the
velopharyngeal valve and the labiodental, linguodental, and lin-
guoalveolar valves.
Velopharyngeal incompetence may be due to absence of struc-
ture (e.g., cleft palate), disproportion of structure (e.g., short
palate, deep nasopharynx, short functional palate), or neurologic
defects (e.g., muscle or central nervous system) (see Fig 5-8).
SHORT SOFT PALATE
~
.0 .•
~.'t-
t'"
i~••"
.;Co
NEUROMUSCULAR DEFICITS
FIG 5-8.
Velopharyngeal incompetency may be due to structural or functional
deficiencies. The soft palate may be short (A) or the pharynx deep
(8). Valving may also be jeopardized by varying degrees of muscle
dysfunction (C and D). (From Warren DW: Aerodynamic studies of
upper airway: Implications for growth, breathing, and speech, in
Maturation of the Orofacial Musculature 83
The velopharyngeal valve not only closes to protect the nasal
passages from bolus entry during swallowing but also during all
voiced sounds in the English language except for rn, nand ng.
With velopharyngeal incompetence, speech is hypemasal. Treat-
ment of velopharyngeal incompetence may involve the dentist
along with the plastic surgeon and speech therapist. The dentist
may be required to construct a speech bulb (in case of cleft palate,
short palate) or palatal lift appliance (in cases of neuromuscular
defect). In patients with short palates, tonsillectomy and ade-
noidectomy should be avoided if at all possible to minimize the
risk of velopharyngeal incompetence.
The articulatory valves involving dental and alveolar struc-
tures represent about one-third of the articulations in the English
language. These are the labiodentals f
and v, the linguodental th
(both voiced and unvoiced), and the linguoalveolar sounds t, d,
s, sh, and I. Dentists may be requested by speech therapists to
treat malposed teeth or provide replacements for missing teeth in
order to improve articulation. While this may be helpful, especially
during the years when speaking skills are being learned, Travis
has pointed out that "abnormalities of orofacial structures cannot
of themselves along be considered as prime causes of defective
articulation. "94 There is evidence of considerable adaptability in
the use of the lips and tongue in compensating for dental malfor-
mations. For example, a subject with missing maxillary incisors
f
may articulate the sound using upper lip and mandibular incisors
instead of the usual apposition of the lower lip and maxillary
DEEP PHARYNX
'IlL..
.,
SHORT FUNCTIONAL PALATE
McNamara JA Jr (ed): Naso-respiratory Function and Craniofacial
Growth, monograph 9. Craniofacial Growth Series. Ann Arbor, Mich-
igan, Center for Human Growth and Development, University of Mich-
igan, 1979. Used by permission.)
84 Growth and Development

incisors. While certain skeletal malocclusions are more likely to TABLE 5-3.
impair speech, it is not inevitable: one micrognathic may be un- Learning Sequence for Avoidance of a Balancing-Side Occlusal
Interference
intelligible, another may be a radio announcer. While lisping is
CONDITIONED UNCONDITIONED UNCONDITIONED CONDITIONED
often associated with tongue-thrust swallowing, Fletcher et al. 27 STIMULUS (CS) STIMULUS (US) RESPONSE (UR) RESPONSE (CR)
found it in only one-third of their sample of abnormal swallowers
Balancing Mandibular
aged 6 to 18 years. As with tongue-thrusting, sibilant distortion interference ---? deviation
spontaneously improves with age. Position of Mandibular
+ Balancing
mandible interference ---? deviation
Position of Mandibular
4. Learned and Unlearned Reflexes mandible ------------- .....••.
deviation
In previous sections, examples have been given .of learned
and unlearned reflexes of the orofacial region. Swallowing, en-
compassing the obligate muscles, is an unlearned reflex. The basis The reflex responses elicited by occlusal interferences were
for ~o designating the reflex is as follows: discussed earlier in this section. When the threshold for a reflex
altering jaw movement was not exceeded, closure into full inter-
a) The reflex is fully functional early in fetal life. cuspation was guided by the inclines of the teeth (and the con-
r
b) The muscles are insensitive to feedback. straints of the joints). When the threshold for reflexes altering jaw
c) The 'reflex is all-or-none. movement was exceeded, an unconditioned reflex was initiated
avoiding the occlusal interference. In time, the occlusal interfer-
Since the reflex necessitates a precise regulation of a number ence may be avoided through conditioning (see Fig 5-6C). Avoid-
of muscles, it must be programmed in a rigid sequence. It is not ance of the interference will be "reinforced" by sporadic contact
surprising that the reflex is unlearned. On the other hand, the on the interference. Elimination of the interference by grinding or
facultative muscles, which play a role in forming an anterior oral tooth movement will "extinguish" the active guidance. This se-
seal and stabilizing the tongue base, are more varied in their par- quence of events is summarized in Table 5-3.
ticipation. They also contribute to jaw stabilization prior to eruption A balancing-side interference (US) gives rise to mandibular
of the teeth. This portion of the reflex can be said to be learned. deviation (UR), an unlearned reflex. Mandibular position near
Anterior open bites, short upper lips, and marked overjets can lead tooth contact, probably detected by mandibular joint and/or mus-
to varying learned or conditioned muscle responses. cle receptors (CS), coupled with balancing-side contact (US),
The genioglossus reflex, which protects the pharyngeal air- results in continued mandibular deviation. Eventually, mandibular
way from obstruction, would be expected to fit into the classifi- position near tooth contact (CS) gives rise to mandibular deviation
cation of unlearned reflexes. Posture of the tongue, as has been (CR) without striking the occlusal interference.
pointed out earlier, is tightly tied to posture of the mandible. Jaw Gagging at the sight or smell of the loaded impression tray
opening (a change in posture) initiates tongue protrusion through is another example of conditioning. In this case, the unconditioned
excitation of temporomandibular jaw receptors. Local anesthetic stimulus is excitation of oropharyngeal receptors in the mucosa.
injected into the joint capsules bilaterally in the cat and monkey Visual or olfactory stimuli, on repeated association with the un-
abolishes the genioglossus reflex.4? Since the reflex is much more conditioned stimuli, give rise on their own to conditioned gagging.
active in subjects with relatively large tongues, it may be that the Extinguishing this reflex by the principle of disassociation suggests
jaw-opening reflex is unlearned and that tongue protrusion is learned. strategies for control alternative to those cited earlier. Disassocia-
If this is so, tongue posturing should be amenable to conditioning. tion strategies might include the use of topical anesthetics.
Current treatment with this objective includes the use of cribs and
myofunctional therapy (see Chapter 18). '
Cribs and myofunctional therapy, in the past, have been pri- D. REFLEX DETERMINANTS OF
marily directed at tongue-thrusting and swallowing. Since swal- MANDIBULAR REGISTRATION POSITIONS
lowing occurs, on average, 600 times per day44 (higher frequencies
An active (i.e., reflex) muscle contribution in the determi-
are extrapolations and erroneous), and the oropharyngeal duration
of swallowing is about I second, tongue-thrusting forces act for nation of the three major registration positions of the mandible has
only 10 minutes per day. It is highly unlikely that forces of this been asserted by some and denied by others. The extent to which
duration, irrespective of magnitude, will move teeth. Therapy di- pos.tural position, intercuspal position, and retruded contact po-
rected at posture is now receiving"greater emphasis?O and has a sitioIi;.are actively or pa;sively determined affects their reliability
better rationale. Treatment directed at changing tongue posture as registration positions.'
should not be undertaken, however, without consideration of the
reason for the abnormal posture. Treatment should take into con- 1. Postural Position
sideration the cause of the abnormal posture and not aggravate the
conditions giving rise to the reflex response. (See also Chapters Postural position is used in orthodontics in diagnosis and in
10 and 18). taking the bite for functional appliances. Postural position may be

FREEW AY SPACE
AFTER AFTER
CONTROL
No THIOPENTAL SUCCINYl CHOLINE
FIG 5-9.
Mean freeway space in a sample of 27 healthy subjects measured
with Frankfort plane horizontal prior to and after intravenous injection
of an anesthetic dose of sodium thiopental and a paralytic dose of
succinyl choline. Vertical lines indicate one standard deviation. The
increases in freeway in the two test procedures compared to the
control are highly significant. Freeway space is unequivocally.de-
termined by reflex mechanisms.
used in the differential diagnosis of functional malocclusions from
dental/skeletal malocclusions. Deviations in the path of closure
from postural position to intercuspal position are useful in diag-
nosing retrusively occluded mandibles (see Chapters 10 and 15).
Postural position is also used in the differential diagnosis of deep-
bite cases: the freeway space will be larger than normal in cases
with inadequate vertical development of the buccal segments and
normal in cases of over-eruption of the incisor teeth. The extent
to which a bite for a functional appliance is taken ahead of and
beyond postural position depends on the rationale for the therapy
(see Chapters 15 and 18).
Since all the registration positions are three-dimensional, the
question as to whether determination is active or passive must be
asked in the vertical, anteroposterior, and mediolateral directions.
Arguments are still advanced for the passive, vertical determination
of postural position. The presence of electrical adivity in the
levator and depressor muscles of the mandible in posutral position
has been attributed to experimental artifact. Irrefutable evidence
that the vertical component of postural position is actively deter-
mined comes from studies in which freeway space is measured
under general anesthetic and neuromuscular blockade. In one such
study,20 freeway space was measured on two separate occasions
in relaxed, awake subjects sitting upright with the Frankfurt plane
horizontal. The mean freeway space in 27 cases was 2.3 mm.
Following anesthesia with intravenous sodium thiopental, the mean
freeway space increased to 8.6 mm and to 10.2 mm on the addition
of a paralytic dose of succinyl choline-chloride. These data are
illustrated in Figure 5-9. Although there is no doubt that the
vertical component of postural position is reflexly determined, the
contributory muscles and reflexes have yet to be specified.
In subjects with normal occlusions, postural position is on
the opening-closing path of the mandible below the intercuspal
position in the same sagittal and transverse planes (Fig 5-10). It
Maturation of the Or(jfacial Musculature 85
is not clear whether the normal anteroposterior and mediolateral
location of the postural position is actively or passively determined.
Malocclusions can effect an anterior or lateral displacement of
postural position. Children with Class 11 mal occlusions due to a
deficient mandible have been observed to posture the mandible
forward. Ingervall,39 in a series of studies in children, found the
mean anteroposterior difference between the postural position and
the intercuspal position to be 1.37 mm and 0.83 mm in Angle
Class 11, Division I and Division 2 cases, respectively. The mean
position of postural position in Class 11cases compared with Class
I occlusions is illustrated in Figure 5-10. It is obvious that postural
position in Class 11 malocclusions is actively positioned forward
of the expected position. This anterior positioning in postural po-
sition has been termed a "Sunday bite." It would be more ap-
propriate to call it a "Sunday posture. " Teleologic thinking attributes
it to a conscious attempt on the part of the patient to improve his
or her profile. Since the child never or rarely sees his or her profile,
it is more likely a reflex regulation, perhaps to maintain an adequate
airway. Children with Class 11 malocclusion, on closure into in-
tercuspal position from postural position, therefore translate the
mandible dorsally. Postural position may also be displaced in a
mediolateral direction (as in the case of functional posterior cross-
bites) to the side of the crossbite. In order to diagnose a "functional
crossbite," it is necessary to observe the closure pattern from
postural position or from retruded contact position (see Chapters
8 and 10). Closure from postural position to intercuspal position
will show no lateral deviation in skeletal crossbites.
Since postural position is clearly determined by muscular
contraction, it becomes important to specify the reflexes account-
ing for that muscle contraction in order to identify the active
reflexes and manipulate them when appropriate. The usual reflex
®
NORMAL
CLASS 11,div.l.
,&
CLASS 11,div.2.··
FIG 5-10.
Mean position of postur5!1 in the mid sagittal plane of children with
eli-l~S 11malocclusions projected onto the border envelope of motion
of the mandible for both division l' and 2 types. The uppermost circle
represents intercuspal position. The solid line circle with dot repre-
sents retruded contact position in the division 1 sample of 32 children
and the broken line circle with dot retruded contact position in the
division 2 sample of 22 children. The square with cross represents
the mean position in a Class I sample referenced to an intercuspal
position common with both Class 1Isamples. Postural position is 1.37
mm ahead of intercuspal position in the division 1 sample and 0.83
ahead in the division 2 sample. (From Ingervall B: Studies of man-
dibular positions in children. Odontol Rev 1968; 19(suppl 15):1-53.
Used by permission.)
86 Growth and Development
cited as the basis for postural position of the mandible is the tonic
stretch reflex of the mandibular levators (i.e., the myotatic reflex).
(The original designation was myostatic reflex but a perpetuated
typographic error dictates the present spelling.) Since the stretch
reflex and its gamma biasing mechanisms are taught in all phys-
iology courses, the spindle mechanism will not be discussed here.
Because the levator muscles of the mandible are richly supplied
with muscle spindles and since the monosynaptic reflex arc has
been demonstrated both anatomically and physiologically, there
seems little doubt that the tonic stretch reflex plays a role in postural
position. Although one of the earliest concepts of spindle function
was that of a length-sensitive, negative feedback system returning
the muscle to its original length (in the case of the mandible, to
its original position), other roles have been postulated for the
spindle. These include an error detector role in identifying mis-
matches between execution of a movement and the central com-
mand for the movement and a load-compensator role whereby the
gain on the contracting muscle is increased in order to execute the
motor task when the load is increased.21
One problem with the concept of the muscle spindle as a
position receptor is the extent to which it can be biased by the
gamma efferents (the motor nerves innervating the intrafusal mus-
cle of the spindle) and thereby change the sensitivity of the re-
ceptor. The gamma efferent system can be likened to a child
changing the sensitivity of a bathroom scale unknown to the parent
being weighed. Although the spindles would appear to be unlikely
candidates for monitoring jaw position, psychophysical experi-
ments clearly implicate them in that function (Morimot059). Re-
ceptors in the temporomandible joint are also well suited for
monitoring position of the mandible (Kawamura and Abe43). A
number of investigators have recorded from tonically firing, po-
sition-sensitive units in the temporomandibular joints of experi-
mental animals. These receptors probably serve as the unconditioned
stimulus for reflexes initiated in the joint and as a conditioned
stimulus for reflexes initiated elsewhere. An example of tempo-
romandibular joint determination of mandibular position is seen.
in patients in which the mandible is postured away from a painful
joint.
Postural position of the mandible is also determined by the
A Benavioral stale
AlerT
Orowsy
DU,iet Sleep
AClM: sleep .
B MasseteriC reflex
100-
'/075-
50-
1.5-
0-
120 observations/min f' ~
FIG 5-11.
The effects of states of wakefulness on the stretch reflex of the jaw.
Behavioral state was assessed from the electroencephalogram and
the masseteric reflex from the electromyogram in eight cats. Note
the extent to which the amplitude of the stretch reflex is dependent
on the state of wakefulness. When the cat is fully awake the reflex
appears without attenuation. When in active sleep (rapid eye move-
ment) the reflex is completely abolished. (From Chase MH, McGinty
OJ, Sterman MB: Cyclic variation in the amplitude of a brain stem
reflex during sleep and wakefulness. Experimentia 1968;
24(specialia):47-48. Used by permission.)
-..
5 10 min
o
2
mm
B
o 5 10 min
mm
FIG 5-12
The effects of affective state or emotion on postural position. Freeway
space was recorded with an intraoral electromechanical device in a
subject watching a suspense film in (A) and a ballet in (B) for 15
minutes. Note the smaller freeway and frequent tooth contacts While
watching the film with more emotional content. 0on the vertical scale
represents intercuspal position. (From Schwindling R, Stark, W:
Physiology of mandibular positions. Front Oral Physio/1974; 1:199-
237. Used by permission.)
demands for a patent upper airway. Where nasal breathing is im-
possible and the patient is forced to breathe through the mouth,
the posture of the mandible changes along with posture of the
tongue and hyoid complex. Where the pharyngeal tonsils are en-
larged so that the pharyngeal airway is partially obstructed, the
postures of the mandible, the tongue, and the hyoid complex are
reflexly repositioned to establish an adequate airway. Although
the initial reflex is probably the result of stimulation of receptors
monitoring adequacy of ventilation (e.g., peripheral and c.entral
chemoreceptors), the reflexes may become conditioned so that
receptors monitoring the position of the mandible, tongue, and
hyoid ·complex assume the regulatory role.
, Experimental studies demonstrating the effects of general an-
esthetic on postural position of the mandible demonstrate the im-
portant effects of the state of wakefulness on the reflex control of
postural position. Chase and.coworkersl4 have shown that the mas-
seteric reflex in the cat parallels perfectly the state of wakefulness
as fPo.nitored by the electroencephalogram. In Figure 5-11 is il-
lustrated the lively nature of the n;flex when the animal is fully
awake and its complete absence when the animal is in deep sleep.
This means the control of postural position of the mandible, tongue,
and hyoid complex must be under different reflex control when
the subject is sleeping than when the subject is awake. The myotatic
reflex cannot be responsible for postural position of the mandible
in the sleeping state. Not only is the postural position of the
mandible under dramatic control by the reticular formation of the
brain but also by the limbic brain which is the seat of the emotions. 9
Figure 5-12 illustrates changes in postural position as a result of
emotional state.

TABLE 5-4 ..
Determinants of Postural Position
PAS'SIVE ACTIVE
Inactive levator muscles Stretch reflex of levator
muscles -
Negative intraoral pressure Temporomandibular joint
reflexes
Airway supportive reflexes
The hypothesized and experimentally verified determinants
of postural position are summarized in Table 5-4. The postulated
passive determinants (left column) have been invalidated.
2. Intercuspal Position (Usual Occlusal Position, Centric
Occlusion)
The' intercuspal registration position is used for the classifi-
cation of mal occlusions according to Angle. It is the position in
which the relationships of the teeth are described prior to and after
orthodontic treatment. Since the intercuspal position can usually
be identified in hand-articulated casts, the natural assumption is
that the position is passively determined by occlusal anatomy and
positions of the teeth. In some cases such as extreme skeletal open
bites and unilateral hyperplasia of one condyle, the temporoman-
dibular joints may function as a passive determinant. lntercuspal
position may be actively determined in functional mal occlusions
such as crossbites (both posterior and anterior) and dual bites (cases
in which intercuspal position is more than an arbitrary 3 mm ahead
of retruded contact position) and in cases with steep incisal guid-
ance where lingually inclined incisors may reflexly cause retraction
of the mandible on closure into full intercuspation. When the
intercuspal position is actively determined, its use in diagnosis
alone can lead to errors. For example, a patient with a pseudo
Class III malocclusion might be misdiagnosed as having a skeletal
Class III malocclusion.
Active guidance may be initiated from the dentition, from the
temporomandibular joints, and from receptors monitoring ade-
quacy of the pharyngeal airway. The conditions under which oc-
clusal factors initiate active guidance were discussed in Section
C-2 (see Fig 5-6). Some of the determining factors are as fol-
lows.89,90 The magnitude of the occlusal force is an obvious de-
terminant. A strong force is more likely to elicit a response than
a weak one. The speed of closing may be a variable. The direction
of the force is likely to play a role based on the known greater
sensitivity of the receptors around the teeth to forces applied at
right angles to the crown rather than along the long axis. Direction
of the force will be affected by the closing patterns and anatomy
and arrangement of the teeth. Since the loading of teeth is more
axial on the working side and more likely to be tangential on the
balancing side, the direction of force favors feedback from bal-
ancing interferences. The threshold of the receptors surrounding
the teeth will also determine whether feedback will occur. Recep-
tors in inflamed tissues are much more sensitive than those in
normal tissues. The frequency and duration of occlusal contacts
will determine whether feedback occurs immediately or is delayed.
Avoidance of occlusal interferences may be delayed for several
days. The discharges from the receptors are ignored for a period
Maturation of the Orofacial Musculature 87
of time ("habituation") if the forces are not immediately threat-
ening to the integrity of the supporting tissues. Perhaps repeated
trauma to the tooth results in periodontal inflammation, lowering
of the receptor threshold, and then avoidance of the interference.
The extent of root development would also appear to be a
factor. The tactile thresholds of maxillary incisor teeth are signif-
icantly lower in incisors with incompletely formed roots compared
to those with fully formed roots. 33
Occlusal feedback may be affected by the position of the
mandible. The jaw-jerk reflex is abolished on the working side
while enhanced in the muscles on the balancing side.29 Feedback
from the levator muscles is suppressed on the working side but
facilitated on the balancing side. This also holds for feedback from
the dentition. Axial forces are increased on the working side but
decreased on the balancing side foIlowing an artificial increase in
mandibular first molar crown height. 30 Levator muscle activity is
increased on the working side and decreased on the balancing side
with4 or without98 premature tooth contact. Other studies have
demonstrated that mandibular levator activity is increased when
occlusal forces are borne only by the posterior teeth and decreased
when they are borne exclusively by the anterior teeth.99 These
studies demonstrate that occlusal feedback is also determined by
the segment of the dental arch bearing the occlusal load. Computer
modeling of jaw mechanics by Smith87 suggests that the muscle
forces and vectors are determined by a prerequisite for minimal
loading of the temporomandibular joints.
There are numerous possibilities for active guidance to be
enhanced by central effects originating in various parts of the
brain. 21, 89 Those parts of the brain associated with state of wake-
fulness, with pain modulation, and with affective state or emotion
are known to exert powerful effects along with basal ganglia and
cerebral cortex. It may weIl be that these central effects override
the other determinants of active guidance in dysfunctional or par-
afunctional states.
The intercuspal position may be also reflexly determined as
a result of reflexes arising in the temporomandibular joint. Nor-
mally the best intercuspation of the teeth dictates the positions of
the joints. However, in cases of inflammation within the joint the
hierarchy may be reversed: the joints may dictate intercuspal po-
sition. An example of such a condition would be that in which a
joint had been traumatized, for example as a consequence of dis-
location and damage to the capsule and ligaments during a difficult
'extraction. The resultant inflammation lowers the threshold of
receptors in the capsule of the joint and initiates protective reflexes
guarding against further damage to the j~ints. As discussed in the
previous section, postural position under these circumstances is
also altered. In cases in which the pharyngeal airway is jeopard-
jz~d, for example, by.enlarged pharyngeal tonsils, the intercuspal
position may be affected as well, as the postural position. Ricketts78
has documented cases in which Class I occlusions have reverted
in Class 11, Division 1, mal occlusions subsequent to the removal
of pharyngeal tonsils.
Reflexes responsible for active guidance are essential for pro-
tection of the teeth, the temporomandibular joints, and the airway.
These reflexes guard against trauma to the teeth or joint and assure
an adequate airway. Since this additional reflex burden diminishes
motor efficiency and may lead to altered posture and subsequent
abnormal development of the jaws in the growing child, the goal
88 Growth and Development

TABLE 5-5. I Posselt, 1968

ngervall., 1952 GOTHIC ARCH NEEDLE Fa I NT

Determinants of Intercuspal Position & Jacoby, 1961

~, ;A" ~'
PASSIVE ACTIVE

Boucher
Anatomy of teeth Occlusal reflexes
Position of teeth Temporomanditiular joint
reflexes
Anatomy of temporomandibular Airway supportive reflexes
joints

of all occlusal therapy, including orthodontic treatment, should

be to eliminate perpetual reflex guidances. This is the basis for
'I'.
the early treatment of all functional malocclusions. The passive ~
and active determinants of intercuspal position are outlined in /PANTOGR:(
Table 5-5.
McMillen, 1972
There are semantic problems with the use ot the term centric
occlusion, sometimes used as a synonymous term for intercuspal concious
position. For, some clinicians centric occlusion is the same as anaesthetized and nm. block

intercuspal position; for others, it is the same as centric relation

occlusion (the tooth contact position when the mandible is centric
relation).
3. Retruded Contact Position
The retruded contact position, like the postural position, is
used in the diagnosis of functional malocclusions and dual bites.
The mandible is manipulated into retruded contact position and
the patient is asked to close into the intercuspal position. Excessive
slides in either the mediolateral or anteroposterior direction are
cause for concern. A small anteroposterior separation between the
retruded contact position and usual occlusal position is normal.
Some clinicians consider coincidence of these positions desirable
in the adult. Ingervall reported that in children with Class I oc-
clusions anteroposterior distance between retruded contact position
and intercuspal position is 0.85 mm39 (Table 5-6). In Class 11
malocclusions this anteroposterior separation is slightly larger.
When the separation exceeds 3 mm the occlusion is referred to as
a "dual bite." Coincident intercuspal position and retruded contact
position has been claimed to predispose to temporomandibular
disorders.6. 34.68.75-77
Reproducibility of the retruded contact position makes it the
most reliable reference position. This reproducibility suggests that
the retruded contact position is passively determined, presumably
by the anatomic structures making up the temporomandibular joint
complex, including the disc. However, there are dental clinicians
who believe that the retruded contact position is at least partly
FIG 5-13.
Diagrammatic representation of changes in retruded contact position
recorded with various instruments in conscious patients and in the
same patients under general anesthesia and neuromuscular block-
ade. Ingervall's study40 was carried out on children; all others in
adults. (Adapted from Posselt,71 Ingervall,40Boucher,9 and McMillenS5)
determined9 The controversy continues because of disparate re-
l
sults in studies registering this position under general anesthesia
and neuromuscular blockade. The registration devices which have
been used in these studies include the gothic arch tracer, the needle
point tracer, and the mandibular pantograph. In studies using the
gothic arch tracer in both adults and children, retruded contact
position was found to be coincident in both the conscious and the
blockaded subjects40·7I (see Fig 5-13). Retruded contact position
would appear to be passively determined. However, in another
study using the needle point device, the retruded contact position
was found to be more retrusive under neuromuscular blockade
(Boucher and Jacoby8). The investigators concluded that retruded
contact position was a "muscular" position (i.e., it was actively
determined). In a study by McMillen,55 using the pantograph, the
investi'gator was surprised to find the condyles dropped vertically
when the muscles were paralyzed.
These surprising and somewhat confusing data can be inter-
pre\ed as follows. Like the articulator, which simulates the passive
determinants of mandibular position and movement, the tempo-
romandibular joint assembly can beconsidered to have stops lim-
iting the condylar movement any further in the dorsal, superior,

TABLE 5-6. ".

y ..•

Anteroposterior Differences Between Retruded Contact and IntetCj.J.spalPositions*t

CHILDREN ADULTS

OCCLUSION
n29
0.89
1.20
0.85 ±elm
M ±0.34
1.25 0.55
SD
0.35 n
0.07
0.7-2.1
35
22
0.06
0.10
0.2-3.1
0.1-1.7
0.3-2.0
RANGE
SD
0040 32
Class 11

*Adapted from Ingervall B: Studies of mandibular positions in children. Odontol Rev 1968; 19(suppI15):1-3.
tM = means; elm = standard error of the means.

FIG 5-14.
Passive and active guidances of the temporomandibular joint as
visualized in the sagittal plane. Anatomical determinants and passive
guidances illustrated on the left are represented schematically to the
right as hatched superior and posterior "stops." Reflexes (solid zig-
zag arrows) are necessary for the condyle to attain the superior (A)
and posterior (B) "stops." Protective reflexes originating in the den-
tition or the joint may cause unilateral or bilateral protraction (C,
dotted zig-zag arrow) of the condyle and disc.
and medial directions (Fig 5-14). These stops are structural (bones
and ligaments) and therefore passive, and with suitable registration
techniques can be duplicated. Reflexes, however, are involved in
reaching these stops, especially the dorsal and superior stops. EMG
studies have shown that retractor muscles are more active in the
retruded contact position than in the intercuspal position.]]' 62. 74
This can be demonstrated readily by palpation of the posterior
temporal and digastric muscles on voluntary retrusion into the
retruded contact position. Retruded contact position is a "strained"
position. In the vertical direction, a levator reflex normally holds
the condyle in a superiorly seated position. However, when the
levator muscles are fatigued, as in lengthy pantographing sessions,
the condyle can be observed to drop. Normally this does not occur.
In summary, retruded contact position is passively determined but
attained by reflex action. This is also true for the medial stops.
These determinants of retruded contact position are summarized
in Table 5-7. The protractor muscle reflex distracts the mandible
from its dorsal stop: it is not a determinant of this registration
position.
Just as there is a semantic problem with centric occlusion,
there is a s~mantic problem with centric relation. While the tra-
TABLE 5-7.
Determinants of Retruded Contact Position
PASSIVE ACTIVE
Anatomy of Protractor muscle
temporomandibular reflex
joints
Levator muscle
reflex
Retractor muscle
reflex
Maturation of the Orofacial Musculature 89
ditional view of centric relation is the jaw position when the con-
dyles are in their "uppermost, rearmost, median" position (i.e.,
synonymous with the retruded contact position), the view that the
condyle should be in an "uppermost foremost position" is be-
coming more widely accepted (Dawson,]9 and Celenza and
Nasedkin]2). These two views account for real controversies (e.g.,
should centric relation ideally be in the rearmost position) and
fancied controversies (e.g., the desirability of a "long centric").
In the healthy joint, the condyle and disc assembly attain the
passive dorsal stop through retractor muscle activity when inter-
cuspal position is in the usual anterior relationship to retruded
contact position. In patients with occlusal interferences giving rise
to protective reflexes, protractor muscles may prevent the mandible
from attaining its most retrusive position. In the patient with the
traumatized temporomandibular joint referred to earlier in this
section, protective reflexes originating in the joint will not allow
reliable registration of retruded contact position since manipulation
of the mandible for recording is difficult. Muscle resistance to
manipulation of the mandible is a sign that the registration position
will not be recorded accurately until the protective reflexes have
been eliminated.
E. GROWTH AND ADAPT AnON OF
OROF ACIAL MUSCLES
A number of concepts regarding the growth of muscles affect
the rationales for orthodontic treatment and should be recognized,
since concepts sometimes are conflicting or paradoxical. A fun-
damental concept at issue is whether the growth of muscles is
secondary to growth of the bones of the face or whether the growth
of the muscles determines growth of these bones. The idea that
muscles determine growth of the bones of the face is much in
vogue, having been popularized by Moss"" (see Chapter 4). In his
concept, the "functional matrix" dictates the development of the
bones of the jaws, face, and cranium. The functional matrix con-
cept has defied rigorous testing and so the question of whether the
muscle is primary or secondary in growth of the jaws and face is
still unsettled.
Another concept that prevails in dentistry is that of a pre-
determined resting length for each muscle and a "memory" of
,resting length which causes the muscle to return to that length
should it be changed. This concept is familiar in the dictum that
the bite should not be increased beyond the freeway in prostho-
dontic treatment and the dictum that "counterclockwise" surgical
advancements of the mandible will relapse because of stretching
of the pterygomasseteric muscle sling of muscles. Increasing the
"o<i,clusal vertical dimeilsion in faces with acute gonial angles is
very likely to result in relapse;'whereas it remains stable in faces
with obtuse gonial angles. Patients who have undergone surgery
for cleft palate frequently demonstrate a large freeway space, usu-
ally attributed to deficient vertical development of the maxilla.
(Vertical development of the levator musculature is considered to
be normal.) These observations could be construed to mean that
the lengths of the mandibular levators are genetically determined
and the jaws develop within this vertical dimension preserving a
normal freeway space where the vertical growth of the jaws is
adequate. As will be seen later this concept may not hold as
90 Growth and Development

rigorously in the growing child where the levator muscles seem 160
- T- T, tendon to tendon
to be more adaptive and where bite openings beyond postural ........T-M, tendon 10 ffXJscle
150
position are readily accepted by the young patient. This concept - - - M-M, fTXISc/e
of fixity of muscle length appears to be implicitly held for facial 10 muscle
140
muscles as well since short upper lips are not expected to elongate
with any form of current orthodontic correction (see Chapter 10). 130

120
1. Structural
110 \
While the growth of facial bones has been extensively studied \
by radiologic measurement (with and without implants) there are ··1',
100
few studies on muscle (organ) growth in either experimental an- Y·- •••
imals or humans. The problem is one of finding a suitable marker
for 11lUscle.Short lengths of barbed broaches have been inserted
90 -
..;::.::.:;~~ 1\
\
•...
\
'..--- - -
,------.
.... .....

into the masseter and digastric muscles of experimental animals, 80

and their movements relative to each other or to other markers in
bone or ligament examined radiographically. 57.64 Interpretation of
results may be complicated by adaptations occurring in muscle
beyond the implants, in the tendon and at the insertion. Silver dust
suspended in gelatin and implanted into the masseter muscle of
growing pigs has been used as a marker. 55 Although muscle im-
plants are not as stable as bone implants, studies using these tech-
niques indicate that jaw muscles do adapt to changes in length in
the growing animal64 but are less likely to do so in the adult57
Petrovic and coworkers69 have shown that functional shortening
of the lateral pterygoid in the rat by means of a functional appliance
(active protraction) results in a reduction in the number of sar-
comeres (Table 5-8). Anterior traction of the mandible with elas-
tics (passive protraction) has no effect.
While growth of the muscle organ would intuitively be thought
to be in the muscle tissue, the role of the investing tissues and
ligaments must also be examined. Some insight into the adaptive
response of jaw muscle tendon comes from the study by Muhl and
Grimm.64 Two markers were placed in the tendon and two markers
in the muscle belly of the digastric muscle of growing rabbits and
changes in distances between markers measured by three- .
dimensional radiography following surgical shortening of the tendon
(Fig 5- IS). All long-term adaptation in this experiment took place
in the tendon.
70
-40 -30 -20 -10 0 .•.10 +20 +30 +40 +50
DAYS
FIG 5-15.
Mean percentage changes in marker distances before and after sur-
gical shortening of the tendon of the digastric muscle of the growing
rabbit. Note that following the length changes due to the surgery the
tendon markedly elongated while the muscle and the junction of the
tendon to muscle shortened. (From Muhl ZF, Grimm AF: Adaptability
of rabbit digastric muscle to an abrupt change in length: A radio-
graphic study. Arch Oral Bioi 1974; 19:829-833. Used by permission.)
the masseter muscle did not keep pace with the mandible-which
slipped forward under the muscle. This tantalizing piece of
information suggests that jaw muscle growth may be secondary to
mandibular growth. The form-function controversy is not dead.
Another possible site of adaptation is at the interface between
muscle and bone. The nature of the interface with bone changes
from an insertion into the periosteum in the growing animal to an
inserti'on into the bone in the adult. The muscle origin and insertion
1

These few implant studies have looked at short-term adaptations must be considered as sites of adaptation to changes in muscle
in jaw muscles to lengthening. Only the single study using silver length imposed by orthodontic treatment (e.g., functional
dust as a marker35 examined adaptation during normal growth (no apR}iances, combined orthodontic-surgical correction, bite planes)
studies have been done on the human). According to these authors as well as normal growth. These limited data have obvious
implications for planning ortho~ontic treatment alone or in
TABLE 5-8. conjunction with surgery where functional muscle length is changed.
Effects of Active and Passive Protraction of the
Where adaptation cannot be' expected, relapse is likely to occur.
Mandible on Length of Lateral Pterygoid in the Rat'
Besides the structural changes associated with growth and
LATERAL PTERYGOID
(NUMBER OF SARCOMERES;
adapUition are those of chang·es in muscle type. The limited literature
CONTROUTEST) on fiber types in orofacial muscles of humans indicates that
Protraction of mandible 2401/2132 differentiation of type I and II fibers occurs at about 20 to 23
(active) (P>0.01) week's gestation8' The proportions of different fiber types during
Protraction of mandible 2417/2334 growth are likely to be determined in large measure by functional
(passive) (N.S.) demand.
'Adapted from Petrovic AG, Stutzmann JJ, Oudet CL: Control
processes in the postnatal growth of the condylar cartilage of the
mandible, in McNamara JA Jr (ed): Determinants of Mandibular
2. Functional and Behavioral
Form and Growth, monograph 4. Craniofacial Growth Series. Ann
Arbor, Michigan, Center for Human Growth and Development. There are no longitudinal studies on the development of the
University of Michigan, 1975, pp 101-153. orofacial musculature similar to those on the development of the

FIG 5-16.
Tongue posture in the neonate. Note that while the mandible is in
its postural position, the tongue is postured forward and touches
the lips while the gum pads are held slightly apart.
facial skeleton. A large literature, mostly of an anecdotal nature,
catalogs the development of orofacial function (see Peiper"7). The
pediatric and neurologic literature documents the ontogony of ~
number of orofacial reflexes such as the rooting reflex, suckling,
and other feeding activity. Speech pathologists have timetables for
normal development of speech similar to those used by dentists
for tooth eruption. These descriptions, after Gesell and Piaget, are
of a behavioral type and have associated with them the concept
of attaining particular behaviors in sequence and by a "normal"
chronologic age."6 Orofacial behavior whose development is per-
tinent to orthodontics includes mandibular and tongue posture,
swallowing, and mastication.
The reflexes and associated biasing mechanisms accounting
for mandibular posture (described earlier in Section D) are func-
tioning at birth though they become sequentially more complex
with normal developmental events (e.g., eruption of teeth, estab-
lishment of occlusion, beginning of mastication) and unpredictably
so with occurrences such as loss of teeth, pain, temporomandibular
disorders, and so forth. In the neonate the postural position is
likely the starting orientation for such activities as suckling, res-
piration, and swallowing.
Tongue posture in the neonate is more forward than later
since the tongue is part of a very active sensory perceptual system
(Fig 5-16). Many oral functions in the neonate are guided pri-
marily by tactile stimuli from the lips and tongue. Later when the
incisors erupt the tongue posture changes to the mature position.
Mandibular growth downward and forward increases the intraoral
volume, and alveolar process growth vertically during eruption
aids in the normal change in the tongue's posture during the first
year of life.63 A retention of the infantile tongue posture is some-
times seen, creating a difficult and persistent open bite (see Chapter
18).62
The infantile swallow, an essential function in the neonate,
is closely associated with suckling, and both are well developed
Maturation of the Orofacial Musculature 91
by about the thirty-second week of intrauterine life.38 During the
infantile swallow the tongue is between the gum pads in' close
apposition the with lips, and its contraction plus those of the facial
muscles help to stabilize the mandible. The mandibular elevators,
which play a prominent role in normal mature swallows, show
minimal activity (Fig 5-17 ,A).63
All occlusal functions are learned in stages as the nervous
system and the orofacial and jaw musculature mature concomi-
tantly with the development of the dentition. During the latter half
of the first year of life, several maturational events occur that alter
markedly the functioning of the orofacial musculature. The arrival
of the incisors cues the more precise opening and closing move-
ments of the mandible, compels a more retracted tongue posture,
and initiates the learning of mastication. As soon as bilateral pos-
ter-ior occlusion is established (usually with the eruption of the
first primary molars), true chewing motions are seen to start, and
the learning of the mature swallow begins. Gradually, the fifth
_cranial
"' nerve muscles assume the role of mandibular stabilization
during the swallow, and the muscles of facial expression abandon
suckling and the infantile swall()w and begin to learn the delicate
and complicated functions of speech and' facial expressions. The
transition from infantile to mature swallow takes place over several
months, aided by maturation of neuromuscular elements, the ap-
pe~ance of upright heAd posture, and, hence, a change in the
direction of gravitational forces'on the mandible, the instinctive
desire to chew, the necessity to handle textured food, dentitional
development, and so forth. Most children achieve most features
of the mature swallow at 12 to 15 months of age. Characteristic
features of the rriature swallow are (I) the teeth are together (al-
though they may be apart with a liquid bolus), (2) the mandible
is stabilized by contractions of the fifth cranial nerve, (3) the tongue
tip is held against the palate above and behind the incisors, and
(4) minimal contractions of the lips are seen during the swallow
(Fig 5-17) 62
92 Growth and Development

Left Anterior- 1'"mporal

Left. Orb1culii'ris Oris-Buccinator

r S'i.'ALLOli
i 100 '"V 1 second

FIG 5-17 40:1£Q. Used by permissiO'ri:) 8, mature swallows. A comparison of

A, an infantile swallow. In this instance, the baby fell asleep at the
mother's breast. The swallow recorded is an unconscious swallow
of saliva during sleep. Note the dominance of the facial muscles and
the minimal activity in the only mandibular elevator sampled. (A from
Moyers RE: The infantile swallow. Trans Europ Orthod Society 1964;
the teeth-together and teeth-apart swallow. The record at the bottom
(R.G.) is that of a typical mature swallow. Note the strong contractions
in the temporal muscle. The record at the top (E.B.) is of a child of
the same age. Note, however, that this child has a teeth-apart swal-
low, since there is far greater activity of the facial muscles than there

...•
 Maturation of the Orofacial Musculature 93

Left Anterior Temporal

1~~N1l~
Left Middle Temporal
~
.
I'WML,~,.......: .J~•..Ill ~~:,\:.~'~~~
..•••
. {, •..,.~"'TT'1'~ I • ')i i: ' \ •••
rr-
Left Posterior Temporal

Left Masseter

R' 19ht Anterior Temporal ~....

,~ __ . ~_:"-''''1".'~~I, I •

Right Middle .••.•.••

-..:.:......""""'-..,.. Tempora 1
iIN'-J.JJ-w~~~"l,. !•• L...•
'TfI~~i 7~~•.... '-n T··;II; l.Ji:'~/I'\!~:~I~~rf""""
IIl~,\Jv....;.....u.......JJ.! (,~II~~
,'II'..· I I "I' ,-

Right Posterior Temporal, , '~~~""~If""

'"
...• , •.••.•.
Q4 Dw I sr<:. I',.
"1 I '

FIG 5-17 (cont.).

is of the mandibular elevators. An unconscious swallow (C) and a (C and 0 from Eggleston WB Jr, Ekleberry JW: An Electromyographic
volitional swallow (D) of water are compared. These records were and Functional EvaluatiQ[1 of Treated Orthodontic Cases, thesis.
taken from the same person during the same experimental period. Scll~ol of Dentistry, University of Michigan, Ann Arbor, 1961.
94 Growth and Development
F. INTERACTION OF OROFACIAL MUSCLES
WITH DEVELOPMENT OF THE
CRANIOF ACIAL SKELETON AND THE
DENTITION
Sections A-2, A-3, C-I, C-2, C-3, ,and E-I in this chapter
and sections in Chapters 4, 6, 7, and 10 contain discussions of
these crucial interactions and their implications in the etiology of
malocclusion and in planning orthodontic treatment. A recurring
theme is that posture dictates the form appropriate to that posture.
Phasic activities such as mastication, swallowing, and speech are
less likely to cause structural adaptations unless tl)e forces, are
heavy and/or act over long periods of time. Bruxism is an example
of a, phasic activity which can cause structural changes in the
muscles, teeth, periodontal ligaments, and alveolar bone" This
function-structure interaction, however, works both ways: struc-
ture can also influence function, Some dentists see the forward-
postured tongue in faces with excessive anterior face height (the
so-called "long face syndrome" or "steep angle case") as an
adaptation to the bony morphology. Other dentists see the altered
facial morphology as the consequence of altered tongue posture,
Tongue protraction in cases of anterior open bites secondary to
digital habits is a good example of an interaction existing in both
directions. Some anterior open bites result from abnormal function
while others cause an adaptation in function (see Chapters 7 and
10).
Much has yet to be learned about the relationships between
neuromuscular growth and function and growth of the craniofacial
skeleton and occlusion. Many of the leading oral biology labo-
ratories in the world concentrate on this important theme. Perhaps
no single advancing area has caused more changes in this ,edition
of this book, both in theory and practice, than the constantly
appearing new knowledge about the old theme of form and func-
tion. The reader is urged to make a serious effort to correlate
similar sections in Chapter 4, Growth of the Craniofacial Skeleton,
and Chapter 6, The Development of the Dentition and Occlusion,
with the ideas in this chapter. Textbooks neatly segregate subjects
for ease in writing and presentation of ideas; the clinician has no
such luxury, and the important concepts of form versus function
presented in Chapters 4 through 6 may often be combined in the
patient. Treatment of such functional aspects of malocclusion is
presented in three chapters on treatment, namely, Chapters 15
through 17.
SUMMARY
The orofacial musculature serves vital functions of respiration
and alimentation as well as expression and communication. Func-
tions in one region are tightly linked to functions in another: posture
of the head, mandible, tongue, and hyoid and supportive and
protective reflexes of the portal area are highly interactive. These
functions are also interactive with the structures they serve: func-
tion may dictate the form or form dictate the function. Posture
would appear to be more important as a determinant of mandibular
form and tooth position than synergies of relatively short duration
such as speech, mastication, and swallowing.
The reflexes which form the basis of orofacial function and
behavior may be unlearned, learned, or a mixture. Learned patterns
are more amenable to change by alteration in form or training than
are unlearned patterns. The three registration positions (postural
position, intercuspal position, and retruded contact position) are
under variable degrees of reflex regulation. The mix is determined
by the position and the conditions under which it is recorded. The
extent to which the position is reflexly regulated determines its
reliability as a registration position.
The forces exerted by the orofacial muscles vary with the
muscle and the conditions. These forces are a combination of active
(reflex) and passive (nonreflex) components. Facial muscles do
not possess spindles and therefore lack a stretch reflex. Jaw mus-
cles are rich in spindles: the contribution of reflex to total tension
is highly variable.
In contrast to growth of the bones of the face, little is known
about the growth of the muscles. Short-term adaptation to changes
in length has been documented as occurring in the muscle, in the
tendon, and at the muscle insertion in growing animals. These
adaptations are much smaller in the adult.
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92. Tabary JC, Tabary C, Tardieu C, et al: Physiological and
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96. Warren DW: Aerodynamic studies of upper airway: impli-

cations for growth, breathing, and speech, in McNamara
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98. Williamson EH: Occlusion and TMJ dysfunction. J Clin
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99. Williamson EH, Lundqvist DO: Anterior guidance: Its ef-
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100. Windle WF: Correlation between the development of local
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J Comp Neurol 1934; .59:487-503.
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18:861-870.
SUGGESTED READINGS
Anderson DJ, Matthews B (eds): Mastication. Bristol, England,
J Wright and Sons, 1976.
Bosma J: Oral and pharyngeal development and function. J
Dent Res 1963; 42:375-380.
Carlson OS, McNarnara JA Jr (eds): Muscle Adaptation in the
Craniofacial Region, monograph 8. Craniofacial Growth Se- .
ries. Ann Arbor, Mich, Center for Human Growth and De-
velopment, University of Michigan, 1975.
Maturation of the Orofacial Musculature 97
Dubner R, Sessle BJ, Storey AT: The Neural Basis of Oral and
Facial Function. New York, Plenum Press, 1978.
Johnston LE (ed): New Vistas in Orthodontics. Philadelphia,
Lea & Febiger, 1985.
Kawamura Y, Dubner R (eds): Oral-Facial Sensory and Motor
Functions. Chicago, Quintessence, 1981.
Kraus BS, Riedel RA (eds): Vistas in Orthodontics. Philadel-
phia, Lea & Febiger, 1962.
McNamara JA Jr, Ribbens KA (eds): Naso-respiratory Function
and Craniofacial Growth, monograph 9. Craniofacial Growth
Series. Ann Arbor, Mich, Center for Human Growth and De-
velopment, University of Michigan, 1975.
McNamara JA Jr (ed): Determinants of Mandibular Form and
Growth, monograph 4. Craniofacial Growth Series. Ann Ar-
bor, Mich, Center for Human Growth and Development, Uni-
versity of Michigan, 1975.
McNamara JA Jr (ed): Factors Affecting the Growth of the Mid-
face, monograph 6. Craniofacial Growth Series. Ann Arbor,
Mich, Center for Human Growth and Development, Univer-
sity of Michigan, 1975.
Marimoto T: Mandibular position sense in man. Front Oral
Physiol1983; 4:80-101.
Peiper A: Cerebral Function in Infancy and Childhood, Nagler
B, Nagler H (trans). New York, Consultants Bureau, 1963.
Perry man HH (ed): Oral Physiology and Occlusion. New York,
Pergamon Press, 1978.
Sessle BJ, Hannan AG (eds): Mastication and Swallowing: Bio-
logical and Clinical Correlates. Toronto, University of To-
ronto Press, 1976.
Wood WW: A review of masticatory function. J Prosthet Dent
1987; 57:222-232.
CHAPTER 6
Development of the Dentition and
the Occlusion
Alphonse R. Burdi, M.S., Ph.D.
Robert E. Moyers, D.D.S., Ph.D.
Adam and Eve had many advantages, but the principal one
was that they escaped teething.-MARK TWAIN.The Tragedy
of Pudd'nhead Wilson. Chapter 4, "Pudd'nhead
Calendar"
KEY POINTS
1. Embryonic development of both dentitions proceeds
through four stages: initiation, bud, cap, and bell.
2. Variations in tooth size, position, sequence of
development, and sexual dimorphisms are also
apparent during prenatal development.
3. The neonate's mouth has no teeth.
4. The relationship of the neonatal gum pads is a poor
indicator of future dental occlusal relations .
5. Calcification of the primary teeth begins about the
fourteenth intrauterine week.
6. Primary teeth emerge in typical sequences beginning
around the seventh month (mandibular incisor) and
ending about the twenty-sixth month (maxillary
second primary molar). ,.
7. The primary occlusion shows less variability than the
permanent and is established by the functional
muscle matrix as the teeth erupt.
8. The primary occlusion changes as an adaptation to
skeletal growth and occlusal wear.
9. Girls are generally more advanced than boys at all
stages of dental calcification.
10. Teeth do not begin to move occlusally until crown
formation is completed.
Wilson's
11. Variation in eruption of permanent teeth may be
produced by racial differences, sexual dimorphisms,
economic status, localized pathosis, extraction of the
primary predecessor, and injury.
12. Tooth size is largely determined genetically.
13. There are relationships among dental agenesis,
delayed development, and diminished size of teeth.
14. Supernumerary teeth are rarer than congenitally
." missing teeth and occur more frequently in males.
15. Dental arch width changes are timed more closely to
dental development than to overall skeletal growth.
16. Dental arch circumference reduces during the late
transitional and early permanent dentition.
J7. The distal surfaces of the second primary molars are
•., determinant factors in tIJe initial permanent molar
occlusion.
18. Subsequent occlusal changes occur as a result of
differential craniofacial skeletal growth, caries, loss
of primary teeth, muscle habits, and other factors.
19. Third molars show more variability in development
than any other teeth.
20. The adaptive mechanisms permitting occlusal
homeostasis vary greatly with the stage of
development.
99
100 Growth and Development

OUTLINE 3. First molar eruption

a) Mandible
A. Prenatal Dental Development (ARB) b) Maxilla
1. The prenatal beginnings of the dentitions 4. Incisor eruption
a) Initiation of odontogenesis - a) Mandible
I) Bud stage b) Maxilla
2) Cap stage 5. Cuspid and bicuspid eruption
3) Bell stage a) Mandible
b) Sequence patterns b) Maxilla
2. Spatial patterns 6. Second molar eruption
a) Arch shape H. DentitionaI and Occlusal Development in the Young Adult
b) Spacing (REM)
c) Fields I. Third molar development
B. The Mouth of the Neonate (REM) 2. Dimensional changes
I. The gum pads 3. Occlusal changes
2. Neonatal jaw relationships 4. Resorption of permanent teeth
3. Precociously erupted primary teeth 5. Arrangement of the teeth in the jaws
C. The Primary Teeth and Occlusion I. Clinical Implications (REM)
I. Development of the primary teeth I. Normal versus ideal occlusion
a) Calcification 2. Models of occlusion
b) Eruption 3. Occlusal adaptive mechanisms
c) Teething and systemic disturbances
d) Size and shape of primary teeth
e) Anomalies A. PRENATAL DENTAL DEVELOPMENT
f) Primary tooth resorption
g) Ankylosis of primary teeth Seeing things from their beginnings is most advantageous;
2. Development of the primary occlusion thus, the concern with morphogenic patterns from their embryonic
a) Neuromuscular considerations inception looks to the future of these patterns in the growing child.
b) Primary dental arches Although the tooth might be regarded clinically as an isolated unit,
c) Occlusal relations its biology (and that of the surrounding tissues) is best understood
d) Disorders of the primary occlusion in the context of the total life cycle of these structures. The length
D. Development of the Permanent Teeth (REM) of the morphogenic period, from the first appearance of the tooth
I. Calcification bud to eruption and functional occlusion, should not be underes-
2. Eruption timated. Both the orthodontist and the general practitioner should
a) Interrelationships between calcification and understand the prenatal origins of typical and atypical spatial ar-
eruption rangements of developing teeth within the jaws. 73
b) Factors regulating and affecting eruption The evaluation of a given tooth within its dental arch is best
c) Timing and variability of eruption carried out in reference to past developmental timing, present
d) Sex differences spatial patterning, and future functional demands.
e) Sequence of eruption
f) Eruption and bodily growth
1. The Prenatal Beginnings of the Dentitions
g) Ectopic development ',.
h) Factors determining the tooth's position during The embryonic development of both deciduous and permanent
eruption teeth proceeds in four stages which are named for the characteristic
E. The Permanent Dentition (REM) features of the stage: initiation, bud, cap, and bell (Fig 6-1).
I. Size of teeth
2. Number of teeth a) Initiation of Odontogenesis
a) Missing teeth '.•The first sign of tootIY'development appears late in the third
b) Supernumerary teeth embryonic week when the epitheliaUining of the oral cavity begins
F. Dimensional Changes in the Dental Arches (REM) to thicken in broad zones. This thickening is brought about from
I. Width deep within the specialized connective tissue beneath the oral lining
2. Length or depth by a combination of cell-cell cytoplasmic contacts and movement
3. Circumference or perimeter of transmissible proteins. The interacting connective tissue. had its
4. Dimensional changes during orthodontic therapy origins in neural crest material. The epithelial thickenings occur
5. Overbite and overjet on the inferolateral borders of the maxillary and on the supero-
G. The Mixed Dentition Period (REM) lateral borders of the mandibular arches where the two join to form
I. Uses of the dental arch perimeter the lateral margins of the mouth. By the sixth week, two additional
2. Occlusal changes in the mixed dentition maxillary odontogenic tissues have arisen more anteriorly. At 6

-.
 Development of the Dentition and Occlusion 101

'''~oral epithelium
dental lamina
~ jaw mesenchyme
A dental bud

dental lamina
permanent

dental
reticulum

~l'~~
enamel

dentin

dental pulp

root sheath

FIG 6-1.
Early stages of tooth formation (A-F) followed by initiations of erup-
tion and emergence (G-H). Approximate ages are 8 weeks (A), 10
weeks (B), 11 weeks (C), 12 weeks (D), 4 months (E), 6 months (F),
8 months (G), and into the postnatal eruption periods. (Modified from
Burdi AR: The develoPrT1ent and eruptions of the human dentitions,
in"Ferrester DJ, Wagner ML, Fleming J (eds): Pediatric Dental Med-
icine. Philadelphia, Lea & Febiger: 1981.)
102 Growth and Development

weeks, the four maxillary odontogenic zones coalesce to form a

continuous dental lamina, and the two mandibular odontogenic
zones fuse at the midline. These upper and lower dental fields now
form C-shaped epithelial arches.
The teeth begin with invagination of the dental lamina into
the underlying mesenchyme at specific locations along the free A B
border of each arch. Morphologic changes in the dental lamina
begin at about 6 weeks in utero and continue beyond birth to the
fourth or fifth year. This occurs in three main phases:
a) Initiation of the entire deciduous dentition occurs during
the second month in utero. Cervical loop
b) Initiation of the permanent teeth that will be the succes-
sors of the deciduous teeth occurs by the growth into
surrounding connective tissues of the free distal end of
the dental lamina, giving rise to the successional lam-
ina. Its continuing growth lingual to the enamel organ
of each deciduous tooth occurs from about the fifth
month in utero (second premolars).
c) The dental lamina elongates distal to the second deci- c D
duous molar and gives rise to the permanent molar tooth
germs. The time of initiation of the first permanent mo-
lar is about 4 months in utero; for the second permanent
molar, 1 year; and for the third permanent molar, 4 to 5
years.
Epithelial
1) Bud Stage.-Soon after dental lamina formation, a ves-
tibular furrow divides the cheeks and lips from the dental arches.
Subsequently, the dental lamina shows specific sites of increased membrane

mitotic activity which produce knob-like tooth buds corresponding
to the ten deciduous teeth in each jaw. The first buds to form (at
about the seventh week) are of the mandibular anterior teeth. By
the eighth week, all mandibular and maxillary deciduous tooth
buds are present.
FIG 6-2.
A-D, arrangement of enamel and dentin forming tissues with the
key tissues involved in root development. (Modified from Orban BJ:
Oral Histology and Embryology. St Louis, CV Mosby Co, 1976.)

2) Cap Stage.- The growth rate throughout the bud is not

uniform, being more active peripherally. By the end of the eighth
week, there appears a concavity on the deep surface of the bud.
The tooth is now in its cap stage. As the epithelium of the cap-
shaped tooth organ enlarges and proliferates into deeper specialized
connective tissues (ectomesenchyme), there is increased activity
in cells contiguous with the ectodermal tooth bud. Areas of in-
creased cellular density eventually give rise to the nonenamel por-
tions of the tooth and its periodontal matrix. At this time the
essential parts of the tooth-enamel organ, dental papilla, and
dental follicle-are identifiable. Collectively they are called the
tooth germ.
3) Bell Stage.- The bell stage represents enlargement of the
overall size of the tooth germ and deepening of its undersurface.
Cells at the center secrete an acid mucopolysaccharide into the
extracellular space between the epithelial cells covering the germ,
which results in a drawing in of the water and an enlargement of
the germ. A zone of stretched but interconnected cells, the stellate
reticulum, is produced at the center of the germ. Epithelial cells
next to the papilla develop into an enamel-producing layer of cells,
the inner dental epithelium; epithelial cells along the leading edge
of the germ form the outer dental epithelium, which eventually
gives rise to the dental cuticle. The transition zone between outer
and inner dental epithelia forms the cervical loop.
The differentiation of dentin-producing odontoblasts in the
dental papilla is initiated by the neigh boring cells of the inner
dental epithelium. Enamel formation cannot occur until the proper
amount of dentin is laid down. This same reciprocal interaction
between the inner and outer enamel epithelia also occurs in tooth
formation. In the cervical loop area, neighboring cells of the two
epithelia progressively constrict around the dental papilla to leave
onJy a small opening, which will become the apical foramen. At
this time, the dentin which forms the tooth root is first laid down
(Fig 6 - 2). The germ loses its connection with the oral epithelium,
and the inner enamel epithelium begins to fold, making it possible
to recognize the crown shape of specific morphologic classes of
teeth. By this process of J:1istodifferentiation, a mass of ectoder-
man;: derived epithelial cells progressively differentiates into the
comp6nents of the tooth which determine crown shape, initiate
dentin formation, and form enamel.
b) Sequence Patterns
The 20 deciduous tooth buds differentiate through the cap
and bell stages at rates that manifest recognizable sequence pat-
terns, or polymorphisms. 11 In the main there is a mesiodistal gra-
dient of embryonic tooth development, dil-di2-c-dml-dm2, but
other developmental sequences are seen in 25% of the cases stud-
ied. These embryonic sequence variations may be the prenatal
 Development of the Dentition and Occlusion 103

2 (/)
II-
0
~14
W
Q « 0r 8~ I,8 I
0A
-- ,6
IIr
Ir
....J
J:
Z
~
W
c:: 12
4
2
01
L46 I
10 ,,
B
15 10
E CHANGING
25wks
ARCH SHAPE PATTERNS CHANGING ARCH SHAPE PATTERNS
E 16 r MAXILLA 16 MANDIBLE
E
.s 14 25wks
J:
I-
~
Z 12
W
....J

J:
U
Ir
«
Ir 8
Q
Ir
W
t; 6
o
0-
I
Ir
o
Ir
~ 2
Z
«
o
o 2 4 6 8 10

ARCH WIDTH (mm) ARCH WIDTH (mm)

FIG 6-3.
Graphic reconstructions of prenatal dental arch quadrants of the of the arch by progressive lingual drifting of the lateral incisor tooth
upper (A) and lower (B) jaws. Note the catenary shape of the aligned germ. Midline length is shown on the vertical axis and arch width on
dental arch at 12.5 weeks. The shadowed areas show a reshaping the horizontal axis.

B
MLP

di 1

,. v
c
~
.~~---------------------------
dm2 baseline DlP

FIG 6-4.
A, photomicrograph of a 10 f.l. frontal section through face of 24-
week human fetus showing the linear distances from the midline to
points on the tooth germ which are subsequently transferred onto
grids for graphic reconstructions. The inset shows transverse cuts
through the body and head of a prenate with marked cervical flexure.
producing a frontal section through the face. B, two-dimensional
reconstruction made from measurements from projected histologic
sections through the prenatal face. This dental arch quadrant shows
the arrangement of tooth germs in the aligned arch (solid lines) and
where the catenary-shaped aligned arch is reshaped by the lingual
drifting of the lateral incisor tooth germ (dashed lines). The horizontal
lines show how data taken from each histologic section is "stacked"
to produce the reconstruction.
104 Growth and Development

antecedents of polymorphisms of sequence in postnatal denti- 50

tions.22 Here are three examples:

a) Postnatally, mandibular incisors tend to erupt earlier

Summed Crown Diameters
than their maxillary opponents, while maxillary prece-
~
dence predominates in the posterior teeth.46 In the em-
bryo, opponent deciduous tooth germs are usually at the (f)
same maturational stage9; but such inter-jaw differences z
as occur show mandibular advancement for the incisor Q
(f)
30
Z
tooth germs and a maxillary precedence for the maxil- W
~
lary molars. (5
b) In postnatal tooth development there is a distance gra- ....J
<I: 20
dient of crown size correlations; teeth closer together ~
Z
within a jaw quadrant show higher correlations in crown W
o
size than widely separated teeth. 29.31.36Observations in ow
a series of human embryos paralleled the postnatal ob- ~ 10
servations for maxillary and mandibular tooth germs in ~ Summed Inferdentol Space
::::l
both male and female embryos.24. 2R
c) In the calcification and eruption of permanent teeth, ex-
(f)
~- tr- ....• o
......
o
~_-&.°oo--a--__ ~_-o_
0 \
cept the third molar,6s girls are advanced; in that of de- o
50 lOO 150 200 250 300
ciduous teeth, boys are somewhat advanced. Prenatally, CROWN-RUMP LENGTH (in mm)
male tooth germ development is consistently ahead of
female. 10 As with palatal closure, which occurs at a FIG 6-5.
faster rate in male embryos than in female," one might Changing relationship between summed crown sizes of di 1-di2-c-
dm1-dm2 and summed interdental spaces in prenates during 10 to
explain the sexual dimorphism as a possible delayed in-
fluence of the second X chromosome at the embryonic 28 weeks of development. Summed crown sizes increase eightfold,
whereas summed interdental spacing shows little correlation with
tissue level. 71
increasing body size.

2. Spatial Patterns
a) Arch Shape
The postnatal human dental arch is generally described by a
catenary curve.62 Scott reported that the catenary pattern also held
for both the embryonic dental lamina and the arrangement of tooth
germs. This has been shown to be an overgeneralization7 The
prenatal dental arch progressively changes shape; at 6 to 8 weeks
it is anteroposteriorly flattened, not a catenary curve at all. By the
bell stage of the tooth germs, the anterior segment of the dental
arch has elongated and approaches the catenary by th~ beginning
of the fourth month. A bilateral cleft lip and palate arrests this
development; with surgical correction of the cleft and continued
facial growth, the maxillary dental arch may proceed toward the
expected catenary shape.3R Figures 6-3,A and 6-3,BR4 show the
general run of arch form change from 3 months to 6 months prenatal
development. Note the lingual drift of the deciduous lateral incisors
and the increase in the dental spacing in the molar region. Figures
6-4,A and 6-4,B show how.these data were derived from thinly
sectioned human prenatal heads by. graphic reconstructions. R4
b) Spacing
There have been many studies on the development of tooth
spacing postnatally, among them the classic contributions of
LundstromSR and Moorrees, 67but less work has been reported about
the prenatal period. The deciduous anterior teeth, especially the
lateral incisor, often appear crowded and out {)f alignment within
the total dental arch before birth (cf. Fig 6-3), but usually erupt
in good alignment. RRThe sum of the mesiodistal diameters of the
five deciduous tooth germs in each jaw quadrant increases over
time until at about 23 weeks it exceeds the length of the aligned
dental arch (Fig 6-5). Interdental spacing is relatively constant
during this period.26 Most tooth germs show significant increase
in mesiodistal crown size related to linear growth phases from II
to 14 and 20 to 26 weeks with a level growth phase in between
the periods of linear growth. Within the anterior arch there is only
a slight increase in interdental spacing; in both jaws the posterior
arch spaces show decreases during this period. Thus, while the
jaws are increasing in absolute size, the interdental tissues do not
keep'pace with the increments in posterior tooth size.
c) Fields
Let us define a tooth field as the tooth germ together with
the space mesial and distal to it within the dental arch. Interdental
spaces are shared by neighboring tooth fields. Figure 6-6,A and
B show how much of a space-toath-space field is occupied by a
given deciduous tooth germ. The greatest level of occupancy of a
tooth field by a tooth germ is about 80% for the first deciduous
mQ!¥ and lateral incisor, There is an adaptation here. By approx-
imately 16 weeks of gestation the lateral incisor tooth germ oc-
cupies 100% or more of its available tooth field in the aligned
arch, but there is often a concomitant rotation and lingual dis-
placement which appears to keep di2 in conformance with the 80%
of tooth germ occupancy in the tooth field. This lingual displace-
ment of the lateral incisor occurs in about four to ten prenates and
demonstrates the early prenatal beginnings of similar lateral incisor
displacement in term prenates reported by van der Linden et al. RR
In summary, soon after the tooth passes through its cap stage
of development, developmental variations are discernible with suf-
 Development of the Dentition and Occlusion 105
TOOTH FIELDS
A
140% MAXILLA

120%

100%

80%

60%

40%

20%

50 100 150 200 250

CROWN-RUMP LENGTH (mm)

TOOTH FIELDS
B
140% MANDIBLE

120%

100% FIG 6-7.

Neonatal maxillary gum pads. Note the segmentations of the gum
80% pads and how they correspond to the developing primary teeth.
(Courtesy of Or. James McNamara.)
60%

40'%

20'%
The size of the gum pads at birth might be determined by
anyone of the following factors, according to Leighton55: (I) the
50 100 150 200 250 state of maturity of the infant at birth; (2) the size at birth as
CROWN-RUMP LENGTH (mm)
expressed by birth weight; (3) the size of the developing primary
FIG 6-6. teeth; and (4) purely genetic factors. The maxillary arch is
A and B, using the concept of a tooth field, it is shown in these figures horseshoe-shaped and the gum pads tend to extend buccally and
that the percentage of occupancy of a tooth field by a tooth germ labially beyond those in the mandible; furthermore, the mandibular
will vary from tooth to tooth, with the maximum percentage at ap- arch is posterior to the maxillary arch when the gum pads contact. 55. 83
proximately 80% for both the upper (A) and lower (B) dental arch
quadrants.

2. Neonatal Jaw Relationships

ficient regularity to be considered as stable patterns or polymorph-
isms involving structural or spatial relationships over time. Sexual
dimorphisms also are apparent. As tooth formation is a develop-
mental continuum from the 3-week embryo to the 5-year-old child,
it is not surprising to see parallels between prenatal odontogenesis
and the patterns of dental formation and arrangement seen by the
practicing clinician'.
B. THE MOUTH OF THE NEONA TE
1. The Gum Pads
At birth, the alveolar processes are covered by gum pads,
which soon are segmented to indicate the sites of the developing
teeth (Fig 6_7).13.89 the gums are firm, as in an adult edentulous
mouth. The basic form of the arches is determined in intrauterine
life (see Fig 6-3).
" Although the upper and lower gum pads touch throughout
much of the arch circumference, in no way is a precise "bite" or
jaw relationship yet seen. Indeed,at birth there is such a variability
in the relationships of the upper and lower gum pads that the
neonatal relationship cannot be used as a diagnostic criterion for
reliable predictions of subsequent occlusion in the primary den-
titiqn.55 Some have held that an anterior open bite of the gum pads
i~ normal and even a prerequisite' for a subsequent normal incisor
relationship. Simpson and Cheung83 found that only 2% of all
neonates have an anterior open bite gum pad relationship. They
also reported oral habits had a definite influence on the infantile
gum pads, resulting in a significant increase in the incidence of
anterior open bite relationships by the age of 4 months.
The mouth of the neonate is a richly endowed sensory guid-
ance system providing input for many vital neuromuscular func-
tions, for example, suckling, respiration, swallowing, yawning,
and coughing, which are discussed iri Chapter 5.
 106 Growth and Development

3. Precociously Erupted Primary Teeth TABLE 6-2.

Occasionally, a child will be born with teeth already present Sequence of Emergence of Primary Teeth
in the mouth. Natal (present at birth), neonatal (erupted during the AB D C E
first month), and pre-erupted (erupting during th~ second or third
months) teeth are almost always mandibular incisors which fre-
#$+t+1H++l H++~Ot-H2:4t-H2:8+1
quently display enamel hypoplasia. There are familial tendencies A B D C E
for such teeth. Such teeth should not be removed, if they are near MONTHS
normal, even though they may cause the mother some discomfort
during nursing, unless they are certainly supernumeraries. between monozygous pairs. She estimates the effect of heredity
on eruption of primary teeth at 78% and the effect of environment
at 22%.
C. THE PRIMARY TEETH AND OCCLUSION
For both blacks and whites, boys precede girls in total number
1. Development of the Primary Teeth of teeth erupted until about 15 months, then girls surpass boys and
remain ahead throughout completion of the primary dentition (Fig
6-9).44 Tooth emergence is most highly associated with height,
a) Calcification then weight and head circumference, though in the very early stage
The sequence of initial calcification of the primary teeth is of emergence birth weight correlates better than height. Black
central incisors (14 weeks), I first molars (151/2 weeks), lateral children complete emergence ahead of white children and are more
incisors (16 weeks), canines (17 weeks), and second molars (18
advanced for most measures of growth during the period of the
weeks) (Table 6_1).59 Since the primary teeth develop at different eruption of primary teeth when socioeconomic status is similar.43
rates, this sequence is not ~ necessarily maintained0 in subsequent
TEETH Q ~
developmental stages.'9 The crowns of the teeth 20 continue
15 to grow
to 35
25
in width until there is coalescence of the calcifying cusps, at which
time most of the crown diameter of the tooth has been determined. ~ ~
( Months)
AGE IN MONTHS
~ ~ ~~ ~
~ 30
~ ~ MEAN VALUE <>
There are few genetic studies of calcification of primary teeth, but ~
there is evidence that genetic control is exercised in some manner
over crown morphology, rate and sequence of growth, pattern of
calcification, and mineral content. Prenatal dental develoment is
characterized by at least as much sexual dimorphism, develop-
mental variability, bilateral asymmetry, and sequence variability
as has been reported in the postnatal development of the deciduous
and permanent dentitions. 27

b) Eruption
Eruption, that is, movement of the tooth toward occlusion,
begins in a variable fashion but not until root formation has begun.
The usual sequence of appearance in the mouth is shown in Table
6-2. The precise time of arrival of each tooth in the l1Jouth is not
FIG 6-8.
too important unless it deviates greatly from the averages (Fig 6-
Variability of ages of emergence of primary teeth. (Adapted from
8).54.60.61.66 There are no clinically significant sexual differences
Lysell. L, Magnusson B, Thilander B: Time and order of eruption of
in primary tooth emergence.
the primary teeth. A longitudinal study. Odontol Rev 1962; 13:217-
Hatton,'l in a study of primary tooth eruption and emergence 234, and Leighton BC: Eruption of deciduous teeth. Dental Practi-
in twins, has shown no left-to-right differences or differences tioner 1968; 200:836-842.)

TABLE 6-1.
Average Age for Critical Events in Primary Tooth Formation
,. CROW/I$.COMPLETED ROOT COMPLETED
(POSTNATAL AGE. MO) (YR) .,
91'/2
611
MAXILLA ONSET
2'/2 3
9
2'/2 OF CALCIFICATION
16
1014
MANDIBLE
17
(INTRAUTERINE
5'/2
18 (mandible),
15'/2 AGE, 19WK)
PRIMARY TOOTH MANDIBLE MAXILLA
232'/2
(maxilla) 3'/,
1'/2
32'/,
3'/,1'/2
1'/2

Modified from Lunt RC, Law DB: A review of the chronology of calcification of deciduous teeth. J Am Dent
Assoc 1974; 89:599-606.
 9.73
8.74
4.10
6.63
4.64
6.61
7.71
5.29
0.35
8.84
6.76
0.47
0.33
0.35
196
144
194
195
175
SD
SD
N
6.74
9.90
0.52
5.82
4.06
5.26
5.84
0.43
0.49
0.65
7.82
0.31
0.53
0.34
0.37
193
4.68
169
171
OA6
OA8
OA9
OA7
OA3
6A8
6A1
OA3
DAD
(MM)
(MM)
(MM)
(MM) 214
144
213
182
189
MEAN 209
166 NFEMALE
212
Development 107
of the Dentition and Occlusion
TOOTH
Lateral
Canine
Lateral
Mandibular
First
Second
First incisor
incisor
molar
molar
molar velopment. Universityof
CentralDevelopment
Occlusal incisor Ann
Michigan.
Arbor.MALE
Mich.Center
1978. Reproduced
for Human
by permission.
Growth and De-
Maxillary
From Moyers RE. van der Linden FPGM. RioloML.et
MEAN al: Standards of Crown Sizes of Primary Teeth White
Diameters
Human
of North American Children)
(in This Case Mesiodistal Crown
TABLE 6-3.
J:
-
---
WHITE BOYS
WHITE GIRLS ,,/
" /'

I-
w
Female
Ad vancement I"
,,"

W
I-
Cfl

o::J::J
o
U
W
o
20
o
I..L..

I8 - BLACK BOYS _.
0:: 16 --- BLACK GIRLS,,/.
W Female ,,"
CD I 4 Advancement"
~
::J
12 -...... I
10 Male '/
Z Advancement /.
...J '2
~ +2.0 "'mU)
~~
oI- ~ )sI
4
2
o
~/
v._/ o ~::tJm
-2.0 Z~x
27 30 ~

FIG 6-9.
Differences in times of emergence of primary teeth for North Amer-
ican blacks and whites. (Adapted from Infante PF: Sex differences
in the chronology of deciduous tooth emergence in white and black
children. J Dent Res 1974; 53:418-421, and Infante PF: An epide-
miological study of deciduous tooth emergence and growth in white
and black children of southeastern Michigan. Ecol Food Nutr 1975;
4:117-124.)
sors. It is clear that common control mechanisms operating from
prenatal time through the period of permanent crown formation
are responsible for primary-permanent crown size correspond-
ences. However, the values are so low that "prediction" of per-
manent diameters is manifestly impossible given only the size of
the primary crowns.

c) Teeth and Systemic Disturbances e) Anomalies

Disagreement as to whether teething is responsible for systemic
disturbances is very prevalent among dentists, physicians, and
parents. Parents often report various symptoms and signs, including
vomiting, fevers, and diarrhea, in association with teething.
Although about one-third of all children record no symptoms during
teething, 60% of infants exhibit disturbances such as rhinorrhea,
irritability, and diarrhea which occur for a short time before tooth
eruption and resolve after tooth emergence."' More serious
symptoms such as upper respiratory infection, febrile'convulsions,
wheezing bronchitis, and infantile eczema, which are often attributed
to teething, have been shown to be unrelated to tooth emergence. '2
"Teething" as a diagnostic label should be avoided by physician
and parent for all but the most trivial symptoms. Parents may be
apathetic about children's complaints during times that teeth are
erupting and, as a result, severe upper respiratory diseases and
fever caused by other extra-oral complications may be overlooked.
d) Size and Shape of Primary Teeth
Good data on the size of primary teeth are available (Table
6_3).70 Primary teeth in boys are generally larger than those in
girls, but the sexual dimorphism is not as marked as in the permanent
dentition. Primary tooth size and its mineral mass are largely
inherited. There are important differences in tooth sizes between
North American blacks and whites. However, racial and ethnic
differences in the size and shape of primary are not as thoroughly
documented as are those of the permanent teeth.
Several attempts have been made to "predict" the size of the
permanent teeth diameters from the size of the primary predeces-
Anomalies of crown development are seen less frequently in
the primary than in the permanent dentition and it is rarer for
primary teeth to be congenitally missing, although thorough studies
of this problem are not as plentiful as for the permanent dentition.
Fewer than I% of all children have congenitally missing primary
teeth, the most frequently missing being the maxillary lateral in-
cisors, the maxillary central incisor, and the first primary molar,
in that order.
f) Primary Tooth Resorption
It is common to suppose that the eruption of the permanent
tooth is the sole factor causing primary tooth resorption; this is
rIot the case, since the primary tooth may resorb even in the absence
of the permanent successor.75 The basic pattern of primary tooth
resorption is hastened by infIamri1ation and occlusal trauma; it is
delayed by splinting (as when a space-maintainer is attached to
the crown) and the absence of a permanent successor. 74
• "g) Ankylosis of Primary Teeth
Primary teeth, particularly molars, may become ankylosed
(fused) to the alveolar process and their eruption prevented. Al-
though permanent teeth can become ankylosed too, primary teeth
are more likely to be involved and lower teeth twice as often as
upper.) There is little evidence that ankylosis is a random phe-
nomenon; nor is it due to trauma or recessive pressure, although
this often is said to be the cause.) The etiologic picture is not yet
clear, but ankylosis occurs during the normal physiologic resorp-
tion of teeth. Resorption is an intermittent process, and it is during
108 Growth and Development
the rest periods of resorption of dentin when the periodontal lig-
ament has already been resorbed, that the osseous bridging and
fusion'between bone and dentin occur, The majority of ankylosed
primary teeth are observed in the late primary and the mixed
dentitions, The condition often is bilateral and -a posterior open
bite appears as the occlusal level of the ankylosed· teeth fails to
keep up with the vertical development of adjacent teeth. Ankylosed
teeth often are referred to as "submerged teeth" -an unfortunate
misnomer, since they do not submerge. Treatment of this condition
is described in Chapter 15.
2. Development of the Primary Occlusion
. a) Neuromuscular Considerations
The neuromuscular regulation of jaw relationship is important
to the development of primary occlusion. Interdentation occurs
sequentially, beginning in the front as the incisors erupt. As other
new teeth appear, the muscles learn to effect the necessary func-
tional occlusal movements. There is less variability in occlusal
relationships in the primary than in the permanent dentition, since
the primary occlusion is being established during periods of ready
developmental adaptation. The teeth are guided into their occlusal
position by the functional matrix of muscles during very active
growth of the facial skeleton. Undoubtedly, the low cusp height
and ease with which the occlusal surfaces wear also contribute to
the adaptability of the primary occlusion. Definitive studies of
interrelationships between skeletal morphology and primary oc-
clusal relations are, unfortunately, lacking. Leighton,55 in one of
the few quantitative studies available, has shown that where per-
sistent sucking habits occur, there is a significantly larger mean
overjet as early as 8 months and the difference increases with age.
Some feel that this is the result of endogenous patterns of oro-
muscular behavior arising independent of skeletal morphology. It
is also held that the muscle behavior is adaptive to the skeletal
morphology. Leighton' s data do not exclude the possibility that
the abnormal sucking habits could arise from environmental con-
ditions (methods of feeding, use of pacifiers, and so forth) and
that the persistent sucking habits either largely cause the skeletal
differences or contribute to them. This latter hypothesis is the one
best supported by experimental data on animals. It must be men-
tioned again that even Leighton's splendid study did not apply
cephalometric analysis until the subjects were 3 to 4 years of age.
When teeth are erupted and muscles are functioning, the arch
formed by the crowns of the teeth is altered by muscular activities,
although the original arch form is probably not determined by the
muscles. As the primary teeth are formed, the alveolar processes
develop vertically and the anterior intermaxillary space is lost in
most children.
b) Primary Dental Arches
Most primary arches are ovoid and display less variability in
conformation than do the permanent arches (see Fig 6-44). Usu-
ally, there is generalized interdental spacing in the anterior region
which, contrary to popular opinion, does not increase significantly
after the primary dentition is completed.2 In fact, it has been found
that the total interdental spacing between the primary teeth de-
creases continually with age. I Although the spacing is most likely
to be generalized, there is no pattern of spacing common to all
FIG 6-10.
Arch dimensions. A, arch length. 8', bicanine diameter. £32, bimolar
diameter. C-C, arch perimeter or arch circumference.
primary dentitions. Somewhat wider spaces, usually found mesial
to all the maxillary cuspids and distal to the mandibular cuspids,
are termed' 'primate spaces," since they are particularly prominent
in the dentitions of certain lower primates.
At birth, the primary arches are almost wide enough to hold
the primary incisors. In the early stages of development, the tongue
seems important in the shaping of the dental arches, for the primary
dentition is molded around it, but its role diminishes with age, the
establishment of occlusal reflexes, and the more mature activities
of the lips after the eruption of the incisors and the cessation of
nursing.53 The anterior part of the dental arches increases slightly
from birth to 12 months and changes very little thereafter, though
the increases are a bit greater in the maxilla than in the mandible
(Fig 6-10, 6-26, and 6-27). Posterior diameters increase more
markedly than those in the front of the arches (see Fig 6-28). For
the first 6 months it accelerates and even exceeds, in some di-
mensions, the maxillary. 80 Dimensional increases in the arches
seem to be associated with eruption of the primary teeth. Palatal
vault width increases from birth to about 12 months and remains
relatively constant throughout the first 2 years.
c) Occlusal Relations
At birth, when the gum pads are in contact, the mandibular
arch is posterior to the maxillary, though this difference reduces
progressively up to 21 months. Attempts to register a specific
"occlusal relationship" or "centric" at this time have been fruit-
less. With the eruption of the primary first molars the first three-
dimensional occlusal relationship is established.
The primary posterior teeth occlude, so that the mandibular
cusp articulates just ahead of its corresponding maxillary cusp (see
Fig 6-44). The mesiolingual cusp of the maxillary molars occludes
in the central fossae of tbe mandibular molars, and the incisors
ar~:Vertical, with mini~~1 overbite and overjet. The mandibular
second primary molar usually is" somewhat wider mesiodistally
than the maxillary, giving rise, typically, to a flush terminal plane
at the end of the primary dentition (Fig 6-11 )-a point of con-
siderable clinical significance. Interproximal cavities, sucking hab-
its, or the skeletal pattern may produce a "step" rather than a
flush terminal plane.
When the terminal plane is straight until the arrival of the
first permanent molars, the latter are usually guided into an initial
end-to-end relationship (Fig 6-12) considered "normal" for whites
 Development of the Dentition and Occlusion 109

FIG 6-11.
A, the two primary second molars in occlusion. Note that although
th-ere is a Class I molar relationship of the mesial surfaces (left),
there is a flush terminal plane on the distal. e, primary and permanent
tooth size relationships in the lateral segment of the dental arch. The
average leeway space in the mandibular arch is greater than in the
maxillary arch. This large difference in leeway space between the
two arches is a factor that permits the late mesial shift of the man-
dibular first permanent molar in some instances_ Note that the figures
shown are mean values. When development of a tooth size-arch
space problem is expected during the mixed dentition, it is important
to compute actual tooth size-space relationships for that particular
mouth. Mean values are of interest but they will not provide the
diagnosis for an individual case.

3 YEARS OLD

5 YE.ARS OLD :, YEARS OLD

7 YEARS OLD 7 YEARS OLD

I:' YEARS OLD

FIG 6-12.
Two patterns of dentitional exchange. A, normal patterns of devel- be normal but that in e
to be more nearly ideal. The changes seen
opment during the transitional dentition. e, more favorable patterns in column A correspond to the theories of Baume,2 while those in
sometimes seen in people living on a diet coarser than that usual to column e represent the ideas of Friel.'8
North Americans. We may consider the pattern of transition in A to
110 Growth and Development

in North America. Among people whose diet includes coarse,
rough food, for example, Eskimos, North American Indians, and
Greek .mountaineers, the occlusal surfaces of the primary teeth
wear to a great extent. This removal of cuspal interferences permits
the mandible, which is growing more at this time-than the maxilla,
to assume a forward position more easily (Johns EE, Moyers RE,
unpublished data). Under these circumstances, the result for Greek
mountain children at age 5 or 6 often is more edge-to-edge incisal
relationship and a distinct mesial step terminally. When such con-
ditions occur, the permanent incisors erupt with less overbite and
the first permanent molars erupt at once into a firm neutrocclusion.
In contrast, children without natural occlusal wear presumably
adopt a temporary functional retraction of the mandible during
clo~ure, since the relatively greater anteroposterior growth of the
mandible produces natural occlusal interferences, usually in the
cuspid region.68
The overjet diminishes markedly during the first 6 months of
life, especially in those children who are to have normal occlusions
later. 55 These anteroposterior changes are associated with skeletal
growth; however, it has been shown in several studies that sucking
habits impede the arrival of a balanced incisal relationship.83 The
cuspid relationship steadily changes too until at age 3 years nearly
one-half of children have a complete Class I cuspid relationship.
The anteroposterior relations of the first primary molars on the
average change slightly and steadily in a fashion similar to that of
the cuspids until about 6 years in girls and 8 years in boys~ None
of the anteroposterior occlusal changes in incisors, cuspids, or
primary molars are related to dental age or dental developmental
events. Second primary molars behave similarly, but more dra-
matic change in occlusion may accompany their loss. The vertical
overbite decreases steadily during the primary dentition, a reflec-
tion of the skeletal maturation.
There is now abundant research proof that the functional
environment can alter greatly the growing 6aniofacial skeleton
and its growth and hence the occlusal relationships (see Chapter
4). Particularly, it has been shown that altering the occlusal pattern
evokes new neuromuscular responses which, in turn, change the
skeletal morphology and finally can produce even severe maloc-
clusions.64 It is likely that much of the occlusal vanability once
considered of "genetic" or "unknown" origin has its beginnings
in altered occlusal and neuromuscular function at an early age. A
discussion of the various patterns of occlusal change during the
mixed dentition appears later in this chapter (see Section G).
In general, a normal primary dentition allows a practitioner
to be more encouraging about developing a normal mixed and
adult dentition. The following normal signs of a primary dentition
should be noted:
a) Spaced anteriors,
b) Primate spaces,
c) Shallow overbite and overjet,
d) Straight terminal plain,
e) Class I molar and cuspid relationship,
f) Almost vertical inclination of anterior teeth,
g) Ovoid arch form.
d) Disorders of the Primary Occlusion
The prevalence of all mal occlusions in the primary occlusion
is not as thoroughly reported as it should be. The data we do have
indicate that malocclusion varies greatly with the population stud-
ied and the method of notation. Ethnic and cultural features are
important not only for the obvious skeletal differences but because
some cultures show much less thumb-sucking and other oral habits
than others, thus having an effect on the percentage of children
displaying posterior crossbites, open bites, and Class II
mal occlusions .47
Some of the specific malocclusion traits in the primary qen-
tition are shown in Table 6-4. Note the significant racial differ-
ences shown in North American children studied by the same
investigator:' Boys tend to have more C1~ss 11 and Class III molar
relations in the primary dentition than girls, and the prevalence of
Class 11 malocclusions decreases during the primary dentition period.
Bruxism in the primary dentition is a special problem which
might be termed a "functional malocclusion." It is found in a bit
less than 10% of all children during the primary dentition. It is
almost always unconscious being manifested by occasional or
habitual grinding or clenching of the teeth, and it is not necessarily
pathogenic. Investigators have concluded that a genetic factor is
involved, and psychosomatic symptoms have been significantly
correlated with bruxism in children. 52 Allergy has also been claimed
to be a factor. 63

TABLE 6-4.
Prevalence of Certain Malocclusion Traits in 3-Year-Old Children
PREVALENCE
TYPE POPULATION INVESTIGATORS -- (%)

Lingual crossbite English Foster and Hamilton" 4.0

I Finnish Jarvinen and Lehtinen47 7.7
N Amer white . Infante45 ,. 7.1
,. N Amer black "lilltante45 •• 2.1
Class II molar relationship N Amer white Infante45 23.5
N Amer black Infante45 4.3
N Amer Indians Infante45 2.7
Class 11cuspid relationship English Foster and Hamilton" 45.0
"Excessive" overjet Finnish (6 mm) Jarvinen and -Lehtinen4? 16.2
English (2 mm) Foster and Hamilton'? 72.0
English Foster and Hamilton'? 24.0
Open bite
Class III molar relationship N Amer white Infante45 1.0
N Amer black Infante45 7.1
N Amer Indians Infante45 8.0
 Development of the Dentition and Occlusion 111

i~if I&~~ 10. Apical end of root completed

iiif II~I 9. Root almost completed, open apex

ti~~m !~~I 8. Two thirds of root completed

mQ~g ~00~ 7. One third of root completed

FIG 6-13.
:!."" •• ~

~~@~ O. Absence 0000

~eea
QQQQ
@~G~
6.of
QOQC)
~~(@a
~.
5.
4.2.
3.
Crown
1. Crown
Presence
crypt
One
Two
completed
ofofofcrypt
almost
Initialthirds
third completed
calcification
crown
crown completed
completed Stages of tooth development based on the work of
Nolla.72 The radiograph is compared with the draw-
ings, and each tooth is given a developmental score
according to the drawing that it most nearly approxi-
mates. If the development of the tooth should lie be-
tween two stages, half values or plus scores may be
used.

Our understanding of the early signs and symptoms of po-
tentially severe malocclusion as viewed in the pri'TIary dentition
is really not very good at this time. Several retrospective studies
reveal that we are not able to predict the features of malocclusion
in the permanent occlusion very well from study of the primary
dentition. It may be that we are looking at the wrong things in
very young children, it may be that the signs are more subtle than
we have known, and it certainly is true that we have much to
learn. Some points have been made clear, however-sucking hab-
its have been repeatedly shown to be involved in the origin of
some malocclusions,55. 87 the skeletal pattern dominates severe mal-
occlusion even in the young, and terminal plane relationship of
the second primary molars can be very misleading as a diagnostic
feature. 68
D. DEVELOPMENT OF THE PERMANENT
TEETH
1. Calcification
Although the calcification of the teeth has been studied in
many ways, serial radiographic methods are the most practical,
since the clinician evaluates patients' dental development from
similar data. Nolla72 arbitrarily divided the development of each
tooth into ten stages (Fig 6-13). The mean stages of calcification
reached by each tooth for ages 3 to 17 years are shown in Table
6-5,A and B. It should be noted that this is an ordinal scale;
}herefore, it cannot be assumed that the quantitative amounts of
tooth material laid down during one stage are the same as during
another. Important stages to remember are stage 2 (initial calci-
fication) and stage 6 (the time teeth begin eruptive movements).
A verage root length development at the time of emergence from
the alveolar process is shown for several posterior teeth in Figure
6-l4 and Table 6-5,C ~nd D.
-Girls are more advanced in' calcification of permanent teeth
than are boys at each stage and more so in the later stages. Sex
differences for tooth calcification are less than for bone development.
Since girls are well ahead of boys by 10 years of age, the differences
cannot be the result of the timing of the secretion of sex hormone. 32
The variability in calcification of the' permanent teeth is much
greater than usually is assumed, probably because the most popular
"standards" of tooth development distributed to the dental
profession were derived from very small samples. In truth, the
variability of tooth development is similar to that for eruption,
 8
~-••112
7
10 916
66615
1411
5
13
12
10 107
18
17
6+8
7
10 98
8+
10 97 98
98999 8+
8
7+
8+
78+ 9 7-998
78
7 8 9 7+ 9
..
••...
...
:;8=
:a
::;
.I:l
76+
76
46
56
5
6
7
4
5
6
810
+ 9 8
8 10
8+
3 Growth and Development
4 7
.. Calcification of Permanent Teeth AGE
A, Boys (Nolla
TABLE 6-5. Stages)

sexual maturity, and other similar growth indicators. 33. 56
Definitive serial studies of racial differences in calcification
have not been published, but such differences must indeed exist
because of the well-documented racial differences in time of
emergence. Similarly, the impact of socioeconomic status on
calcification can be deduced from detailed reports of significant
differences in timing of emergence due to economic status. 34
2. Eruption
a) Interrelationships Between Calcification and Eruption
Eruption is the developmental process that moves a tooth from
its crypt position through the alveolar process into the oral cavity
and to occlusion with its antagonist. During eruption of succe-
daneous teeth, many activities occur simultaneously: the primary
tooth resorbs, the root of the permanent tooth lengthens, the al-
,.
veolar process increases in height, and the permanent tooth moves
through the bone (Fig 6-15). Although all these processes are
interrelated, they are more independent than once thought. Teeth
do not begin to move occlusally until crown formation is complete,
but the rate of their eruption does not correlate well with root
el2ngation (Fig 6-l6)~ 'Procedures, for predicting emergence of a
permanent tooth in the mouth is described in Chapter 11.
Permanent teeth do not begin eruptive movements until after
the crown is completed (see Fig 6-16). They pass through the
crest of the alveolar process at varying stages of root development
(see Fig 6-14). It takes from 2 to 5 years for the posterior teeth
to reach the alveolar crest following completion of their crowns
and from 12 to 20 months to reach occlusion after reaching the
alveolar margin. The roots usually are completed a few months
after occlusion is attained. The moment of emergence into the oral
cavity often is spoken of as the "time of eruption." Intra-oral
 Dev,elopment of the Dentition and Occlusion 113

TABLE 6-5. Continued

C, Mean Root Lengths (mm) for Mandibular Teeth by Chronologic Age
3.7
2.7 MALE
3.7
2.5
10.65.3
3.0
13.05.3
4.2
1.2
1.4
.6.8
19.317.7
8.0
19.017.4
4.6
6.010.9
15.9
13.0
11.2
12.5
14.6
17.0
11.8
14.6
7.1
7.8
17.4
14.5
17.8
15.7
13.4
3.7
12.4
15.2
16.1
17.0
16.2
4.5
2.2
2.1
3.2
12.3
12.0
7.1
13.1
12.1
14.9
2.8
4.3
7.9
2.0
6.4
4.6
9.7
n.a.
1.1
1.7
.6
.9
18.817.1
18.616.4
17.614.4
14.2
15.0
13.9
13.4
5.2
14.0
17.6
9.7
17.1
10.4
15.1
16.8
16.5
3.4
15.6
16.6
15.5
15.8
4.8
15.3
14.4
2.0
2.6
5.3
10.1
12.6
11.7
13.2
15.2
1.6
15.0
8.9
5.4
10.2
14.6
5.6
3.1
1.9
7.3
8.8
6.2
SECOND
SECOND
BICUSPID
CANINE
MOLAR
BICUSPID
n.a.MOLAR
FIRST
MOLAR FIRST FIRST FEMALE

D, Mean Root Lengths (mm) for Maxillary Teeth by Chronologic Age

10.3 16.4
12.5
16.3
15.3
18.517.2
4.1
6.4
19.218.2
11.7
13.5
14.7
15.4
10.6
11.4
12.8
14.5
15.0
3.6
4.1
4.7
8.6
4.2
5.6
6.8
14.2
17.6
15.1
16.5
11.7
12.8
11.4
16.2
16.6
5.9
6.3
15.5
11.1
4.1
9.2
3.0
4.3
4.5
14.2
15.6
15.7
7.0
11.0
14.3
15.9
6.3
7.6
8.8
15.5
9.2
5.0
5.7
6.8
9.0
17.4
15.3
16.8
17.0
14.0 MALE
16.815.9
5.3
3.7
8.1 13.5
13.3
12.3
18.917.8
12.411.6
14.513.9
'16.7
15.9
13.9
3.5
3.4
5.3
7.3
8.3
16.1
16.9
10.0
13.7
14.6
4.6
9.8
3.1
2.5
5.2
7.8
7.3
2.8
3.6
5.6
13.4
15.4
15.2
5.4
9.6
9.5
8.1
9.3
18.917.9
SECOND
FIRST
FIRST
BICUSPID
CANINE
MOLAR
BICUSPID
MOLAR
MOLAR FIRST FIRST FEMALE

35-40 % 70% 50% 50% 25-30% tD

E
FIG 6-15.
Developmental processes during eruption of succedaneous teeth. A,
FIRST CUSPID FIRST SECOND SECOND
MOLAR BICUSPID BICUSPID MOLAR elongation of the permanent root. B, resorption of the primary pred-
ecessor. C, movement of the permanent tooth occlusally. D, growth
FIG 6-t4. of the alveolar process. E, the inferior border of the mandible, which
Crude approximations of mandibular root lengths at the moment of shows much less growth activity than the other four processes.
emergence through .the alveolar crest.
114 Growth and Development

eruption achieves in a few months the first half of the crown's
exposure, but its emergence occurs at a progressively slower rate
thereafter. Figure 6-16 depicts in graphic form the relationships
between calcification and eruption for selected teeth. Note care-
A has clinical significance. Eruptive movements do not correlate well
"~
fully the common pattern of eruptive movements beginning as root
formation starts.
Various theories of eruption have been proposed, studied, and
debated for some time. This is no place to continue such interesting
arguments without new data, but some of the research on eruption
with the amount of root lengthening, and rat's teeth have been
shown to erupt when the roots have been destroyed experimentally.
Further, it has even been suggested that the teeth erupt, allowing
the roots to grow, and, therefore, root elongation might better be
thought of as a result of eruption rather than one of its causes.
Melcher and Beertsen65 present a useful, current review of our
knowledge of eruption.
Figure 6-17 depicts the mean values for time of emergence
of the permanent teeth for North American white children and
estimates of the range of variability.

b) Factors Regulating and Affecting Eruption

It is unfortunate and remarkable how few details we know
1 about some of the factors affecting eruption. Both the sequence
10 12 14 16 18
and timing of eruption seem to be largely gene determined. Further,
AGE (Years)
there are sequences and timings of eruption that are typical for
B
mm certain racial groups; for example, Europeans and Americans of
FEMALE MANDIBULAR FIRST BICUSPID
European origin tend to erupt their teeth later than American blacks
and American Indians. 20 Most studies of eruption in humans are
36
42~
based on radiographic data or intra-oral visualization of the effects
of the basic biologic mechanisms. We know much about when
eruptive events are seen clinically. What is not known is how
24 • ~-J..- ..•.- genes mediate the fundamental processes of calcification and
t>.\~ea;~!..£~':s~_/~,:"_-~.?'"
30 L~O~-:'-~CI~US!2.0!...1
[ /-::::-=-..:-=-~ eruption.
------- ~PI~an~e~__ .
,•..........
/ •
-~.::,::,:::::c-::. ='='W'
Thorough study of the impact of economic status on tooth
18f-L ~~:':..
,,1\\> ..... /./ / emergence has shown that the teeth of both North American blacks
•...-;: .•• \ (}o"';/
and whites at the poverty level (income-to-needs ratio = I) tend
12r --
_ ... ~'\ ce(~.':':~--·/
to be delayed in emergence when compared with children of me-
6 - ...-
dian per capita income.34
f <_._.End of R0:t There are important racial differences in timing of permanent
OL--'----'_-'----'_~~_~~_~~_~~_~~__,_
4 6 8 10 12 14 16 18 tooth emergence, differences apart from socioeconomically caused
AGE (Years)
variations. North American black boys and girls showed system-
c atically earlier emergence of all teeth when compared with low-
income North American white children of European ancestry. 43.44
The greatest differences were for incisors and molars; the least,
for cuspids and premolars. When economic status is similar the
me;m difference between races is approximately 0.3 standard
deviations. 34
The nutritional influences on calcification and eruption are
relatively much less significant than the genetic, for it is only at
the extremes of nutritive variation that the effects on tooth eruption
have .peen shown.25 This,should not be surprising, for it is well
known'that both calcification and eruption are less responsive to
endocrine disturbances than is skeletal development.'7.40
Mechanical disturbances can alter the genetic plan of eruption,
as can localized pathosis. Periapical lesions, pulpitis, and pulpo-
4 6 8 10 12 14 16 18 tomy of a primary molar will hasten the eruption of the successor
AGE (Years) premolar" (Fig 6-18). If the primary tooth is extracted after the
FIG 6-16. permanent successor has begun active eruptive movements, the
permanent tooth will erupt earlier. If the primary tooth is extracted
A-C, tooth development and eruptive movements in females. Plots
for males are similar but generally later at each stage. prior to the onset of permanent eruptive movements (prior to root
formation), the permanent tooth is very likely to be delayed in its

-..
 Development of the Dentition and Occlusion 115

Gi rls Boys

Moxi 110

FIG 6-17.
~\;:,
o 0 Emergence of permanent teeth. A, mean times and
± 1 standard deviation (late and early). e, average
Years Year, number of emerged teeth by age and sex. (Adapted
from Moyers RE, van der Linden FPGM, Rialo ML, et
al: Standards of Human Occlusal Development. Ann
Arbor, Mich, Center for Human Growth and Develop-
ment, University of Michigan, 1976. Used by permission.)

Mond i ble

Gi rls Boys

•.
B 21.58
22.39
10.32
11.26
10.68
3.99
96
846.56
1.18
2.53
0.67
1.71
1.57
72
.54
25.10
25.18
92
10.11
13.53
13.64
12.23
12.47
12.63
14.87
17.24
18.39
13.24
11.66
12.31
12.88
6.10
6.97
9.09
9.84
4.35
5.56
8.15
4.49
5.62
5.69
27.35
13.69
13.65
27.89
14.02
13.76
~84
11.70
98
>~.6.45
2.46
2.23
4.03
13.36
6.40
8.00
96
89
27.16
26.76
55
27.48
13.79
13.71
27.40
13.87
(SD) N
81
84
89
9.90
6.54
70N72
72
578.49
70
.87
42
4692
98
87
70
98
87
55
38
49
98
70
49
42
34
42
34
46
25
46
25
96
81
(SD)89
57
6.87
87
96
89
55
38
(4.81)
5.49, MEAN
MEAN
LOWER
MEAN
UPPER
TOTAL
LOWER
(3.51)
(1.66)
(4.82)
(2.58)
(1.39)
(2.80)
(1.80)
(2.71)
(1.92)
(2.38)
(2.74)
(2.65)
(2.47)
(2.65)
(1.72)
(0.85)
(2.79)
(1.49)
(1.23)
(0.97)
(1.08)
(1.13)
(0.92)
(1.86)
(2.42)
(0.87)
(3.33)
(1.92)
(2.27)
(0.70)
(3.71)
(1.64)
(1.46)
(2.16)
(0.95)
(1.51
(1.97)
(1.90)
(1.30)
(2.09)
(.68) )
(0.56)
(1.37)
(0.72)
(0.69)
(1.35)
(0.45)
(0.50)
(0.66)
(0.76)
(1.30)
(1.29), FEMALE

MALE
116 Growth and Development

FIG 6-18.
Alteration in eruption due to a pathologic lesion at the apical area of first bicuspids. Radiographs were taken at yearly intervals. A, 6 years;
a primary molar. Compare the eruption of the left and right mandibular B, 7 years; C, 8 years.

'.
 Development of the Dentition and Occlusion 117

eruption, since the alveolar process may reform atop the successor BOYS
tooth, making eruption more difficult and slower. The possible
effects of extraction of the primary tooth on the eruption of its
successor cannot be correlated well with the chronologic age of
! ~~t? '! UPPER

the subject (although this is frequently done in research~ papers)

but can be related to the stage of development of the permanent
tooth. It also has been shown that crowding of the permanent teeth 6 7 8 13 YEARS

i
L
affects, to a small degree, their rate of calcification and eruption.5 2
Intrusion or exarticulation of the primary incisors may occur ac- r
LOWER
cidentally during early childhood, resulting in disturbances in mi-
neralization of the permanent successors in some instances and
even occasionally intrusion of the permanent incisor. On rare oc- GIRLS
casions the injury is so severe that the permanent tooth cannot
erupt normally. Early treatment, during the stages of root for-
mation, improves the chances for normal root development of the ~t? [ !of
UPPER

permanent incisor. Primary anterior teeth which have suffered

trauma must be reviewed periodically by the clinician ~ to identify
any conditions which may be harmful to the normal eruption of
the permanent successor.
3
6
i . 5..1
4
7
2
8
.
9 10 11 12 13 YEARS

LOWER
c) Timing and Variability of Eruption
The constant referral to tables showing mean times of eruption
often obscures, in my opinion, the wide variability seen in time
of intra-oral emergence. Study of Figure 6-17 will reveal that in
fully 10% of all children, the "6-year-molar" will emerge either
earlier than 5.0 years or later than 8.0 years and the so-called" 12-
year molars" will appear earlier than 9.6 years and later than 15.2
years. Eruption timing tends to be earlier in American Negro and
American Indian populations and in Asiatics than in Americans
of European orgin. Moreover, timing of emergence tends to be
systematically late within lineages. Finally, timing is correlated
within a dentition; that is, those children who erupt any tooth early
or late tend to acquire other teeth similarly early or late.
d) Sex Differences
Except for third molars, girls erupt their permanent teeth an
average of approximately 5 months earlier than boys (Figs 6-17
and 6-19). The true sex difference in timing of intra-oral emer-
gence is much less than the sex difference in the timing of ap-
pearance of most postnatal ossification centers, and the variability
of normal eruption timing is small when compared with the normal
variability in skeletal development.
e) Sequence of Eruption
The apparent sequence of calcification development is not a
sure clue to the sequence of emergence into the mouth, since the
factors regulating and affecting the rate of eruption vary among
the teeth. There is wide variability in the sequence of arrival of
teeth in the mouth; some of the variations are important clinically.
In the maxilla, the sequences 6-1-2-4-3-5-7 and 6-1-2-4-5-
3-7 account for almost half of the cases, whereas in the mandible,
the sequences (6-1)-2-3-4-5-7 and (6-1)-2-4-3-5-7 include
more than 40% of all children. 57 Some problems are introduced
in comparing various studies and in attempting to predict gingival
emergence from the radiograph. Cross-sectional studies in which
sequence is discussed are a special problem since the authors have
not studied sequence at all but have attempted to derive an assumed
FIG 6-19.
Normal order of eruption of the permanent teeth.
sequence. The rate at which the incisors erupt is much faster than
that of the molars at the time of immediate emergence into the
mouth. If one is seeing a child at 6-month intervals, for example,
it may look as if the incisor has come in first, whereas, in truth,
the molar has preceded it but is moving so slowly that the incisor
passes it by. Investigators who have studied eruption sequence at
short intervals tend to report the mandibular molars as erupting
first, 57 whereas those studying eruption at longer intervals tend to
note the central incisor as erupting first. 48 There seems to be no
clinical significance attached to either the 6-1 or 1-6 sequence.
On the other hand, the appearance of the second molar ahead of
the cuspids or premolars has a strong tendency to shorten the arch
perimeter and may create space difficulties. Fortunately, the most
common sequence in each arch (viz., maxillary 6-1-2-4-5-3-
(and mandibular 6-1-2-3-4-5-7) is favorable for maintaining
the length of the arch during the transitional dentition57 (Fig 6-
20).
fJ Eruption and Bodily Growth
. Tooth calcificatioIJj;orrelates positively in a rough way with
h~ight, weight, body fat, and ossification of wrist bones, but such
correlations rarely are significant therefore, their clinical useful-
ness is limited. 50 Many proper and even important research papers
on such correlations have appeared, which I do not intend to
demean, but the practical clinical applications of such data thus
far are very limited indeed except in the most obvious generali-
zations. The use of "bone age" derived from carpal radiographs
to plan orthodontic treatment to coincide with active periods of
bone growth, as for example the pubescent growth spurt, is quite
another matter and is on sounder theoretical ground.
118 Growth and Development
FIG 6-20.
Favorable eruption sequence, the most common of several favorable
sequences.57
g) Ectopic Development
Ectopic teeth are teeth developing away from their normal
position. The most common teeth found in ectopy are the maxillary
first permanent molar and the maxillary cuspid followed by the
mandibular cuspid, maxillary second premolar, other premolars,
and maxillary lateral incisors. Girls show significantly more tooth
germs in ectopy than do boys.
Approximately 3% of North American children may be ex-
pected to show ectopically erupting maxillary first permanent mo-
lars.20 Ectopic eruption of maxillary first molars is associated with
(1) large primary and permanent teeth, (2) a diminished maxillary
length, (3) posterior positioning of the maxilla, and (4) an atypical
angle of eruption of the first molar. 79 Treatment of ectopic eruption
is discussed in Chapter 15.
About one-half of all tooth germs in ectopy, other than first
molars, are maxillary cuspids, and two-thirds of all upper ectopic
cuspids are found in girls. The treatment for this difficult problem
is best begun early in dental development in order to utilize the
natural forces of eruption. Usually, surgical uncovering and pos-
sible repositioning are required before orthodontic tooth move-
ments are begun. Chapter 15 contains a discussion of the treatment
of ectopically erupting cuspids.
A differentiation should be made between ectopy and im-
paction. In the latter condition, teeth cannot erupt because of
impingement. Third molars and maxillary cuspids may be seen as
impacted, even though they began development in normal posi-
tions, and hence are not ectopic. In other instances; they may be
both ectopic and impacted. Mandibular third molars, the most
frequently impacted teeth, may begin development in a normal
position relative to the ramus but become impacted when the man-
FIG 6-21.
Stages of eruption. 1, pre-eruptive; 2, intra-alveolar; 3, intra-oral; 4, occlusal.
>
dibIe fails to grow sufficiently for resorption of the anterior border
of the ramus to permit their eruption. Transposition of teeth, a
very rare form of ectopy, typically involves exchanged positions
between cuspids and first premolars or cuspids and lateral incisors.
h) Factors Determining the Tooth's Position During Eruption
During eruption, the tooth passes through four distinct stages
of development (Fig 6-21). The factors that determine the tooth's
position vary with the stage. At the onset, the position of the tooth
germ is thought to be dependent on heritable traits. During intra-
alveolar eruption, the tooth's position is affected also by the pres-
ence or absence of adjacent teeth, rate of resorption of the primary
teeth, early loss of primary teeth, localized pathologic conditions
(see Fig 6-18), and any factors that alter the growth or confor-
mation of the alveolar process. There is a strong tendency of the
teeth to drift mesially even before they appear in the oral cavity.
This phenomenon is called the mesial drifting tendency. Once the
oral cavity has been entered (intra-oral or preocclusion stage of
eruption), the tooth can be moved by the lip, cheek, and tongue
muscles, or by extraneous objects brought into the mouth (e.g.,
thumbs, fingers, pencils), and drift into spaces created by caries
or extractions. When the teeth occlude with those of the opposite
dental arch (occlusal stage of eruption), a most complicated system
of forces determines the position of the tooth. For the first time,
the muscles of mastication exert an influence through the inter-
digitation of the cusps. The upward forces of eruption and alveolar
growth are countered by the opposition of the apically directed
force of occlusion. The periodontal ligament disseminates the strong
forces of chewing to the alveolar bone.
The axial inclination of the permanent teeth is such that some
of the forces of chewing produce a mesial resultant through the
contact points of the teeth, the "anterior component of force"
(Fig 6-22). The tendency forthe teeth to move forward as a result
of mastication and swallowing varies greatly according to the an-
gulations of the teeth with each other and is especially affected
by the steepness of the occlusal plane. Orthodontists pay particular
attention to the cant of the occlusal plane since the anterior com-
ponent of force is an important determinative factor in ease of
distal movements of teeth, stabilization of treated malocclusions,
and crowding of teeth after dental development and craniofacial
growth have diminished. The anterior component of force often
is'confused with the mesial drifting tendency. The former is the
result of muscle forces acting through the intercuspation of the
occlusal surfaces, whereas the mesial drifting tendency is an in-

FIG 6-22.
The anterior component of force.
herent disposition of most teeth to drift mesially even before they
are in occlusion. The anterior component of force is countered by
the approximal contacts of the teeth and by the musculature of the
lips and cheeks (Fig 6-23). The forces of occlusion may deflect
a tooth in another direction if the intercuspation is incorrect. Van
Seek,"7 in a most definitive study, altered the occlusal relationship
of monkeys' teeth and studied the effects on the anterior component
of force and mesial drifting. He concluded that occlusion plays a
more important role than the transseptal tissues in mesial migration.
The angle between the upper and lower teeth was a factor in the
rate and direction of migration. The role of erupting third molars
in mesial drift of anterior teeth appeared to be small, but the sample
size did not make possible firm conclusions about this point. Al-
though occlusal wear decreases the height of the crowns of the
teeth, it does not increase the interocclusal distance (freeway space),
FIG 6-23.
The position of the incisors relative to the lip and tongue posture.
Development of the Dentition and Occlusion 119
because alveolar growth compensates nicely throughout most of
life. As the crown diminishes in height, the alveolar height in-
creases a like amount.
E. THE PERMANENT DENTITION
During evolution, several significant changes took place in
the teeth and jaws. When Reptilia evolved into Mammalia, the
dentition went from polyphyodont (many sets of teeth) to diphyo-
dont (only two sets of teeth) and it went from homodont (all teeth
alike) to heterodont (different types of teeth, i.e., incisors, canines,
premolars, and molars).50 There also arose the necessity for teeth
and bone to develop somewhat synchronously in order that the
function of occlusion could be facilitated. The facial osseous struc-
tures also have changed markedly but not quite so radically. Fi-
nally, the number of cranial and facial bones has been reduced by
loss or fusion and the dental formula has progressed from
5-1-4-7 3-1-3-4
-4--1--4--7 in the mammal-like reptiles to -3-_-1_-3_-4-asa generalized
2-1-2-3
mammalian pattern to 2-1-2-3 as the generalized pattern for
primates. 50The first number is the number of incisors, the second
cuspids, the third premolars, and the fourth molars in each quadrant.
1. Size of Teeth
In humans there is strong evidence to support the idea that
tooth size is largely determined genetically, although there is ex-
perimental proof that extreme environmental variations such as
malnutrition can alter tooth size in certain animals.76-78 Marked
racial differences exist in the size of the teeth, with the Lapps
probably having the smallest teeth and Australian aborigines the
largest.23 The sex-size difference averages 4% and is greatest for
the maxillary canine and least for incisors (Table 6-6). There is
strong evidence of X-linkage in relation to tooth size, since sister-
sister correlations are higher than brother-brother and brother-sister
and female tooth size commonalities are greater than males.'o The
range of size encountered varies with the tooth and is much larger
than most dental anatomy books indicate. Since tooth size is so
variable and facial skeletal structures not only vary greatly but
also are more subject to varying environmental influences, one
frequently encounters in dental practice marked disharmony be-
tween the size of the teeth and the bones in which they are placed.
Tooth size and bone size seem to be under~ separate control mech-
anisms, an unfortunate biologic problem for clinical orthodontic
practice.
" Much recent researeh relates to the various theories about
"ge'Iretic fields" which produce cpmmunalities of size, shape, and
position during development. There are overlapping gradients which
produce patterns of similarity of a tooth with its antimere on the
opposite side of the same arch, its functional antimere in the
opposite arch, and other teeth in its own quadrant. The details of
this important research are beyond the range of this book, but the
clinical implications, as we now know them, can be
summarized-indeed, they must be, because they are so important.
Left-right size corre!ations are extrelpely h~gh for individual teeth
(average r = .9) and even higher if all teeth In a quadrant are
 120 11.53
10.29
10.18
10.57
10.35
10.74
11.76
6.50
10.58
191
196
145
148
138
160
161
143
134
100
192
140
112
127
N so
0.32
0.34
5.46
0.67
8.72
0.64
7.08
0.38
7.74
7.37
0.49
0.39
5.38
0.44
0.46
0.57
0.42
0.55
7.61
6.67
6.58
9.98
0.47
7.07
0.63
0.70
5.54
9.12
0.58
7.26
5.53
7.76
7.22
6.04
92
125
172
1220.74
0.58
0.73
0.56
0.64
0.63
0.72
0.36
7.49
0.71
6.76
7.99
6.88
7.41
10.94
11.28
11.04
9.50
10.71
158
0.56
0.53
0.43
6.94
5.99
6.86
0.51
0.50
0.37
0.40
6.96
6.89
5.92
8.19
7.66
7.25
6.13
7.85
99
8.79
189
156
102
(MM) SO
0.60
0.52
0.62
0.86
0.59
8.67
6.78
6.60
8.91
9.50
0.73
80
(MM)
0.46 201
212
152
157
121
216
208
214
153
142
104
158
159
1'48
150
147
132
115
MEAN 21580N FEMALE
146
148
136
170
Growth and Development
nden FPGM, Riolo
UsedML,
crown by etpermission.
Universityof
Development,
Central al:
dimension Standards
Michigan,
Monograph
incisor of 5.Used
of the1976. Human
permanent
Annby Occlusal
Arbor,
dentition
permission.Part
Michigan,
of American
Center
B from
Negroes.
RichardsonER,
for Human
Am J Growth
MalhotraSK:
Orthod 1975;
and Development,
68:157-164.
Mediodistal
Mesiodistal Diameters of Permanent Dentition*
MALE
A, North American TABLE Whites 6-6.

,.

summated. 2) In no place in the body is symmetry. so well and after noting one tooth's abnormality of size or development, looks
rigorously defined': Upper-lower size correlations also are high immediately for others in the most likely positions, namely, third
(average r = .7)Yln a general way, the more mesial teeth within molar, second premolar, and lateral incisor.
each group in each quadrant show the \east variability in development
and size2) (Fig 6-24). The most distal tooth within each group 2. Number of Teeth
displays the greatest variability in size, is the most apt to be
congenitally missing, and is most frequently abnormal in shape a) Missing Teeth
and aberrant in its calcification timing. The careful diagnostician, Complete absence of teeth is termed anodontia (no teeth),

FIG 6-24.
Genetic fields influencing dental development. The most distal tooth
in each field, marked X, is the most variable in development, size,
and shape and the one most apt to display agenesis.
and incomplete formation of the dentition is properly called oli-
godontia (some teeth). The latter condition is sometimes incor-
rectly termed' 'partial anodontia." Congental absence of teeth in
modem man may be an expression of anisomerism (i.e., a reduc-
tion of the number of teeth by loss or fusion).
In the United States of American between 2% and 7% of the
population have congenital absence of some tooth other than the
third molar (depending upon which research you read and accept).
Not including third molars, which are reported absent as much as
25% of the time in North American whites, 35teeth most frequently
absent are mandibular second premolars, maxillary lateral incisors,
and maxillary second premolars, in that order. Any tooth may be
congenitally absent, though these four account for the greatest
percentage of all missing teeth. Most studies claim that women
are more likely to have congenitally missing teeth than men. The
frequency of oligodontia is usually bilaterally equal except when
it involves the maxillary lateral incisors where the left tooth is
more often missing than the right, which may be related to the
fact that unilateral cleft palate is seen more frequently on the left
side.
Although congenital absence of teeth is known to result from
heritable factors, no single direct genetic mechanism has been
identified and the mode of genetic transfer is argued. Congenital
absence of teeth is also frequently associated with gross dyplasia
syndromes of far-reaching medical and developmental signifi-
cance. The dentist, when congenitally missing teeth are noted,
should extend the examination to look for developmental problems
elsewhere. Although it is possible that oligodontia seen alone is a
microform of systemic ectodermal dysplasia, in the majority of
cases it is more apt to be determined by a dominant autosomal
gene pattern with incomplete penetrance of the trait and variable
expressivity.39
The genetics of congenitally missing teeth is quite complex
and familial tendencies are well known and are of clinical impor-
tance. Not so appreciated are the relationships among agenesis,
delayed development, and size diminution (see Section E-l and
Fig 6-24). Lee Graber has written a very useful review of our
current knowledge of congenitally absent teeth in humans and its
inheritance patterns.39 Gam and his group35 have studied third
molars thoroughly and found that agenesis of third molars is related
to agenesis of other teeth, delayed calcification of other posterior
teeth, different developmental sequences, and smaller teeth else-
where in the mouth. In man, there is an evolutionary tendency to
Development of the Dentition and Occlusion 121
lose teeth and have smaller jaws, but these two trends do not seem
to be correlated.
b) Supernumerary Teeth
Supernumerary teeth are encountered less frequently than are
congenitally missing teeth. They occur more often in the maxilla,
particularly in the premaxillary region, than in the mandible, and
are seen about twice as often in men than in women. They may
be classified according to type:
a) Teeth with conical crowns are usually found at the max-
illary midline, either singly or in clusters. Often they erupt ectop-
ically and may even be inverted and erupt toward the nasal floor.
Teeth of this shape occur because they develop from only one lobe
at the time of odontogenesis. The most common example is the
so-called "peg" lateral incisor, which has only the middle de-
vel omental lobe.
b) Teeth of normal form and size that are supplemental to
those of the regular dentition.
c) Teeth showing variation in size and cuspal form. These
may be larger or smaller than normal or the occlusal surface may
be deeply pitted. They are recognized by their anatomy, however,
and are usually found near their "proper" place in the dental arch.
The microform maxillary lateral incisor is seen fairly often and
must be clearly differentiated from the "peg" lateral incisor. When
deciding whether to use supernumerary teeth of this category or
the normal tooth in the plan of occlusion, do not base the decision
solely on the shape and position of the crown: supernumerary teeth
frequently have abnormalities of root shape and development as
well.
F. DIMENSIONAL CHANGES IN THE
DENTAL ARCHES
Three sets of measurements often are confused: (1) the com-
bined widths of the teeth; (2) the dimensions of the dental arch in
which the teeth are arrayed; and (3) the dimensions of the mandible
or maxilla proper, that is, the so-called basal bone (Fig 6-25). It
may· seem paradoxic that during growth these values change in
different fashions (viz., the sizes of the teeth stay the same but
Dental Arch
Alveolar Arch .. f
Basal Arch
Fl~ 6-25.
The'Telationship of the three arches. The basal arch is largely de-
termined ,by the configuration of lhe~mandibTeitselCThe alveolar arch
[oins the tooth to the basal arch and thus is 'always a compromise
in size and shape between the basal arch and the dental arch. The
dental arch reflects the relationship between the combined sizes of
the crowns of the teeth, tongue, lip, and buccal wall function, an-
gulation of the teeth, anterior component of force, etc .. When the
combined mesiodistal diameters of the teeth are harmonious with
the size of the basal arch and the relationship of the maxillary to the
mandibular basal arch, the dental arch is synonymous with the com-
bined sizes of the teeth.
122 Growth and Development

A
B 28 Primary Permanent
27
26
~ 25
~ 24
w
~ 23
-.J
~ 22
::E 21
20
19

FIG 6-26. 246 8 18

MaAdibular bicanine width changes. A, the movement of the primary

cuspids distally into the primate spaces with the eruption of the per- C1.4 Primary Permanent
I
manent mandibular incisors. Note that if one is measuring the di- 1.2
I
ameter between the primary cuspids, a wider diameter is recorded 1.0
I
as they are pushed distally on the divergent arch. 8, bicanine width
~ 0.8
w I
versus chronologic age. C, bicanine width increments versus dental
age. 0 = moment of arrival of first permanent incisor. This chart ~ 0.6 I
shows clearly that primary cuspid movements distally are timed by ~ 0.4 I
-.J
the eruption of permanent incisors. (Adapted from Moyers RE, van :::! 0.2 + I
J:J
der Linden PGM, Riolo ML, et al: Standards of Human Occlusal cr'
::E 0.0
Development, Monograph 5, Craniofacial Growth Series. Ann Arbor,
Michigan, Center for Human Growth and Development, University
of Michigan, 1976.)
-0.2
-0.4
:+~
I

-2 o 2 4 6
YEARS

the circumference of the dental arch, wherein the teeth are placed,
diminishes), while the length of the mandibular and maxillary
bones increases. The size and shape of the arches are first deter-
mined by the cartilaginous skeleton of the fetal maxilla and man-
dible."' A close relationship then develops between the tooth germs
and growing jaw bones, but dental arch size does not correlate
well with the sizes of the teeth contained within it. In this section
the growth changes in the dental arches are discussed'. Tooth sizes
were dealt with earlier in this chapter. Growth of the bones of the
craniofacial complex is treated in Chapter 4.
The usual arch dimensions measured are (I) widths at the
canines, primary molars (premolars), and first permanent molars;
(2) length (or depth); and (3) circumference (see Fig 6-10). They
are discussed separately because they change somewhat inde-
pendently of one another and because there are misconceptions
which are more easily dealt with by discussing one dimension at
a time.
1. Width
It is important when studying width changes in the dental
arches to keep in mind three important facts:
a) Width dimensional increase involves alveolar process growth
almost totally since there is little skeletal width increase at this
time (none in the mandible) and it contributes little to dental arch
change.
b) There are important clinically significant differences in the
magnitude and manner of width changes in the maxilla and man-
dible. Dental arch width increases correlate highly with vertical
alveolar process growth, whose direction is different in the upper
than in the lower arch. 70 Maxillary alveolar processes diverge while
the mandibular alveolar processes are more parallel. As a direct
result, maxillary width increases are much greater and, a most
important clinical point, they can be more easily altered in treatment.
c) Dental arch width increases are closely related to the events
of dental development, less to the endocrinally mediated events
of overall skeletal growth such as the adolescent spurt in stature
(Figs 6-26 and 6_27)70
The intercanine diameter increases only slightly in the man-
di~le, and some of this increase is the result of the distal tipping
of the primary cuspids into the primate space, since the mandibular
incisors are not normally moved labially through time (see Fig 6-
26).
Note that in the mandible the only significant increase in
intercanine width occurs during the eruption of the incisors when
the'primary cuspids are m-;Jved distally into the primate spaces. It
does not widen significantly thereafter (see Fig 6-26). Because
the maxillary alveolar processes diverge, forming the palatal walls,
width increases tend to be timed with periods of vertical alveolar
growth, that is, during active eruption of the teeth. The maxillary
permanent cuspids are placed further distally in the arch than the
primary and erupt pointing mesially and labially. Hence their ar-
rival is an important factor in widening and changing the shape
of the maxillary dental arch. There are also important sex differ-
ences in the maxillary bicanine width increases which are not so
evident in the mandible (see Figs 6-26 and 6-27).
 Development of the Dentition and Occlusion 123
,
33 lars. Note that all measures in Figure 6-28 are made to centroids
32 not buccal cusps. When the latter are used mandibular widths in
31 the premolar region do not seem to increase so much.
5.5mm
30 Marked Maxillary first premolar width increases significantly more
Sexual
(/)
29 than does the mandibular, especially in males (see Fig 6-28).
Dimorphism
ffi 28 Although the alveolar process growth is almost vertical in the
t;j 27
mandible, the crowns of the first molars erupt tipped somewhat
~ 26 lingually and do not upright fully until the time of the eruption of
::! 25
::;: the second molars. As the first molars upright, they cause an
24
increase in the bimolar width, but this is not, of course, an increase
23
22
in the diameter of the mandible itself. Furthermore, both first
21
molars move forward at the time of the late mesial shift to preempt
20 any remaining leeway space and thus assume a narrower diameter
2 4 6 8 10 12 14 16 18 along the convergent dental arch.
YEARS
It is important to note the reasons for the rather marked dif-
FIG 6-27. ferences in width increases between the two dental arches. The
Width changes in maxillary bicanine diameter compared with man- only postnatal mechanism for widening the basal bony width of
dibular bicanine diameter. (Adapted from Moyers RE, van der Linden the mandible is that of deposition on the lateral borders of the
PGM, Riolo ML, et al: Standards of Human Occlusal Development, corpus mandibularis. Such deposition occurs, but only in small
Monograph 5, Craniofacial Growth Series. Ann Arbor, Michigan, Cen- amounts, and offers little help for the clinician wishing to widen
ter for Human Growth and Development, University of Michigan, the mandibular dental arch. The maxilla, in sharp contrast, widens
1976.)
with vertical growth simply because the alveolar processes diverge;
therefore, more width increase is seen and more can be procured
during treatment (see Fig 6-32). Furthermore, the midpalatal su-
Maxillary premolar width increases reflect the general wid-
ture can be reopened with "rapid palatal expansion" (see Chapter
ening of the arch coincidental with vertical growth (Fig 6-28). 15) to acquire surprisingly large amounts of actual widening {)f
On the other hand, mandibular width increases in the premolar the maxilla. There is little correlation between dental arch widths
region occur because the crowns of the premolars are placed further and any skeletal or facial width measurements; therefore, knowl-
buccally than the centers of the crowns of the wider primary mo- edge of the latter is of no real use in planning orthodontic treatment.

48 2. Length or Depth
47
46 Dental arch length (or more properly, arch depth) is measured
45 at the midline from a point midway between the central incisors
A 44 to a tangent touching the distal surfaces of the second primary
43 molars or second premolars (see Fig 6-10). Although often meas-
42 ured and reported, it does not have the clinical importance of the

n
41 circumference, and any changes in arch length are but coarse
(/) 40 reflections of changes in perimeter. Sometimes one-half the cir-
ffi 39
~ cumference is referred to as "arch length."
w 2 4 6 8 10 12 14 16 18
~
...J
37
::! 36
3. ,Circumference or Perimeter
::;: 35
+-+-+-+--+ +
34 The most important of the dental arch dimensions is arch

{]
B 33 circumference or perimeter, which usually is measured from the
32 distal surface of the second primary molar (or mesial surface of
31 the first permanent molar) around the arch over the contact points
30 and incisal edges in a smoothed curve to the distal surface of the
29
sec~nt\. primary molar (or first pen,nanent molar) of the opposite
28
side (see Fig 6-10). A wide range of variability is seen in cir-
27
4 6 8 10 12 14 16 18 cumferential increments and the mandibular and maxillary perim-
YEARS
eters behave a bit differently; therefore, they will be discussed
FIG 6-28. separately.
Width changes in (A) molar and (B) bicuspid regions. (Adapted from The reduction in mandibular arch circumference during the
Moyers RE, van der Linden PGM, Riolo ML, et al: Standards of transitional and early adolescent dentition is the result of (1) the
Human Occlusal Development, Monograph 5, Craniofacial Growth late mesial shift of the first permanent molars as the "leeway
Series. Ann Arbor, Michigan, Center for Human Growth and Devel- space" is preempted, (2) the mesial drifting tendency of the pos-
opment, University of Michigan, 1976.) terior teeth throughout all of life, (3) slight amounts of interprox-
124 Growth and Development
20
A " -0.5
B
ii-10
I-...Ja:
w
1.5
-1.5 3.0
-2
0.5
00
1.0
::J
-4
'" 2.5
88
86
84
82
80
78
76
74
'"
a:
w
I- 74
w
" 73 o 2 4 6 10 12
~ 72
" 71
20
15
70

A'-~V
69 (/) 1.0
a:
68 w 0.5
I-
67 ~ 0.0
66 :J -0.5
...J
65 ii -10
-1.5
64 +
63
-2.0
-2.5
4 6 8 10 12 14 16 18 -4 -2 0 4 6 8 10 12
YEARS YEARS

FIG 6-29.
Perimeter changes. A, perimeter versus chronologic age. The range
and sex differences (0 = males, + = females) ± 1 standard de-
viation are noted. e, perimeter change/year based on dental age.
(Adapted from Moyers RE, van der Linden PGM, Riolo ML, et al:
Standards of Human Occlusal Development, Monograph 5, Crani-
ofacial Growth Series. Ann Arbor, Michigan, Center for Human Growth
and Development, University of Michigan, 1976.)

imal wear of the teeth, (4) the lingual positioning of the incisors
as a result of the differential mandibulomaxillary growth, and (5)
the original tipped positions of the incisors and molars. The last
point is a reflection of the skeletal pattern, steepness of the occlusal
plane, and vertical alveolar growth, which in some in-
stances-where incisors are tipped lingually and molars are tipped
mesially-shortens the available arch perimeter markedly. 42 Note
the great variability in perimeter dimensions at various ages (Fig
6-29) and notice the important sexual differences. The arch pe-
rimeter in females is particularly vulnerable to severe losses during
the ages displayed. This point is made more important when one
realizes that the study was done in Ann Arbor, Michigan, which
has had a fluoridated water supply throughout the time of the study.
In a most important report, Northway73 analyzed children from
Montreal of the Growth Center, Universite de Montreal who had
had little dental care and whose water supply was unfluoridated.
He found that moderate caries, severe caries, and early loss of
primary molars caused dramatic increases in the amount of perim-
eter loss (Fig 6-30). Hunter and Smith42 noted that children with
crowded arches in the early mixed dentition showed less arch
perimeter loss by the time of the completed permanent dentition
and more continued crowding.
The role of the mandibular third molar in crowding of the
incisors is a much argued and studied topic which has occupied
much of our attention in recent years. Briefly, some feel so strongly
that the third molars are responsible for incisal crowding that they
recommend prophylactic removal during their early development
before they can disrupt the arch alignment or ruin orthodontic
treatment results. Good research is very difficult to complete on
this problem, but there is no overwhelming evidence yet to support
the view that third molars are a primary" cause" of incisal crowd-
ing. In fact, most of the evidence denies this hypothesis. Attempts
have been made to predict which third molars will become im-
pacted and which not; which will "push" the other teeth forward
and which will not. The best clinical guides on this problem are
still largely subjective despite some very ingenious efforts. Some
clarification may come when a sufficiently large serial sample
permits analysis according to the several facial types with their
varying growth patterns. It is possible that third molars exacerbate
a tendency already present in some children, but that is an unproven
hypothesis at this time. There is evidence to show that differential
mandibulomaxillary growth and/or occlusal interferences with re-
sultant "slide" into occlusion cause incisal crowding, but these
two important factors are often forgotten.
In summary, the mandibular arch perimeter shows great var-
iability in its extensive diminution during natural development.
The variation is caused by differences in skeletal pattern, sex
(women's arches shorten more), and caries experience. The im-
portance of monitoring this dimens·ion and preserving it during the
critical periods of development cannot be emphasized too much
for it is a dimension whose losses are difficult to recover.
'; ..Maxillary arch per1meter, in contrast, typically increases
slightry although it has about an equal chance to either increase
or decrease (see Fig 6-29). The very marked difference in an-
gulation of the maxillary permanent incisors, as compared with
the primary (Fig 6- 31), and the greater increases in width probably
account for the tendency to preserve the circumference in the upper
jaw even though the permanent molars are drifting mesially.
4. Dimensional Changes During Orthodontic Therapy
In Figure 6-32 the normal growth changes in both dental
arches are summarized and compared with changes that can be
 Development of the Dentition and Occlusion 125
'"
w
E
""-u'"A
E
16
15
19

17
12 -,
13-
18 14-

NON-MUT
SEVERE CAR I ES
<>-----D 0- LO S S
"' •••..•. ,6.
E· LOS S
0--0 D+E LOSS
N.r.

1---,----- r
FIG 6-31.
6 7 8 9 10 11 12 13 14
DE NTAL AGE Comparison of the angulation of the permanent and primary incisors.

[,
-I
u
I--'
:J
I-
-..
0u
.•
0-'
:J
"-
W
'"
<n
E
>
<n
'"w
W
;;;
B
-5
-'-3
--42 AGE
6 YR S
AT LOSS
.6.- ..••• .6, ++----
00000 0 0
+?+Growth
???Tx
Growth
Growth + Primary
No
TxTransitional
Tx Skeletal Growth Skeleta I Growth
Permanent Plus
Perimeter
" (\~) "/I~ 7 YRS 0'---0
Width
Width~"s/o0..,
Maxilla
Mandible Growth 8 y RS 0-----0
E 9 '(RS "'--4
10 Y RS a....-----e
I I Y RS ---.

.l".

o Some + Mild increase occurs or con be obtained

I
, 10
11
12
13 I / -- Decreases greatly ++ Significant increase occurs or con be obtained
9 / ? Some change possible in particular instances

6 7 8 Summary of changes in arch dimensions resulting from grow1h, and
CHRONOLOGICAL
FIG 6-30.
Perimeter changes resulting from caries and loss of teeth. A, lower
first and second primary molar space. B, effect of age at loss of
primary molars. (From Northway WM: Antero-posterior arch dimen-
sion changes in French-Canadian children: A study of the effects of
dental caries and premature extractions, thesis. School of Dentistry,
University of Montreal, Quebec, Canada, 1977. Used by permission.)
,.
brought about by orthodontic therapy. It is important to note very
carefully that it is far easier to increase dental arch width and
length in the maxilla than it is in the mandible. In fact, it is
relatively simple to increase the maxillary dental arch width and
length, difficult to increase and retain the mandibular dental arch
width, and difficult to move mandibular molars distally signifi-
cantly to increase the perimeter. There are means to increase the
perimeter in certain cases, including lip bumpers, utility arch wires,
FIG 6-32.
AGE estimates of possible expectations during treatment (Tx).
'and functional appliances which alter the posture of the tongue or
activities of the lips. It is most important to realize the strict
limitations of such procedures for they ar,e successful only where
specific conditions obtain which can be altered by the use of an
appropriate appliance. Few mandibular arch perimeters can be
lengthened permanentlY and there are no magic appliances for
doing so. Success is secured when alteration of muscle function
and/or the positions of teeth within the alveolar process is safely
possible. The effects of orthodontic treatment on dental arch di-
mensions are not to be confused with the effects of orthodontic
treatment on craniofacial skeletal dimensions. For a discussion of
this subject read Chapter 4.
5. Over bite and Overjet
Overbite (vertical overlap of the incisors) and overjet (hori-
 126 Growth and Development

to the primary teeth' are termed accessional teeth.

From a clinical point of view, there are two very important
aspects to the mixed dentition period: (I) the utilization of the arch
perimeter and (2) the adaptive changes in occlusion that occur
during the transition from one dentition to another. The alveolar
process is one of the most actively adaptable areas of bone growth
-- -= == IOVERBITE
during the period of transition between the dentitions. Therefore,
it is an ideal time for most major orthodontic interventions.

1. Uses of the Dental Arch Perimeter

Misconceptions regarding the normal changes in and uses of

the dental arch perimeter probably cause more clinical failures in
FIG 6-33. mixed dentition therapy than anything else. In the discussion that
Overbite and overjet. follows, concentration will be on the mandible, since it is by far
more critical clinically than the maxilla.
There are three uses of the arch perimeter:
zontal overlap, Fig 6-33) undergo significant changes during the a) Alignment of the permanent incisors: they arrive typically
primary and transitional dentitions (see Figs 6-44 and 6-52).70 crowded (Fig 6-35).
During the primary dentition, the overbite normally decreases a b) Space for the cuspids and premolars.
slight amount, and the overjet often is reduced to zero. From the c) Adjustment of the molar occlusion: the first permanent
early mixed dentition to the completion of the permanent occlusion molars, which typically erupt end-to-end, must change to a Class
the average overbite increases slightly and then decreases, but there I relationship if normal occlusion is to be obtained.
is great variability in its behavior (Fig 6_34).70 Overbite is cor- As the larger permanent incisors erupt, they find space in the
related with a number of vertical facial dimensions (e.g., ramus arch only because (I) the arch width increases slightly, (2) there
height), whereas overjet usually is a reflection of the anteropos- was some interdental spacing in the primary dentition, (3) the
terior skeletal relationship. 16 Overjet is also sensitive to abnormal permanent incisors tip labially a bit (see Fig 6-38,A), and (4) the
lip and tongue function. During growth of severe Class 11 and primary cuspids are moved distally. Still, there is a typical slight
Class III malocclusions the overbite and overjet must adapt to the
crowding which usually is not relieved until the primary cuspids
abnormal skeletal relationships and thus they behave differently are lost. When the incisors then align, they do so at some expense
from the mean changes just described. to the posterior space available for cuspid and premolar eruption
and molar adjustment. The cuspid and premolars erupt into the
normally excessive posterior leeway space. If molar adjustment is
G. THE 'MIXED DENTITION PERIOD
to be achieved by dental means, there must be some posterior
space left after the arrival of the cuspid and premolars so that a
That period during which both primary and permanent teeth late mesial shift of the first permanent molar may take place.
are in the mouth together is known as the mixed dentition. Those Usually such a late mesial shift occurs to some extent but there
permanent teeth that follow into a place in the arch Qnce held by are other mechanisms of occlusal adjustment and great variability
a primary tooth are called successional teeth (e.g., incisors, cus- can be expected. It is naive and somewhat hazardous clinically to
pids, and bicuspids). Those permanent teeth that erupt posteriorly assume the individual patient will show the exact normal changes:
it is even worse to hope that the ideal can be expected except in
the rarest of circumstances.
04261
w
:; 3
-I-~
w
>- Primary Permanent
-1
a:
::<
5-3
2 , There have been divergent opinions concerning where, how,
Ul
and when arch perimeter shortening takes place. These differences
of opinion are not just interesting theoretical points; the planning
of space management is altered significantly according to which
of several concepts is correct. It has been suggested that the erup-
1 II16
to 1I8 2
6II414
18 ,.
~ YEARS +, + I tion.,of the first permanent:molar causes an "early mesial shift"
which"'Closes the primate space and, other interdental spaces from
I
~ the rear2 In the alternative theory the primary space is closed by
the eruption of the incisors without loss of perimeter. The leeway
space is the difference in size between the primary teeth and their
FIG 6-34. permanent successors. Anteriorly, this is a mean negative value
v (the primary teeth are bigger), even if one includes the interdental
Overbite changes with age (reported as mean ± 1 SO). (Adapted
spacing around the primary incisors (see Fig 6-35). Posteriorly,
from Moyers RE, van der Linden PGM, Riolo ML, et al; Standards
of Human Occlusal Development, Monograph 5, Craniofacial Growth £he m!an I~eway space is positive, since the_com!?ined_ widths of
Series. Ann Arbor, Michigan, Center for Human Growth and Devel- c + d + e exceed the combined widths of 3 + 4 + 5 (Figs 6-
opment, University of Michigan, 1976.) 11, 6-36, and 6-37). However, the total leeway is the important
 21.61
22.83
24.26
23.84N
11.36
20.38
22.1228
24
20.82
11.15
21.48
11.32
11.34
23.00
23.50
22.96
22.49
24.12
23.77
24.07
24.18
22.98
23.4932
43
40
11.14
11.13
11.30
55
59
49
50
23.76
11.17
10.76
11.11
23.38
11.49
8.92
9.98
8.85
9.79
22.09
8.87
8.3175
76
71
43
78
23.99
23.8625
11.33
23.64
24.14 58
23.69
60
70
42
74
62
66
73
67
72
8.73
8.84
23
20
20
10.87
8.69
8.79
48
(mm) 252 MEAN
ANT
POST
(SO)(SO)
(0.69)
(1.16)
(1.46)
(0.62)
(0.60)
(1.26)
(1.74)
(1.28)
(1.64)
(0.54)
(0.55)
(1.40)
(1.39)
(1.52)
(1.34)
(0.56)
(0.59)
(1.02)
(0.88)
(1.15)
(0.91)
(1.25)
(1.12)
(0.96)
(0.61)
(0.53)
(0.79)
(0.94)
(1.20)
(0.98)
(1.00)
(1.05)
(0.52)
(0.33) FEMALE 127
Development of the Dentition and Occlusion
ANT

DENTAL
AGE
(YRS)

-4

-3
-2

-1
o

FIG 6-35.
Arch space available in the mandible by dental age (0 = arrival of space and the decreases in posterior space with time. /
first incisor) and sex. Note the increases in the available anterior ~

clinical consideration. The method of utilization of the ·leeway
space is the key factor in the transitional dentition. It has now been
shown that the early mesial shift does not occur. '4> 15. 68 However,
most children show a distinct "late mesial shift" with the loss of
the mandibular second primary molar (Figs 6-36 to 6-38).
seem to be important sexual differences in available posterior lee-
way space related to the occlusal status (see Figs 6-36 and 6-
37).
Some of the details and variabilities of the transitional den-
There tition are lost or missed by the tendency of authors and researchers

lOWER ANTERIOR (1 + 2 - A + B) AN[)'POSTERIOR (3 + 4 + 5 - C + D + E)

lEEWAY SPACE BY ORIGINAL OCCLUSAL STATUS AND SEX
2.68
-2.35
-2.65
3.02
-3.16
2.60
2.58
(SO)15
12
16
14
18
NN25 23
~'2.16
-3.15
-2.94
2.99
2.69
(SD)
(SD)· 24
19
N
19 •.• POST
ANT
MEAN
(0.47)
(0.58)MEAN
(1.00)
(0.73)
(0.70)
(1.01)
(0.69)
(1.07)
(1.24) >~. MALE FEMALE

FIG 6-36.
Mean anterior and posterior leeway space arrayed according to orig- available and original second primary molar occlusion. (See also Fig
inal occlusion and sex. Note important relationships between space 6-37.)
128 Growth and Development

LOWER ANTERIOR (1+2 - A+B) AND POSTERIOR (3+4+5 - C+D+E)

LEEWAY SPACE BY ORIGINAL OCCLUSAL STATUS AND SEX
Q. -14
~0
~
III 0
g
>-
CD

'E' CD -2
-3
-4
3
2

Legend
lZ2I CL I
_ EtoE
~CIII

male female male female

Anterior Posterior

FIG 6-37.
Relationships among leeway space, occlusal status, and sex. Note more in males than in females.
that posterior leeway space seems to be related to occlusal status

to depend upon chronologic age rather than a developmental age
based on events of dentitional growth. The graphs in this chapter
utilize both chronologic and biologic ages. Figures 6-29, 6-'35,
and 6-38 are good examples of the use of biologic age based on
the dentition rather than the moment of birth.
In the maxilla, similar accommodative adjustments occur dur-
ing the mixed dentition, although the matter is less critical since
the upper incisors alter their inclination more and the maxillary
perimeter does not display such a tendency to shorten as does the
mandibular (see Figs 6-29 and 6-31). Furthermore, it is easier
to alter maxillary arch dimensions during treatment (see Fig 6-
32).
2. Occlusal Changes in the Mixed Dentition
As noted earlier, the usual flush 'terminal plane of the primary
dentition typically provides an end-to-end relationship of the first
permanent molars. The first permanent molar normally then achieves
a Class I relationship by (1) a late mesial shift after the loss of
the second primary molar (see Fig 6-38, E and F); (2) greater
forward growth of the mandible than the maxilla; or, most likely,
(3) a combination of (1) and (2) (Fig 6-39,A). Theoretically, one
might presume that there are 12 paths through the mixed dentition,
since each of the three occlusal classifications on the left side of
Figure 6-39 might become one of the four adult classes on the
right side, but several possibilities are not found in actuality. Ce-
phalometric studies (Moyers and Wainright68) show clearly a much
more complicated variation of patterns of occlusal change during
the transitional dentition than was previously thought. Their work
shows the dominance of the skeletal pattern of growth over den-
titional mechanisms of adjustment (Figs 6-40 through 6-43). A
distal step in the primary dentition reflects a likely skeletal im-
balance and likely will result in a Class II occlusion in the per-
manent dentition (see Figs 6-39,B and 6-41). A Class II skeletal
pattern may worsen the occlusal relations with time (Fig 6-42).
The two most common paths and hence the "normal" routes are
from a flush terminal plane to Class I and from a mesial step to
Class I occlusions (Figs 6-39 and 6-40).68 Of particular clinical
interest are the factors that induce a flush terminal plane to change
by ways other than the expected end-to-end and later Class I molar
inter~tispation. If, for exa~ple, a child has a flush terminal plane
in the primary dentition, a mild CI~ss II facial skeleton, and in-
sufficient arch perimeter space to permit a late mesial shift of the
first permanent molars, the occlusion likely will become Class II
by the end of the mixed dentition period (see Fig 6-39,D)or an
end-to-end molar relationship may obtain by the time of the erup-
tion of the premolars (see Fig 6-39,E) depending on the severity
of the Class II skeletal growth pattern. It is particularly advanta-
geous to obtain a Class I molar relationship prior to the loss of
the second primary molars, since all of the arch perimeter can be
 Development of the Dentition and Occlusion 129

A B
..........••105 70
8 G'
S w
e.
~
z"
w
+ •• + w
..J
'" "
Z 65
w
Z '"
w
~ 95 Z
'"
Q.
\ ..J

\.
'" "- 60
:5 ..J
::>
'" 90 i'!
'"
Cl
Z ..J
'"
'"
::<

~ 85 8 55
er +
o'" Legend o
(/) Legend
U1
U + I.4~LE+1STD + Ir.4ALE+1STD
~ eo ~ 50
'" tJ.~ er ""~
.'3~ o~
+ rOU,LE -15
~ o~
75,
TO
'3 .•. F"EMAl[-l$TD
45,
-4 -3 -2 -1 0 1 2 3 4 5 6 7 8 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8
DEVELOPMENTAL AGE (YEARS) DEVELOPMENTAL AGE (YEARS)

c o
~ .0 120

s~8 G'
w
S
"'"z "
w

w
Z
j
Q.
50

'" +
:5
'"
::>

z'"
Cl

::<

~ 40
'"
o Legend Legend
U1 .•. WAlE+1STD
U + tr.l.•.LE+1STD

~ 35 a~_ '" A~
15 + o f[)~A~_ w
"- o~
It + .•. fEt.4AL[-lSTD "-
+ FU'Al[-lSTD
::> '0 =>
90
-4 -3 -2 -1 0 1 2 3 4 5 6 7 8 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8
DEVELOPMENTAL AGE (YEARS) DEVELOPMENTAL AGE (YEARS)

E F
45 45
'i' :?
-6 + -6
w
u +
w
u +
Z 40 Z
i'! + '" 40
U1 " >-
(/)
Cl Ci
>- >-
Z Z
6"- 35 + Ci
"-
fa :-:
8 + o
>-
er '0 er
:5
o j
,.0 ".
::<
>- ,. Legend ~~ -'¥.'<

Legend
U1
er 25
+ tr.lAl[+ISTD :n"- .•. tr.lALE+1STD
;;: ~ 25
er 6~
er t:.~
w
~ o~ w
"-
"-
o~
'3 20
+ fE •••.•.L[-lSTD => .•. fEIl4AL[-lSTD
20
-2 -1 o 1 2 345 6 7 8 -2 -1 0123456 7 8
DEVELOPMENTAL AGE (YEARS) DEVELOPMENTAL AGE (YEARS)

FIG 6-30.
A-F, developmental changes in tooth positions and angulations,
130 Growth and Development

DISTAL STEP CLASS n _.

AGE

30 I
56--!PROTRUSIVE +
LATE MESIAL SMFT

82

108

END-TO-END 134

£ 160
\
\
\
\
\
\
186 \
\
\
\
212 \

-5.25 -3.75 -2.25 -.75 6.75 2.25 3.75 5.25

FIG 6-40.
Computer plot of a "protrusive" pattern of occlusal change with a

CLASS m late mesial shift. In this and subsequent diagrams (Figs 6-41 through
6-43) 0 = end-to-end, and positive values are towards Class I,
negative towards Class 11.The scale is in millimeters. (From Moyers
RE, Wainright R: Skeletal contributions to occlusal development, in
McNamara JA Jr (ed): The Biology of Occlusal Development, Mon-
ograph 7, Craniofacial Growth Series. Ann Arbor, Michigan, Center
for Human Growth and Development, University of Michigan, 1977.
FIG 6-39.
Patterns of transitional occlusal adjustment. Used by permission.)

used for alignment of teeth and none need be allotted to molar of the skeletal growth and translating some into occlusal change.
adjustment (Fig 6-39,F). In minor skeletal disharmonies with We do know that predicting skeletal change, at which we have
large leeway spaces, dentitional adjustments can be overcome with lately become more proficient, does not provide a sure insight into
timely orthodontic intervention, but no child has enough mandi- future occlusal relations. The clinician's only recourse at this time
bular leeway space to achieve naturally a Class I molar relationship is to study the patient carefully through time until one of the paths
within a severe Class n facial skeleton. of occlusal change has revealed itself and then to take appropriate
Three other interesting and frustrating patterns must be de- therapeutic action, if necessary. It is not enough to relax when
scribed, the homeostatic occlusions which remain as Class n, end- viewing an end-to-end molar relationship (flush terminal plane)
to-end, or Class I from the primary through the mixed to the and be comforted that it is normal, for a high percentage of flush
permanent dentition (Figs 6-41 to 6-43,A-C). It is not yet known terminal planes do not grow normally (Table 6-7). There is no
why some occlusions change and some remain constant. The den- way to understand and treat malocclusions without studying growth
toalveolar region apparently acts as a buffer zone absorbing some variabilities.

TABLE 6-7.
Patterns of Occlusal Change in the Transitional Dentition
STARTING OCCLUSION FINISHING OCCLUSION PATTERN OF CHANGE

Distal step = 52 Class 11 = 21 Homeostatic I1

End-to-end 0= 6 Protrusive ,.
Class I :'25 Protrusive
Class III o
Flush terminal plane = 85 Class 11 7 Retrusive
End-to-end 22 Homeostatic end-to-end
Class I 56 Protrusive
Class II1 o
Mesial step = 67 Class 1I = 9 Retrusive
End-to-end = 3 Retrusive
Class I = 30 Homeostatic I
Class I = 23 Protrusive
Class III 2 Protrusive
 Development of the Dentition and Occlusion 131
AGE
Months
30 I A
AGE
Months
I
56-4HOMEOSTATIC 30
(CLASS It + TREATMENT)
82 56-1HOMEOSTATIC
(CLASS I:)

'08 82

'34 t08

'60 .34

'86 t60

2'2 t86

-5.25 -3.75 -2.25 -.75 6 75 2.25 3.75 5.25

FIG 6-41. 212
,-
-5.25 -3.75 -2.25 -.75 6 .75 2.25 3.75 5.25
Homeostatic Class I1 pattern plus orthodontic treatment begun at
about 11 years of age. (From Moyers RE, Wainright R: Skeletal
contributions to occlusal development, in McNamara JA Jr (ed): The
Biology of Occlusal Development, Monograph 7, Craniofacial Growth
Series. Ann Arbor, Michigan, Center for Human Growth and Devel-
opment, University of Michigan, 1977. Used by permission.)
B
AGE
Months
30 I
56
To a large extent, the occlusal relationships are at the merc)
HOMEOSTATIC
of the skeletal growth. Several distinct patterns of skeletal growth
82 -HENO- TO- ENO)
and occlusal adjustment have now been identified, but we are not'
yet clever enough in predicting which path a child is apt to follow. to8
It will be learned later that the amount of space in an arch for
dental adjustments can be predicted quite accurately, a procedure .34
used routinely when planning mixed dentition treatment. We are
now able to predict within practical limits some aspects of skeletal 160
growth (see Chapter 12), but such skeletal predictions are of little
value, as yet, in predicting occlusal changes.

I
'86

AGE
Months 212
30 I I I I I I I I I I
-5.25 -3.75 -2.25 -.75 0.75 2.25 3.75 5.25
56
FIG 6-43.
82 Homeostatic patterns of occlusal development (see also Fig 6-41).
A, Class I; B, end-to-end. (From Moyers RE, Wainright R: Skeletal
t08 con'tributions to occlusal development, in McNamara JA Jr (ed): The
Biology of Occlusal Development, Monograph 7, Craniofacial Growth
Series. Ann Arbor, Michigan, Center for Human Growth and Devel-
'34
opment, University of Michigan, 1'977. Use9 by permission.)
.60
,.
t86 3~F!rst Molar Eruption

2t2 In Sections G-3 to G-6, the reader should refer to Figures 6-

TI---r- 44 through 6-52 (a normal cast series), Figures 6-53 and 6-54
-5.;'5 -3.75 -2.25 -.75 6 .75 2.25 3.75 5.25
FIG 6-42. (serial radiographic views), and Figures 6-55 through 6-59 (skull
dissections). They depict well ideal or typical growth but cannot
"Retrusive" pattern of occlusal development. (From Moyers RE,
convey the wide variability seen in practice.
Wainright R: Skeletal contributions to occlusal development, in
McNamara JA Jr (ed): The Biology of Occlusal Development, Mon-
ograph 7, Craniofacial Growth Series. Ann Arbor, Michigan, Center a) Mandible
for Human Growth and Development, University of Michigan, 1977. The majority of children erupt the first permanent molar prior
Used by permission.) to the central incisors, although some children reverse this order
132 Growth and Development

FIG 6-44.
Primary occlusion at 5 years. Note the generalized interdental spac-
ing, primate spaces (distal to lateral incisors in the maxilla and distal
to cuspids in the mandible), moderate overbite and overjet, and flush
terminal plane. (Courtesy of Or. R. R. Mclntyre.)

FIG 6-45.
Occlusion at6 years. Note diminished overbite and overjet and be-
ginning of a mesial step at the distal surfaces of the primary molars.

FIG 6-46.
Occlusion at 7 years. All first molars and central and lateral incisors
have erupted. A distinct mesial step has permitted Class I interdig-
itation of the permanent molars, and the erupting incisors have closed
the primate spaces in both arches.
 Development of the Dentition and Occlusion 133

FIG 6-47.
Occlusion at 8 years. Ordinarily, the mandibular lateral incisors erupt
into the line of arch, completing closure of the primate spaces. Note
interdental spacing in the maxillary incisor region. The permanent
molars have a firm Class I occlusion by this age if a mesial step has
been available at the time of their eruption.

FIG 6-48.'
Occlusion at 9 years. Mandibular permanent cuspids have erupted
in this case. Although this is desirable, often the mandibular cuspid
and first bicuspid arrive almost simultaneously.

FIG 6-49.
Occlusion at 10 years. First bicuspids are erupted and maxillary
permanent cuspids are appearing. In most mouths, the maxillary
second bicuspids erupt before the cuspids.
134 Growth and Development

FIG 6-50.
Occlusion at 11 years. Interdental spacing in the maxillary incisor
region has been closed by eruption of the cuspids, and one second
bicuspid has appeared in each arch. Eruption of second molars in
the mandible at this time is not the most favorable sequence; it is
better if they are delayed until all bicuspids have erupted.

FIG 6-51.
Occlusion at 12 years. All permanent teeth except the third molars
are in position. Note absence of any interdental spacing and the
slight tendency to procumbency of the dentition. The procumbency
typical of the recently completed dentition seems to diminish soon
unless there is gross discrepancy between the size of the teeth and
the alveolar perimeter.

FIG 6-52.
Occlusion at 13 years. There are few changes except the tendency
to less dental procumbency than seen previously.

(see Fig 6-19). There seems to be no clinical significance in either
sequence. The first permanent molar is guided into its occlusal
position during eruption by the distal surface of the second primary
molar (see Figs 6-12 and 6-39). The occlusal relationship that
the mandibular first permanent molar initia11y obtains with its
maxillary antagonist is thus determined by the terminal plane re-
lationship of the second primary molars (see Figs 6-11 and 6-
12). Changes in occlusal relationship that occur during the period
of the first molar eruption are not caused by that eruption, but are
due to coincidental skeletal growth.
b) Maxilla
During formation, the crowns of the maxillary molars face
d.orsally rather than occlusally. As the maxilla moves forward,
space is created posteriorly, permitting appositional enlargement
of the maxillary tuberosity. During this rather rapid tuberosity
growth, the first permanent molar rotates, and by the time the
crown pierces the gingiva, it is facing more occlusally (see Fig
6-58). Occasionally, the maxillary first permanent molar is found
in ectopic eruption.
4. Incisor Eruption
a) Mandible
The mandibular first permanent molars are followed almost
immediately by eruption of the mandibular central incisors. Al-
though the incisors usually follow the first permanent molars iri
piercing the gingiva, they reach their full clinical crown height
sooner. The permanent mandibular incisors develop lingually to
the resorbing roots of the primary incisors, forcing the latter la-
bially to be exfoliated (see Fig 6-57). The lingual eruptive position
is no cause for alarm if the primary incisors are resorbing normally.
As soon as the primary central incisors have been exfoliated,
further eruption and lingual activity moves the permanent incisors
labially to their normal balanced position between the tongue and
the lip and facial musculature (see Fig 6-23).
The size of the primary teeth, the amount of interdental spac-
ing, and the size of the anterior perimeter of the dental arch are
factors that determine whether the permanent incisors will erupt
crowded. Normally there is some crowding after the lateral incisors
are erupted. The lateral incisors, as they emerge, not only push
the primary lateral incisors labially but also move the primary
cuspids distally and laterally, closing the primate spaces (see Fig
6-26). When the permanent incisors are disproportionately large
for the arch in which they are found, the eruption of the lateral
incisor may cause the exfoliation of the primary cuspid or an
unusual resorption of the primary cuspid root. In other instances,
such disharmony of tooth size and' arch perimeter will maintain
the lateral incisors in their original lingual position. As soon as
the lateral incisors emerge into the mouth, a Mixed Dentition
Analysis may be made to estimate the amount of arch space avail-
able for the permanent teeth and the occlusal adjustments that
accompany the transitional dentition period (see Chapter 11). When
the mandibular primary cuspids are prematurely lost, the anterior
arc is less stable and the incisors may be tipped lingually by
hyperactivity of the mentalis muscle, a condition frequently found
with Class n, Division 1 malocclusion or thumb-sucking. Lingual
tipping of the incisors permits the developing permanent cuspid
Development of the Dentition and Occlusion 135
to slide labially, where it may erupt later in labioversion. This is
a sensitive time and a sensitive region. The first symptoms of some
malocclusions frequently are diagnosed at the time of eruption of
mandibular incisors. Space supervision therapy (q.v., Chapter 15)
begins at this time and must be synchronized well with dental
development. Good timing is one of the fundamentals of good
orthodontic therapy.
b) Maxilla
The maxillary anterior dental segment is supported by the
mandibular, which has formed earlier, providing the functional
stops against which the maxillary incisors erupt. Usually, the max-
illary central incisors erupt just after the mandibular central incisors
or concurrently with the mandibular lateral incisors (see Fig 6-
46). The maxillary permanent incisors erupt with a more labial
inclination than their predecessors, in accordance with their greater
labiolingual thickness and wider diameter. Little variation is seen
in eruption of the maxillary central incisor unless one is deflected
by abnormal exfoliation of the primary tooth, a supernumerary
tooth, or by trauma. The maxillary central incisors erupt with a
slight distal inclination and some midline space between them,
which space is diminished with eruption of the lateral incisors and
closed as the cuspids wedge their way into the arch.
The maxillary lateral incisors, on the other hand, often ex-
perience more difficulty in assuming their normal positions, for,
as they are erupting, the developing crowns of the maxillary cus-
pids lie just labially and distally to their roots (see Fig 6-57). The
cuspid in this position often can cause the crown of the lateral
incisor to erupt more labially than the central incisor. After the
erupting cuspid has changed its course (it often seems to have
been deflected by the root of the lateral incisor), the lateral incisor
then rights itself and comes into position beside the central incisor.
Minor rotations may been seen in the positions of both the central
and lateral incisor but they usually are corrected as the cuspids
erupt (see Figs 6-48 and 6-49). Ordinarily, it is not good practice
to attempt alignment of central and lateral incisor while the cuspid
crown is atop the root of the lateral incisor, since orthodontic
pressure against the lateral incisor's crown may press the root
against the erupting cuspid crown and cause root resorption.
5:"CUSpid and Bicuspid Eruption
Favorable development of occlusion in this region is largely
dependent on four factors: (1) a favorable sequence of eruption;
(2) a satisfactory tooth size-avaiIable spac~ ratio; (3) the attainment
of a normal molar relationship with minimal diminution of the
space available for the bicuspids; and (4) a favorable bucco-lingual
f~lf~ionship of the alveolar processes.
a) Mandible
The most favorable eruption sequence in the mandible is
cuspid, first bicuspid, second bicuspid, and second molar. For-
tunately, this also is one of the most frequent sequences. It is
useful if the cuspid erupts first, since it tends to maintain the arch
perimeter and to prevent lingual tipping of incisors. When the
incisors are tipped lingually, they may overerupt, since by lingual
tipping they lose their centric stops with the maxillary incisors. In
severe Class n malocclusions, mandibular incisors erupt past the
136 Growth and Development
FIG 6-53.
Eruption of first permanent molars when there is a mesial step on
distal surfaces of the deciduous teeth. A, age 5. Note distinct mesial
step established before eruption of first permanent molars. The man-
dibular primate space is open. 8, age 6. The erupting first permanent
molars are guided by the distal.surfaces of the second primary mo-
lars. The mandibular primate space persists. C, age 7. Erupting first
permanent molars are firmly interdigitated into Class I occlusion with-
out closing the mandibular primate space .
. ..

FIG 6-54.
Serial radiographs of the same child at different ages. A, oentition
at 5 years showing a flush terminal plane. Compar~ with Fig 6-53,
noting the sequence of eruption and positions of the permanent teeth.
e, dentition at 8 years. Note end-to-end molar relationship and po-
sitions and sequence of erupting teeth. C, dentition at 10 years. In
this case, the mandibular first bicuspid is arriving just before the
FIG 6-55.
A, a skull dissection of a neonate. Note the overlap of the parietal
and frontal bones. Note, too, the calcifying primary teeth. e, front
Development of the Dentition and Occlusion 137
cuspid. This is not serious if there is space for the cuspid. The
maxillary first bicuspid is just ready to appear in this mouth. D, den-
tition at 12 years of age. The permanent teeth have settled into
excellent occlusion. Note the mesial step on the distal surface of the
first molars, proving that the mandibular first molars have moved
mesially more after loss of the primary second molar.
view.
138 Growth and Development
FIG 6-56.
A, a skull specimen at approximately 8 months of age. The mandib-
ular left second primary molar has been lost from its crypt. Note how
advanced is the calcification of the first permanent molars. By this
time, one sees rapid alveolar process growth and considerable re-
FIG 6-57.
A, the dentition and its relationship to developing bony structures at
approximately 4 years of age. Now the crypt for the second per-
manent molar is clearly visible and the first permanent molars are
moving rapidly toward the plane of occlusion with sufficient space in
plane of occlusion until they find functional stops against the
maxillary palatal mucosa. In Class 11 malocclusion, such over-
eruption often occurs without lingual tipping. A complication of
this enhancement of the occlusal curve is the movement of the
mandibular cuspid during eruption into labioversion, a malposition
far more likely to occur if the first bicuspid precedes it in eruption.
It is quite normal for the cuspid to lag behind the first bicuspid
during early development, but it moves more rapidly during the
latter stages of eruption and usually passes the first bicuspid before
breaking through the alveolar crest. Eruption of the cuspid may
be hastened by extraction of the primary cuspid while the root of
the permanent cuspid root has just started to form (see Space
Supervision in Chapter 15). Where the tooth size-space available
sorption already on the anterior border of the ramus In anticipation
of the eruption of the first permanent molar. B, front view. Note the
relationship of the calcifying and erupting primary teeth.
the line of arch for them. Space has been provided by the resorption
at the anterior border of the ramus. B, a front view of the same
specimen. Note the intimate relationship of the calcifying permanent
incisors to the roots of the primary incisors.
ratio is poor, the cuspid may be stopped in its eruption by the first
primary molar or the primary molar may be hastened in its
exfaliiltion .• ~.
Only rarely does the first biouspid experience difficulty in
erupting. Bicuspid rotations sometimes occur with uneven resorp-
tion of the roots of the primary molars (Fig 6-60). If such rotations
are seen to be developing, it is good practice to construct a space-
maintainer, extract the primary molar (no earlier than completion
of the crown), and hold space for the erupting tooth.
Since the second bicuspid is the last of the mandibular suc-
cedaneous teeth to erupt, there will not be room for it if there has
been a shortening of the dental arch perimeter by mesial movement
of the first molar, nor will there be room for the second bicuspid
 Development of the Dentition and Occlusion 139

FIG 6-58.
A, the dentition at approximately 6 years. At this time, a very com- either lingually to their primary predecessors or directly beneath them
plicated situation exists. Note the presence of all the permanent teeth as in the molar region. B, a front view of the same specimen.

FIG 6-59.
A, the dentition at approximately 9 years of age. Now one can see relationship of the cuspids to the roots of the lateral incisors in this
the maxillary cuspid erupting at an angle against the root of the lateral projection. Great care and caution must be taken in moving lateral
incisor. B, a front view of the same specimen. Note the hazardous incisors at this stage of development.

FIG 6-60.
A, uneven resorption of the second primary molar, resulting in dis- roots? B, the spontaneous correction of the second premolar mal-
placement of the second premolar-or did the displacement of the position after extraction of the primary predecessor.
second premolar cause the uneven resorption of the primary molar's
140 Growth and Development
if the tooth size-space available ratio is poor. When the secondary
primary molar is lost prematurely, the erupting second molar often
helps the first molar move mesially before the second bicuspid
can erupt. The eruption of the mandibular second molar out of
sequence may be a troublesome problem in space management if
it is not detected early enough to maintain the arch perimeter.
Before the primary molars are lost, a Mixed Dentition Analysis
must be done to determine whether mesial movement of the first
permanent molar need be controlled. When the leeway space is
insufficient, the first molar must not be allowed to move mesially
until the second bicuspid has had a chance at its proper position
in the arch.
Mandibular second bicuspids display extreme variation in
their calcification and development schedule. Therefore, it is dif-
ficult to predict the exact time of their emergence in the mouth,
and they often are congenitally missing. The determination of
congenital absence of mandibular second bicuspids must be done
carefully because of their wide developmental variability.
b) Maxilla
The sequence of eruption is typically different in the maxilla,
being either first bicuspid, second bicuspid, and cuspid or first
bicuspid, cuspid, and second bicuspid. Although the maxillary
anterior segment is not prone to collapse lingually, since normally
it is supported by the mandibular arch, it is very easily displaced
labially by thumb-sucking, tongue-thrusting, or a hyperactive men-
talis muscle. Such displacement of the maxillary anterior segment
affects the eruptive pattern of the cuspids and bicuspids. The max-
illary first bicuspid usually erupts uneventfully, following the man-
dibular cuspid and/or the mandibular first bicuspid. Since the
maxillary first bicuspid is very nearly the same size as its prede-
cessor, usually neither the primary cuspid nor the primary second
molar is displaced by its arrival. The greater mesiodistal widtb of
the second primary molar permits easy eruption of the second
bicuspid into its place in the arch. However, this leeway in the
second bicuspid region may be necessary to provide space' ante-
riorly for the accommodation of the wider permanent cuspid even
though the anterior arc is increasing at this time. A tight situation
exists in the maxillary arch, which is emphasized by the tendency
to mesial drifting and the hazardous and circuitous eruptive course
of the cuspid. There should be an excess of space in the arch when
the second bicuspid arrives, the cuspid must follow immediately,
and the first permanent molar must not be allowed to rotate and
tip mesially or the cuspid is likely to be blocked out of the arch
in labioversion. The eruption of the second permanent molar ahead
of a cuspid or bicuspid is thus as critical in the maxilla as in the
mandible.
The maxillary cuspid follows a .more difficult and tortuous
path of eruption than any other tooth. When the child is 3 it is
high in the maxilla, with its crown directed mesially and somewhat
lingually. It moves toward the occlusal plane, gradually uprighting
itself until it seems to strike the distal aspect of the lateral incisor
root, apparently becoming deflected to a more vertical position.
It often erupts into the oral cavity with a marked mesial inclination,
appearing high in the alveolar process, a cause for concern on the
part of some parents. The eruption of the cuspid closes the inter-
dental spacing between the incisors, providing space for the final
uprighting of the cuspid. When in its correct occlusal position, it
has a slight mesiai'inclination. Should the arch length become
shortened due to interproximal caries or an unfavorable sequence
of eruption, the cuspid will have insufficient space for its final
positioning. It is then left in labioversion with a decided mesial
inclination. This maxillary malocclusion is analog<:lUsto the block-
ing out of a mandibular second bicuspid lingually. If arch length
is short in both arches, the upper cuspid and lower second bicuspid
arrive malposed because they are typically the last teeth ahead of
the first molars to erupt in their respective arches.
6. Second Molar Eruption
Normally, the mandibular second molar arrives in the oral
cavity after all the teeth anterior to it. When it precedes a second
bicuspid, it may tip the first molar mesially, the sequelae to which
have been discussed previously. The mandibular second molar
typically erupts into the mouth before the maxillary second molar.
The maxillary second molar also should follow all of the teeth
anterior to it into the arch. There is a greater tendency to loss of
arch length in the maxilla when the primary teeth are lost pre-
maturely. The eruption of the maxillary second molar ahead of
the mandibular second molar is said to be symptomatic of a de-
veloping Class II malocclusion.57 It also is seen with premature
loss of maxillary primary molars and sometimes may be seen in
skeletal Class II malocclusion because there may be more space
than normal in the maxilla for maxillary second molar development
or less space in the shortened mandible for mandibular second
molar development.
H. DENTITIONAL AND OCCLUSAL
DEVELOPMENT IN THE YOUNG ADULT
l. Third Molar Development
Third molars show more variability in calcification and erup-
tion than do any other teeth. The third molar is unique among
human teeth, since it apparently displays no sexual differences in
formation nor is its formation related as closely to somatic growth
and sexual maturation as are the other teeth. On the other hand,
the third molar shows high constancy with its own pattern of
development; that is, early calcifying third molars erupt early and
complete their roots early. There is evidence of ethnic differences,
since the Finns acquire their third molars later than Middle Amer-
ican whites.35 Greeks have a mean eruption time of 24 years and
some South Indians erupt third molars as early as 13 years. North
AIl,I~rican blacks erupt tpi:Fd molars earlier than do whites.
'Third molar agenesis occurs 16% of the time in middle west-
ern American whites.35 When one or more third molars are missing
there is a strong tendency for agenesis of other teeth, delayed
formation of other posterior teeth, differences in developmental
sequences, reduction in the size of other teeth and even delayed
timing and eruptive movement of the third molar in the siblings
of affected children." Since the third molar may not begin its
calcification until as late as 14 years, the diagnosis of agenesis
cannot always be made with certainty in the mixed dentition.
However, it should be noted that there is symmetry of develop-

ment, which aids in the diagnosis when one molar seems to be
missing. When a third molar usually is missing the clinician should
not be surprised to see a greater incidence of hypoplastic maxillary
laterill incisors, less frequent eruption of second molars before
second premolars, and smaller than normal te.eth.
The question of the role of the third molar in the crowding
of mandibular incisors during the late teenage period has been
much debated. A number of simultaneous phenomena confuse the
issue: the arch perimeter shortens, the incisor crowding increases,
the third molars develop, and the mandible grows forward more
than the maxilla. Events that occur together do not, of course,
necessarily depend on one another. Incisor crowding has been
found to correlate better with mandibular increments than with the
eruption of third molars.4 More crowding is seen in men than in
women. This observance is probably true because their mandibular
increments are greater at this time. 4
The first molars have been found to be farther forward and
the incisors more procumbent in individuals with third molars than
in those with third molar agenesis. 19 Therefore, third molars could
not play a primary role in the position of any teeth mesial, since
the differences in first molar position and incisal procumbency
appear before significant development of the third molar. The
evidence favors absolving the third molar of the increased crowding
(see Section F-3 earlier in the chapter).
Impaction of third molars is a frequent and serious problem
in modern man. Mandibular third molar impactions, which are
usually the more serious, are seen more frequently with skeletal'
Class Il particularly when the body of the mandible is short and
acutely angled. Although a number of measures can be used to
discriminate groups with impacted third molars from those without,
accurate prediction of third molar impaction at age 10 or 11 years
is not yet possible in a statistically significant way. Many clinicians
do such predictions and the methods are ingenious and interesting,
but none of the procedures yet suggested have withstood critical
testing, nor are they precise enough for sure predictions in indi-
vidual cases.
2. Dimensional Changes
The dental arch perimeter decreases a surprising amount dur-
ing the late adolescent and young adult periods (see Fig,6-29).
During these same periods, maxillary and mandibular arch widths
increase, but these increases are completed in both arches by 12
years of age in girls (see Figs 6-27 and 6-28). There are only a
few studies of arch dimensional changes after age 15 years, but
they seem to show a continued shortening of the perimeter.
3. Occlusal Changes
Both overbite and overjet decrease throughout the second
decade of life, probably due to the relatively greater forward growth
of the mandible. The changes in sagittal relationships of the den-
titions can be related to the growth of the jaws better than to dental
events; for example, the developmental course of the third molars.
Such posterior occlusal changes are due to the mesial drifting
Development of the Dentition and Occlusion 141
tendency, slight' interproximal wear and, most importantly, the
continuing growth of the mandible (see Figs 6-36 and 6-37).
4. Resorption of Permanent Teeth
By the end of the second decade, most persons display idio-
pathic resorption of one or more teeth. Nearly 90% of all teeth
show some evidence of resorption by the time a person is 19 years
of age. Although most of the instances are mild and confined to
apical blunting, nearly 10% show between 2 mm and 4 mm of
root resorption. There is a significant increase in the frequency of
the more severe types of resorption with age and an increase in
both the number of resorbed teeth and the severity of the resorption
when orthodontic treatment has occurred (see Chapter 13). Teeth
that are likely to resorb more rapidly during orthodontic therapy
can be predicted quite well by a careful examination of the radio-
graphs prior to therapy. Obviously, there is a general potential for
resorption of permanent teeth varying with the person and the
tooth-a potential that may be triggered by orthodontic tooth
movements. However, serious root resorption is only rarely seen
during orthodontic therapy. When it does occur it is most apt to
be seen in patients with a potential for resorption whose teeth have
been "jiggled" (i.e., moved back and forth by the appliance or
the appliance and occlusal forces).
5. Arrangement of the Teeth in the Jaws
Most reports of occlusion are concerned with the arrangement
of the crowns of the teeth; however, Dempster et al.16 have reported
an exhaustive study of the relationship of the roots to the cranio-
facial skeleton. The bicuspid roots are the most nearly perpendic-
ular to the plane of occlusion. The lower incisor cuspid and molar
roots are directed obliquely backward. The roots of the maxillary
teeth, anterior to the second bicuspid, are directed posteriorly and
inward, whereas the roots of the maxillary molars are more vertical
than the opposing lower molars.
A number of attempts have been made to describe the dental
arc mathematically in an effort to seek a basic or ideal pattern.
The line of occlusal contact between the upper and the lower teeth
also has been studied many times and is referred to as the occlusal
curve, the occlusal plane (although it is not a plane), the curve of
Spee, the compensating curve, etc. Attempts have been made, in
both the natural and artificial dentitions, to relate the occlusal curve
to movements of the jaw. Finally, worker; in prosthodontics have
extended these ideas into a concept of a three-dimensional spherical
c~rvature involving bot,h:otheright and left posterior teeth and both
mahdibular condyles, suggesting that a sphere of 8 inches or 20
cm in diameter was the "correct" dimension for all occlusal arc
designs. Such ideas are based on the conjecture that the roots of
the teeth converge to a center. The roots do not converge toward
a common center and the occlusal surfaces of the posterior teeth
cannot be fully congruent with the surface of any size sphere. As
might be expected, there is great variability in the positions of the
teeth within the skull. It is obvious that any attempts to reduce all
human occlusal patterns to one "ideal" or basic pattern are naive
at best and ridiculous at worst. 69
 142 Growth and Development

FIG 6-61.
A, ideal intercuspation, buccal view. 8, ideal intercuspation, lingual view.

I. CLINICAL IMPLICATIONS 2. Models of Occlusion

1. Normal Versus Ideal Occlusion
The word "normal" implies variations around an average or
mean value, whereas "ideal" connotes a hypothetical concept or
goal. There is a particular clinical difference between a "normal
occlusion" and an "ideal occlusion." Unfortunately, the' word
normal has been used for years in orthodontics as a synonym for
ideal, causing both semantic and treatment difficulties. It is per-
fectly proper to label as normal a mouth in which all of the teeth
are present and occluding in a healthy, stable, and pleasing manner
but with variations in position within measurable normal limits.
Perhaps no one has ever seen a perfect or ideal occlusion, but that
does not diminish the practical use of the concept, for every dentist
treating occlusions must have an ideal pattern in mind even if "it
is never achieved. Nature herself rarely shows an ideal occlusion.
Her best effort usually is within a range of normality. It is perfectly
reasonable, when planning orthodontic treatment, to have in mind
the image of ideal intercuspation (Fig 6-61). It also is perfectly
proper and practical to accept at the end of treatment an arrange-
ment of the teeth within the jaws in positions that are neither ideal
nor normal but may be stable ina particular person's face. One
of the most difficult tasks in orthodontic treatment planning is that
of determining just where to place the individual teeth within an
abnormal facial skeleton to achieve the best possible occlusion for
that particular face. It is impossible, naive, and wrong to attempt
to achieve ideal or normal tooth positions in a patently abnormal
set of circumstances, such as a severe skeletal dysplasia.
Occlusion is certainly the common theme of all branches of
dentistry, but the concepts of occlusion that are held by practi-
tioners of the different dental fields tend to be contradictory. The
working clinical occlusal hypotheses of one field are often not
applicable, understood, or used in another branch of dentistry.
Anyone of a number of mental images or models of occlusion
may be in a dentist's mind. Some regard human occlusion as a
very precise machine, the fit of whose parts must be done with
great care. As in any machine, all parts are needed for it to ·run
well. Such a model does not explain where the energy that runs
the machine originates and avoids the important aspect of control
of the machine. Another occlusal model suggested is that of teach-
ing a pet a new' trick. Such a concept introduces the idea of
neuromuscular learning. All tricks cannot be learned by all and
some learn better than others. It is the dentist's duty to decide
which "tricks" patients should learn for their own benefit. A
patient must be taught how to adapt to a new set of dentures, for
example, and once the "trick" of handling the dentures is learned
the problem is over. The difficulty with this concept is that there
are innumerable occlusal "tricks" that cannot be mastered by any
patient. No person with a Class II skeletal pattern and occlusion
can "learn" to hold his or her jaw forward in a more favorable
Class I occlusal relationship because the conscious cortical control
of this new mandibular position is constantly overcome by the
primitive reflexes that tend to maintain the mandible posteriorly.
T'iilley, an English orthodontist, has likened the treatment of oc-
clusion to playing a never-ending game of chess with the devil.

aptation . '.
.
~
TABLE 6-8. Traumatic
MUSCULATURE
reflexes;
Supportive
Learning, occlusal
DENTITION
anterior
dentistry
Resorption
pathology
Repair
occlusal
Loss of sensory
Eruption
Prosthetic
imprinting tooth reflexes
BONE extrusion,
Reconstructive
Growth
protective
Wear, component
input
and
dentistry
,.
ent Healthy adult occlusal responses
STAGE

The dentist sits down after the game has started and is not always
able to guess what moves have been made previously. The rules
that govern the game have not all been chosen by the clinician,
that is, the rules of bone biology, nerve physiology, muscle learn-
ing, psychology, and other factors. The rules change as the game
progresses or conditions alter. The analogy breaks down when one
asks, "What is winning?" There is no victor; it is enough to keep
the game going. Life, after all, is more than the mere maintenance
of structures; events must be kept going, functions must be per-
petuated. The best occlusion, and hence the best model of occlu-
sion too, is that which adapts best through time.
3. Occlusal Adaptive Mechanisms
What, then, is good occlusion? What concept or model of
occlusion should the dentist have? That of normal? Ideal? Perhaps
that occlusion is best which best adapts to its changing functions.
Such a concept implies that adaptive mechanisms are present and
necessary and that there are feedback mechanisms from the oc-
clusal system that help provide occlusal homeostasis. Any occlusal
treatment that lacks functional homeostasis is destined to clinical
failure.
A look at Table 6-8 reveals the adaptive mechanisms of the
dentition, bone, and musculature through various stages of occlusal
development and maintenance. During development, such factors
as eruption, tooth movements, dental wear, and loss of primary
teeth provide the period of greatest dental adaptability. The alveolar
process during growth is highly adaptable, as is the craniofacial
skeleton. Childhood also is a period of developmental neuromus-
cular learning. Clinical treatment at this time takes advantage of
these responsive adaptive mechanisms ..
In the healthy adult, however, most of the dental adaptive
mechanisms have been lost except for wear, extrusion of the teeth,
the anterior component of force, and drifting. The only bony
adaptations left are those of repair and remodeling since growth
is largely over. Orthodontic treatment during this period can thus
still utilize the diminished rate of remodeling but cannot be helped
by growth of the basal skeleton, which has practically ceased.
Protective reflexes are constant adaptations but some such reflexes
(see Chapter 5) can be destructive. The supportive occlusal reflexes,
for example, the unconscious swallow, can be stabilizing to the
occlusion of the adult although much less adaptive.
If the adult dentition begins to deteriorate, there are few
natural means left for dental adaptation and these mostly must be
provided by reconstructive dentistry. Pathologic bone loss provides
adaptation of a kind but it must not be allowed to proceed, and
the dentist, during therapy, attempts to restore conditions providing
bone repair. Occlusal equilibration procedures may obliterate
potentially destructive reflexes. After disease and tooth loss have
occurred, when growth is really not possible in usable amounts
and when many of the healthy, reparative processes have gone,
occlusal treatment becomes a very difficult problem if functional
homeostasis is to be achieved.
Finally, in the edentulous adult there are no natural dental
adaptive mechanisms left and the prosthesis made by the dentist
adapts and changes entirely differently than the natural dentition
did. Resorption of bone is the most common bony adaptive function
now seen, for the neuromusculature shows very diminished
Development of the Dentition and Occlusion 143
conditioning possibilities. Therefore, the prosthetic occlusion usually
is established within the b9undS of the most primitively controlled
neuromuscular restrictions, that is, the mandibulomaxillary
relationship determined by the_unconscious swallow.
Clinical goals are not necessarily either normal or ideal. Rather,
they are pragmatic and are determined by the conditions of the
individual patient. The determining factors are the adaptive
mechanisms the clinician can yet best utilize. The goal of occlusal
treatment is not just to maintain structures. It is not to meet some
hypothetical norm or idea. Rather, it is to keep events going. That
occlusion is best which most easily provides continuing functional
homeostasis.
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1976.
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36:996-1003.
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Development of the Dentition and Occlusion 145
phogenesis: Biological and Clinical Relevances, thesis,
Horace H Rockham School of Graduate Studies, University
of Michigan, Ann Arbor, 1979.
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56(special issue):C71-78.
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SUGGESTED READINGS*
I. Carlson DA, Ribbens KA (eds): Craniofacial Growth Dur-
ing Adolescence, Monograph 20. Craniofacial Growth Se-
ries. Ann Arbor, Michigan, Center for Human Growth and
Development, The University of Michigan, 1987.
2. Garn SM: The genetics of dental development, in Mc-
Namara JA Jr (ed): The Biology of Occlusal Development,
Monograph 7. Craniofacial Growth Series. Ann Arbor,
Mich, Center for Human Growth and Development, The
University of Michigan, 1977; pp 61-88. '
3. Graber LW: Congenital absence of teeth: A review with
emphasis on inheritance patterns: J Am Dent Assoc 1978;
96:266-275. (R)
4. Hagg U: Pubertal growth and orthodontic treatment, in
Carlson DA, Ribbens KA (eds): Craniofacial Growth Dur-
ing Adolescence, Monograph 20. Craniofacial Growth Se-
ries. Ann Arbor, Michigan, Center for Human Growth and
Development, The University of Michigan, 1987, pp 87-
116.
5. Kraus BS, Jordan RE: The Human Dentition Before Birth.
Philadelphia, Lea & Febiger, 1965. (M)
6. Lunt RC, Law DB: A review of the chronology of calcifi-
cation of deciduous teeth. J Am Dent Assoc 1974; 89:599-
606. (R)
7. Lunt RC, Law DB: A review of the chronology of eruption
of deciduous teeth. J Am Dent Assoc 1974; 89:872-879.
(R)
,,8. McNamara JA Jr (ed): The Biology of Occlusional Develop-
ment, monograph 7. Craniofacial Growth Series. Ann Ar-
bor, Mich, Center for Human Growth and Development,
The University of Michigan, 1977.
9. Melcher AH, Beertsen W: The physiology of tooth erup-
tion, in McNamara JA Jr (ed): The Biology of Occlusal De-
',' '. velopment, monograph 7. Craniofacial Growth Series. Ann
"'Arbor, Mich, Center for Human Growth and Development,
University of Michigan, 1977; pp 1-23. (R)
10. Moyers RE, van der Linden FPGM, Riolo ML, McNamara
JA Jr: Standards of Human Occlusal Development, Mono-
graph 5, Craniofacial Growth Series. Ann Arbor, Mich,
Center for Human Growth and Development, University of
Michigan, 1976. (M)
11. Moyers RE, Wainright R: Skeletal contributions to occlusal
*(R) = useful reviews of our current knowledge of the subject;
(M) = monographs.
146 Growth and Development
development, in McNamara lA lr (ed): The Biology of Oc-·
clusal Development, monograph 7. Craniofacial Growth Se-
rie's. Ann Arbor, Mich, Center for Human Growth and
Development, University of Michigan, 1977; pp 89-111.
12. Nanda SK: The Developmental Basis of Oca-lusion and
Malocclusion. Chicago, Quintessence, 1982. (M)
13. Smith BH, Garn SM: Polymorphisms in eruption sequence
of permanent teeth in American children. Am J Phy Anthro
(in press.)
14. van der Linden FPGM (ed): Transition of the Human Den-
tition, Monograph 13. Craniofacial Growth Series. Ann Ar-
bor, Mich, Center for Human Growth and Development,
University of Michigan, 1982. (M)
15. van der Linden FPGM: Development of the Dentition. Chi-
cago, Quintessence Publishing Co, 1983.
16. van der Linden FPGM: Facial Growth and Facial Or-
thopedics. Chicago, Quintessence Publishing Co, 1986.
-.
0".·,
CHAPTER 7

Etiology of Malocclusion
Robert E. Moyers, D.D.S., Ph.D.

The origin of all science is in the desire to know causes; and

the origin of all false science and imposture is in the desire
to accept false causes rather than none; or, which is the same
thing, in the unwillingness to acknowledge our own igno-
rance.-" Burke and the Edinburgh Phrenologists." The At-
las, February 15, 1829

KEY POINTS nasal respiratory function undoubtedly is etiologic to

some malocclusions: current research will likely show
1. Rather than having specific "causes," as do some details.
diseases, malocclusions are usually clinically 8. Dental caries is a significant cause of some
significant variations from the normal range of growth malocclusions resulting from premature loss of
and morphology. Etiologic factors contribute to the primary teeth, and drifting and early eruption of
variance more often than they simply "cause" it. permanent teeth.
2. The primary etiologic sites of malocclusion are (a) the
craniofacial skeleton, (b) the dentitions, (c) the
orofacial neuromusculature, and (d) other "soft
tissues" of the masticatory system, though rarely is
one site alone involved. OUTLINE
3. The different mechanisms of adaptation of the primary
etiologic tissue sites provide much of the complexity A> The orthodontic equation
and variability of malocclusions. B. Primary etiologic sites
4. The "causes" of malocclusion are usually grouped I. Neuromuscular system
2. Bone
because they are usually nonspecific and our
3. Teeth
knowledge is often imprecise.
4. Soft parts (excluding muscle)
5. Heredity is held to be an important factor in the C. * "'Time
etiology of malocclusion, but surprisingly little is D. Causes and clinical entities
known that is of precise c.linical applicability. I. Heredity
6. Deleterious orofacial muscle habits known to be 2. Developmental defects of unknown origin
etiologic to some mal occlusions include digital 3. Trauma
sucking, tongue-thrusting, lip-sucking, and abnormal a) Prenatal trauma and birth injuries
tongue posturing. b) Postnatal trauma
7. That nasopharyngeal disease and disturbed respiratory 4. Physical agents
function may produce mouth-breathing and altered a) Premature extraction of primary teeth
craniofacial morphology is now widely held. Impaired b) Nature of food

147
 148 Growth and D.evelopment

5. Habits "norms," even tho'ugh the range of population values is useful in

a) Thumb-sucking and finger-sucking diagnosis. Nor does an experienced clinician base treatment solely
b) Tongue-thrusting on the patient's whims, for the patient is unaware of such matters
c) Lip-sucking and lip-biting as growth and development and stability of occlusion after ortho-
d) Posture dontic treatment. There is great variability in the range of func-
e) Nail-biting tioning craniofacial relationships and significant variability in our
d) Other habits response or reaction to those variances: all of which makes it
6. Disease difficult to discuss etiology and maintain a reasonable perspective.
a) Systemic diseases
b) Endocrine disorders
c) Local diseases A. THE ORTHODONTIC EQUATION
I) Nasopharyngeal diseases and disturbed
respiratory function The equation shown in Figure 7 - I is a brief expression of
2) Gingival and periodontal diseases the development of any and all dentofacial deformities. Certain
3) Tumors original causes act for a time at a site and produce a result. It is
4) Caries an expression of Koch's postulates, but it is an oversimplification
(a) Premature loss of primary teeth to assume that Koch's logic applies to developmental problems
(b) Disturbances in sequence of (e.g., malocclusions) as it does to diseases, for there are few
eruption of permanent teeth specific causes of precise malocclusions. Tuberculosis may always
(c) Loss of permanent teeth be caused by Mycobacterium tuberculosis, but open bite is not
7. Malnutrition always caused by thumb-sucking.
Since we cannot isolate and identify all of the original causes
It is traditional to discuss the etiology of mal occlusion by beginning for ease in study, Dockrell6 has grouped them as follows: (I)
with a clinical classification and working back to the causes of heredity; (2) developmental causes of unknown origin; (3) trauma;
each problem, but our knowledge is scanty about the "causes" (4) physical agents; (5) habits; (6) disease; and (7) malnutrition.
of many malocclusions. Further, malocclusions which appear sim- It will be seen that there is a certain overlapping of these groups.
ilar and are classified alike may have quite different origins. This The duration of operation of these causes and the age at which
.discussion of etiology will center on the tissue which seems to be they are seen are both functions of time, and thus are grouped
primarily involved. The idea of discussing etiology in terms of the together. The primary sites principally involved are: (1) the bones
primary tissue site was first suggestea by Dockrell,6 was used in of the facial skeleton; (2) the teeth; (3) the neuromuscular system;
earlier editions of this book, and later was adopted by such prom- and (4) the soft parts, excepting muscle. It will be noted that each
inent orthodontic scholars as Mayne,14 Harvold,8 and Moore.'6 of the regions involved is made up of a different tissue. Bone,
While it is logical to discuss the primary tissue sites wherein muscle, and teeth grow at different rates and in different manners.
malocclusion may seem to have its origins, the reader is cautioned They adapt to environmental impact in different ways. Regardless
that the matter is not as simple as it may appear because of adapt- of the original cause of a growth variation, it must be remembered
ability and variability. that the place where that cause S!lOWS its effect is important. The
Particularly during the exuberant growth of childhood, the difference in tissue response during development is a determining
entire orofacial region is highly adaptive to any intrusive etiologic factor in differentiating among many clinical problems that are
factors. Adaptive development may camouflage or exacerbate from similar in appearance. Rarely is one site alon~ involved; usually
a visual clinical viewpoint. The body in its wisdom and effort to others become affected, and we term one the site primarily in-
maintain functional homeostasis pays little attention to the Angle volved and consider the others as being secondarily concerned.
classification, the ideal Sella-Nasion-" A" point cephalometric an- The 'result is malocclusion, malfunction, or osseous dyspla-
gle, or the dentist's narrowly defined concepts of what is "nor- siil'-more probably a combination of all three. The orthodontic
mal." The ability of each tissue system to adapt varies greatly, equation more fully developed is shown in Figure 7 - 2. The outline
and all adaptability diminishes with aging. Therefore, the same for this chapter is based on this elaboration of Dockrell's equation.6
etiologic factor may have a different effect at different ages and Most malocclusions are simply c1inic~lIy significant varia-
in different persons. tions from the normal range of growth or morphology. In contrast
A further problem in discussing the etiology of malocclusion to .disease or pathologic ](}sions, malocclusion may result from a
is rooted in the great variability of skeletal and dental relationships co~6i.nation of minor variations from the normal; each is too mild
which can function well and appear esthetic. The clinician attempts to be classed as abnormal but thei; combination summates to pro-
to define malocclusion within narrow quantifiable limits of single duce a clinical problem. While all parts of the face and masticatory
features rigidly labeled as "normal" (e.g., the molar relationship
or the ANB angle), assuming all other values to be "abnormal,"
and therefore malocclusions requiring treatment. Patients are more
pragmatic, seeking treatment only when they are aware of mal- CAUSES ACT AT) TIMES ~ TISSUES PRODUCING) RESULTS
function or unesthetic appearance: but what is malfunction or ug- FIG 7-1.
liness to one patient does not bother another. Only the naive or The orthodontic equation. (From Dockrell R: Classifying aetiology of
simple dentist bases treatment goals on population means or malocclusion. Dent Rec 1952; 72:25. Used by permission.)
 Etiology of Malocclusion 149

CAUSES ACT AT. TIMES ~TISSUES PRoDueI'NG.RESUlTS

SOME PREDISPOS· PRENATAL SOME PRIMARILY MAY BE THE
ING OR FOLLOWING
SOME SECONDARILY
SOME EXCITING POSTNATAL OR A COM-
BINATION
OF THESE

1. HEREDITY AGE
TENT
OR
TISSUETION LEVelS
DYSPLASIA
INTERMIT.
DIFFERENT
SION CLES
1.
2. 2. NEUROMUSCULAR
3.
MAY
1.
TEETH
LAGE
3. OSSEOUS
CONTINUOUS
1.
2. ACT
BONE MALFUNC.
MALOCCLU.
ANDATCART!- OTHER THAN MUS-
4. SOFT TISSUES-
5.
6. HABITS
DISEASE 7. MALNUTRITION

FIG 7-2.
The orthodontic equatiol'l elaborated. (From Dockrell R: Classifying
aetiology of malocclusion. Dent Rec 1952; 72:25. Used by permission.)

system may subsequently adapt, often only one tissue system is

involved in the beginning. The words we use in orthodontics reflect
our understandings of the different primary etiologic sites; mal-
occlusion (teeth), malfunction (the neuromusculature), and osseous
dysplasia or dysgnathia (the craniofacial skeleton).
In order to illustrate the idea of a single tissue system in-
volvement at the start, three examples of crossbite are shown in
Figures 7 - 3 through 7 - 5. These three problems, although bearing
the same name, have disp.atate origins, one arising in skeletal
asymmetry, one a functional shifting of the mandible by the mus-
cles, and one a simple tipping of teeth. All are crossbites, yet they
are entirely different in their beginnings, their treatment, and their
prognosIs.

B. PRIMARY ETIOLOGIC SITES

The neuromuscular system plays its primary role in the etiol-
ogy of dentofacial deformity by the effects of reflex contractions
on the bony skeleton and the dentition. Both bones and teeth are
affected by the many functional activities of the orofacial region.
The region is a source of enormous and varied sensory input,
making possible an infinite variety of reflex activities, all of which
help determine the skeletal form and occlusal stability.

FIG 7-3.
Skeletal crossbite. Note that although the occlusal relationship seems
correct on the patient's left side, there is a crossbite involving one-
half of the dental arch on the right side. The patient also has obvious
mandibular prognathism, even at this early age. The patient's face
shows that the crossbite is primarily the result of an osseous dys-
" plasia rather than dental or muscular factors.
1. Neuromuscular System
Some neuromuscular contraction patterns are adaptive to skel-
etal. imbalances or dentin malpositions; others are the primary
etiOlbgic factor. Imbalancing contraction patterns are a significant
part of nearly all malocclusions. Treatment of malocclusion must
involve conditioning reflexes to bring about a more favorable func-
tional environment for the growing craniofacial skeleton and the
developing dentition and occlusion, or relapse may result.
2. Bone
Since the bones of the face (particularly the maxilla and man-
dible) serve as bases for the dental arches, aberrat~ons in their
150 Growth and Development

FIG 7-4.
A muscular or functional crossbite. It can be seen in A that the
midlines do not coincide and that half of the mandibular denture is
outside the maxillary denture. This patient's dentition was equili-
brated very carefully and B shows the result when the patient re-
turned to the clinic 1 week later. Note that the removal of the occlusal
interferences in the primary teeth enabled the muscles to return the
mandible to its proper position and to a proper occlusion. (See Chap-
ter 10, Analysis of the Orofacial Musculature.) Treatment of this
patient consisted of removing the sensory input to an imbalancing
eccentric occlusal reflex (See Chapter 5). No teeth were removed,
though a maxillary incisor exfoliated, nor was there time for significant
bone growth to occur.

morphology or growth may alter occlusal relationships and func- 3. Teeth

tioning. Many of the most common serious malocclusions are the
result of craniofacial skeletal imbalances. Cephalometric proce- The teeth may be a primary site in the etiology of dentofacial
dures (see Chapter 12) aid in the identification and localization of deformity in many ways. Gross variations in size, shape, number,
osseous disharmony. or position of teeth can all produce malocclusion. Often forgotten
Orthodontic treatment of skeletal disharmony must either (I) is the possibility that malpositions of teeth can induce malfunction
alter the growing craniofacial skeleton or (2) camouflage it by and, indirectly through the malfunction, alter the growth of the
moving teeth to mask its disharmony. bones. One of the most frequent problems is teeth that are too

FIG 7-5.
A dental type crossbite. Note here that the mandibular and maxillary
bases are harmonious with each other, that the midlines coincide,
and that the cross bite is localized in the right incisor region. This
crossbite is due to tipping of individual teeth. The adequate result of
tipping them back to their proper position is shown at the right. The
treatment was done by a simple appliance, applying forces mostly
to the teeth out of position. Correction of such cases usually occurs
in a few months.
 Etiology of Malocclusion 151

large for the arches in which they are found (or arches too small
for the teeth they hold).
Teeth may be moved in orthodontic treatment to correct the
malocclusion, camouflage a skeletal dysplasia, or aid in the re-
moval of neuromuscular dysfunction.

4. Soft Parts (Excluding Muscle)

" The role of the soft tissues, other than neuromuscular, in the
etiology of malocclusion is not as clearly discernible, nor is it as
important as that of the three sites discussed previously. Maloc-
clusion, however, can result from periodontal disease and loss of
the attachment apparatus and from a variety of soft-tissue lesions
including the temporomandibular joint structures.

C. TIME

The time factor in the development of malocclusion has two

components: the period during which the cause operates and the
age at which it is seen. It should be noted that the length of time
that a certain cause may be operative is not always continual; in
fact, it may cease and recur in an intermittent fashion. From an FIG 7-6.
etiologic point of view, the most useful division of the age com- Genetics and occlusion: the occlusions of four siblings. Occlusion is
ponent is into those causes active prenatally and those whose similar enough to look like serial record casts of the same individual.
effects are noted only after birth. A cause may be either continual.
or intermittent and it may show its effect either prenatally or
postnatally.
2. Developmental Defects of Unknown Origin
Developmental defects of unknown origin is a term applied
D. CAUSES AND CLINICAL ENTITIES to gross defects of a rare type probably originating in failure of
differentiation at a critical period in embryonic development. Ex-
amples sometimes cited include congenital absence of some mus-
With the foregoing brief description of the orthodontic equa-
cles, micrognathia, facial clefts, and some instances of oligodontia
tion, we are now in a position to discuss, as we are able, the
and anodontia. Some gross craniofacial syndromes fit this category
various groups of causes and their specific clinical manifestations.
while others have known genetic factors.
In some instances, something is known about the effects of a
specific cause but, for the most part, we are forced to generalize.
3. Trauma

1. Heredity Both prenatal trauma to the fetus and postnatal injuries may
result in dentofacial deformity.
Heredity has long been indicted as a cause of malocclusion.
Aberrations of genetic origin may make their appearance prenatally
a) Prenatal Trauma and Birth Injuries
or they may not be seen until many years after birth (e.g., patterns
• Hypoplasia of the mandible ·can be caused by intrauterine
of tooth eruption). The role of heredity in craniofacial growth and
pressure or trauma during delivery.
the etiology of dentofacial deformities has been the subject of many
• "Vogelgesicht," inhibited growth of the mandible due to
studies, yet surprisingly, few specifics are really known. For a
discussion of the genetic aspects of the growth of the craniofacial ankylosis of the teJ!lporomandibular joint, may be a devel-
• "Qpmental defect or may result from trauma.
skeleton read Chapter 4. The genetics of tooth and occlusal de-
• Asymmetry. A knee or a leg may press against the face in
velopment are described in Chapter 6. Very little is yet understood
concerning the part genes play in the maturation of the orofacial such a manner as to promote asymmetry of facial growth
or retardation of mandibular development.
musculature. Interesting familial resemblances are seen frequently
(Fig 7-6), yet the mode of transmission or even the site of gene
action is not understood, except for a few clean-cut problems, for
example, absence of teeth or the appearance of some gross cran- b) Postnatal Trauma
iofacial syndromes. Scant though our quantified knowledge, all • Fractures of jaws and teeth.
agree heredity plays an important role in the etiology of dentofacial • Habits may produce "microtrauma" operative over an ex-
anomalies. tended period.
152 Growth and Development
FIG 7-7.
Occlusal wear of primary teeth. Typical of occlusal wear seen among
many people who exist on a primitive, coarse diet. The two pictured
• Trauma to the temporomandibular joint has been reported
to impair growth and function leading to asymmetry and
temporomandibular dysfunction.
4. Physical Agents
a) Premature Extraction of Primary Teeth
Since premature extraction of primary teeth usually is due to
caries, it is discussed under Disease later in this section.
b) Nature of Food
People existing on a primitive, fibrous diet stimulate their
muscles to work more and thus increase the load of function on
the teeth. This type of diet usually produces less caries (less sub-
strate for cariogenic organisms), greater mean arch width, and
'increased wear of occlusal surfaces of the teeth (Fig 7-7). The
importance of occlusal wear in the transitional dentition is dis-
cussed in Chapter 6. The evidence seems to indicate that our highly
refined, soft, pappy modem diets play a role in the etiology of
some malocclusions. Lack of adequate function results in con-
traction of the dental arches, insufficient occlusal wear, and ab-
sence of the kind of occlusal adjustment normally seen in the
maturing dentition. For a discussion of the role of function in the
growth of the craniofacial skeleton see Chapter 4.
S. Habits
All habits are learned patterns of muscle contraction of a very
complex nature. Certain habits serve as stimuli to normal growth
of the jaws; for example, normal lip action and mastication. Ab-
normal habits which may interfere with the regular pattern of facial
growth must be differentiated from the desired normal habits that
are a part of normal oropharynge"al function and thus play an
important rQle in craniofacial growth and occlusal physiology.
Concern here is with those likely to be involved in the etiology
of malocclusion. The maturation of the orofacial musculature, in
its normative role, is discussed in Chapter 5. Deleterious habitual
patterns of muscle behavior often are associated with perverted or
impeded osseous growth, tooth malpositions, disturbed breathing
habits, difficulties in speech, upset balance in the facial muscu-
lature, and psychological problems. Therefore, one cannot correct
malocclusion without involvement in such reflex activities.
are Greek children from the mountain province of Euritania.
a) Thumb-Sucking and Finger-Sucking
Digital sucking is practiced by many children for a variety
of reasons; however, if it is not directly involved in the production
or maintenance of malocclusion, it probably should not be of
primary clinical concern to the dentist. As we shall see, most
digital sucking habits begin very early in life and frequently are
outgrown by 3 or 4 years of age. Unfortunately, dentists see few
children before this time. Often the family physician or pediatrician
attending so young a child is unaware of the possible dental com-
plications resulting from these habits. It should be remembered
that many children practice digital sucking habits without any
evident dentofacial deformity, but it also is true that the digital
sucking pressure habit may be a direct cause of a severe maloc-
clusion. The mechanotherapy for the treatment of the resulting
mal occlusion may be easy but the psycho logic implications of the
therapy are less clearly understood and have often been overstated.
The time of appearance of digital sucking habits has signif-
icance. Those that appear during the very first weeks of life are
typically related to feeding problems. The neonate surely is not
yet involved in sibling rivalries, and insecurities are more apt to
be related to such primitive demands as hunger. However, some
children do not begin to suck a thumb or finger until it is used as
a teething device during the difficult eruption of a primary molar.
Still .later, some children use digital sucking for the release of
emotional tensions with which they are unable to cope, taking
solace in regressing to an infantile behavior pattern. All digital
sucking habits should be studied for their psychologic implications,
for they may be related to hunger, satisfying of the sucking instinct,
insecurity, or even a desire to attract attention.
Developmental psychologists have produced a number of the-
ories to explain "non-nutritive digital sucking" (as they term it).
Most early ideas concerning digital sucking were firmly based on
cl~ssic Freudian theory. f~eud suggested that orality in the infant
is related to pregenital organization and that sexual activity is not
yet separated from the taking of nourishment. Thus, the object of
one activity, thumb-sucking, is also that of another, nursing. A
logical development of this theory relates to attempts to stop the
thumb-sucking habit, for the Freudian belief holds that an abrupt
interference with such a basic mechanism will likely lead to the
substitution of such antisocial tendencies as stuttering or mastur-
bation. Digital sucking also has been related to inadequate sucking
activity. It was found in a series of studies that there was less
thumb-sucking in both animals and humans when fed ad lib than
 Etiology of Malocclusion 153

FIG 7-8.
Malocclusion from finger-sucking.

there was when feedings were widely separated. Further, it was quite possible that thumb-sucking may begin for one reason and
learned that, in general, nonthumb-sucking children took a longer be sustained at subsequent ages by other factors. Most of the
time for feeding than was taken by thumb-suckers. In opposition findings reported thus far seem to support best the learning theory,
to the theory of inadequate sucking activity is the oral drive theory particularly if the learning of digital sucking is associated with
of Sears and Wise,20 whose work suggests that the strength of the unrestricted and prolonged nutritive sucking.
oral drive is in part a function of how long a child continues to For the dentist, the most important question is, simply, does
feed by sucking. Thus, it is not the frustration of weaning that digital sucking cause malocclusion? Many children who practice
produces thumb-sucking but, rather, the oral drive, which has been digital sucking habits have no evidence of malocclusion; however,
strengthened by the prolongation of nursing. The theory of Sears Popovitch and Thompson'8 have reported a high association of
and Wise is in keeping with a Freudian hypothesis that sucking abnormal sucking habits with the mal occlusion sample at the Bur-
increases the erotogenesis of the mouth. Benjamin, I in an inter- . lington Orthodontic Research Centre in Ontario; Canada. Cook4
esting series of experiments with monkeys, found that there was measured the forces of thumb-sucking, finding three distinctly
far less thumb-sucking among those whose nutritive sucking ex- different patterns of force application during sucking, all utilizing
perience had been greatly reduced. This theory holds that thumb- forces sufficiently strong to displace teeth or deform growing bone.
sucking is an expression of a need to suck that arises because of Melsen et al. 15found that both digital sucking and pacifier sucking
the association of sucking with the primary reinforcing aspects of increased the tendency toward abnormal swallowing. Sucking hab-
feeding. Another very interesting theory has been proposed by its were related to an increase in severe malocclusion symptoms
Benjamin, who suggests that thumb-sucking arises very simply apart from the type of swallow presented. It has been found that,
from the rooting -and placing reflexes common to all mammalian although digital sucking appeared to be more detrimental than
infants. I These primitive reflexes are maximal during the first 3 pacifier sucking, providing children with pacifiers does not solve
months of life. Her hypothesis was tested by covering infant's
hands with mittens the very first few weeks of life so that the
thumb was not accidentally involved in the placing reflex.
All thumb-sucking theories are not Freudian in origin, for it
has been suggested that thumb-sucking is one of the earliest ex-
amples of neuromuscular learning in the infant and that it follows
all the general laws of the learning process. A multidisciplinary
research team at the University of Alberta reported that children
who sucked their thumbs failed to demonstrate any consistent
psycho logic differences from a control sample. This team's well-
documented results strongly support the theory that digital sucking
habits in humans are a simple learned response!' 10They found "
no support for the psychoanalytic interpretation of thumb-sucking
as a symptom of psycho logic disturbance. Further proof for their
ideas was presented by studying the psychologic effects of ortho-
dontic intervention; typical orthodontic therapy for arresting the
habit failed to produce any significant increase in alternative or
substitutive undesirable psychologic behavior.
The various theories concerning "non-nutritive digital suck-
ing" are not completely incompatible with one another. Rather, FIG 7-9.
they suggest that the thumb-sucking habit should be viewed by Adaptation of oral and facial musculature to thumb-sucking. Note
the clinician as a behavioral pattern of multivariate nature. It is malposition of tongue, mandible, and circumoral muscles.
154 Growth and Development

the problem of malocclusion22 Sucking habits were strongly cor-

related with distocclusion and open bite and with crossbite and
maxil!ary overjet.
It should be remembered that the type of malocclusion that
may develop in the thumb-sucker is dependent on a number of
variables-the position of the digit, associated orofacial muscle
contractions, the position of the mandible during sucking, the facial
skeletal morphology, duration of sucking, and so forth. An anterior
open bite is the most frequent malocclusion (Fig 7-8). Protraction
of the maxillary anterior teeth will be seen, particularly if the
pollex is held upward against the palate (Fig 7-9). Mandibular
postl!ral retraction may develop if the weight of the hand or arm
continually forces the mandible to assume a retruded position in
order to practice the habit. Concomitantly, the mandibular incisors
may be tipped lingually. When the maxillary incisors have been
tipped labially and an open bite has developed, it becomes nec- FIG 7-10.
essary for the tongue to thrust forward during swallowing in order Direction of application of force to the dentition during thumb-sucking.
to effect an anterior seal, thus a simple tongue-thrust is necessarily Maxillary incisors are pushed labially, mandibular incisors are pushed
associated with a digital sucking habit. The simple tongue-thrust lingually, while buccal muscles exert pressure lingually against te~th
in the lateral segments of the dental arch.
does not "cause" the open bite; rather, it is an adaptive abnormal
tongue position during the swallowing. During thumb-sucking,
buccal wall contractions produce, i'n some sucking patterns, a for example, if the skeletal pattern is normal, the habit is stopped
negative pressure within the mouth, with resultant narrowing of early, the deformity has been mild, there is a teeth-together swal- ;
the maxillary arch (Fig 7- 10). With this upset in the force system low, and the associated neuromuscular habits are of a mild nature.
in and around the maxillary complex, it often is impossible for Unfortunately, many thumb-suckers produce malocclusions that
the nasal floor to drop vertically to its expected position during require orthodontic therapy. The treatment by the dentist of digital
growth. Therefore, thumb-suckers may be found to have a nar- sucking habits is discussed in Chapter 15.
rower nasal floor and a high palatal vault. The maxillary lip be-
comes hypotonic and the mandibular lip becomes hyperactive, b) Tongue-Thrusting
since it must be elevated by contractions of the orbicularis muscle Tongue-thrust swallows that may be etiologic to malocclusion
to a position between the malposed incisors during swallowing. are of two types: (I) the simple tongue-thrust swallow, which is
These abnormal muscle contractions during suckin,g and swallow- a tongue-thrust associated with a normal or teeth-together swallow;
ing stabilize the deformation. Some malocclusions arising from and (2) the complex tongue-thrust swallow. The child normally
sucking habits may be self-corrective on ~essation of the habit; swallows -:vith the teeth in occlusion, the lips lightly closed, and

FIG 7-11.
The tongue during normal and one type of abnormal swallowing. A,
normal swallowing. Teeth are in contact, lips are closed, and the
dorsum of the tongue is elevated to touch the roof of the mouth. 8,
abnormal swallowing resulting from hypertrophied tonsils and ade-
noids. As the tongue is retracted it touches the swollen tonsils and
may restrict the oral airway; the' mandible drops, and the tongue
"thrusts" forward away from the pharynx. With the mandible lowered,
the lips must be closed forcibly to keep the tongue in the oral cavity
and to effect a seal so the swallow can be completed. This is an
example of a complex tongue-thrust since the teeth are held apart
during the swallow. There is a necessary strong elevating contraction
of the mentalis muscle in all tooth-apart swallows to help with both
the lip seal and mandibular stabilization.

'I
FIG 7-12.
Malocclusion associated with a simple tongue-thrust swallow.
the tongue held against the palate behind the anterior teeth (Fig
7 -11). The simple tongue-thrust swallow usually is associated with
a history of digital sucking, even though the sucking habit may
no longer be practiced, since it is necessary for the tongue to thrust
forward into the open bite to maintain an anterior seal with the
lips during the swallow. Figure 7-12 is an example of the simple
tongue-thrust swallow and its attendant malocclusion. Complex
tongue-thrusts, on the other hand, are far more likely to be as-
sociated with chronic nasorespiratory distress, mouth-breathing,
tonsillitis, or pharyngitis (Fig 7-13). When the tonsils are in-.
flamed, the root of the tongue may encroach on the enlarged facial
pillars (see Fig 7-11). To avoid this encroachment, the mandible
reflexly drops, separating the teeth and providing more room for
the tongue to be thrust forward during swallowing to a more com-
fortable position. Pain and lessening of space in the throat pre-
cipitate a new forward tongue posture and swallowing reflex, while
the teeth and growing alveolar processes accommodate themselves
to the attendant upset in neuromuscular forces. During chronic
mouth-breathing, a large freeway space is seen, since dropping
the mandible and protruding the tongue provide a more adequate
airway. Because maintenance of the airway is a more primitive
and demanding reflex than the mature swallow, the latter is con-
ditioned to the necessity for mouth-breathing. The jaws are thus
FIG 7-13.
Open bite associated with a complex tongue-thrust.
Etiology of Malocclusion 155
held apart during the swallow in unler mat the tongue can remain
in a protracted position. The differential diagnosis of different
swallows and tongue-thrusts is given in Chapter 10. The prognosis
for treatment of these two tongue-thrust types is very different (see
Chapter 15). Melsen et aI., 15 in one of the most definitive studies
yet reported, state that both tongue-thrust swallow imd teeth-apart
swallow favor the development of disto-occlusion, extreme max-
illary overjet and open bite. There is an increase in tongue-thrust
swallowing (simple tongue-thrust) seen with both pacifier sucking
and digital sucking.
Other tongue habits that often are confused with tongue-thrust
swallow include tongue-sucking, the retained infantile. tongue pos-
ture and the retained infantile swallow (see Chapter 15). But per-
haps the most frequent confusion arises with the skeletal open bite
wherein the mandibular plane is steep and the anterior face height
much greater than the posterior face height (Fig 7-14). Under
these circumstances the tongue has great difficulty sealing the
anterior portal during the swallow. An increase in the mandibular
alveolar process height helps but cannot obviate the abnormal
tongue behavior. It seems to be unfortunate that some consider
this natural neuromuscular adaptation a "tongue-thrust."
FIG 7-14.
Skeletal open bite. For the result of orthodontic treatment, without
orthognathic surgery, see Fig 10-20.
156 Growth and Development

FIG 7-15.
Malocclusion associated with lip-sucking. Note labioversion of maxillary anterior teeth and anterior open bite.

c) Lip-Sucking and Lip-Biting angulation showed the most comprehensive correlation with cran-
Lip-sucking may appear by itself or it may be seen with iofacial morphology and that craniocervical angulation was related
thumb-sucking. In almost all -instances, it is th~ mandibular lip to steepness of the mandibular plane.
that is involved in sucking, although biting habits of the maxillary
lip are observed as well. When the mandibular lip is repeatedly
6. Disease
held beneath the maxillary anterior teeth, the result is labioversion
of these teeth, often -an open bite, and sometimes linguoversion a) Systemic Diseases
of the mandibular incisors (Fig 7-15). Febrile diseases are known to upset the dentitional develop-
mental timetable during infancy and early childhood. For the m'ost
d) Posture
Persons with faulty body posture frequently demonstrate un-
desirable mandibular postural positioning as well21 Both may be
expressions of poor general health. On the other hand, those who
hold themselves straight and erect with the head well placed over
the spinal column will almost reflexly hold their chins forward in
a preferred position. Body posture is the summated expression of
muscle reflexes and, therefore, is usually capable of change and
correction.
Abnormal tongue posturing is a frequent cause of open bite
and should not be confused with the various forms of tongue-thrust
(Fig 7-16). Some tongue posture problems can cause extensive
open bites, and many are intractable to treatment.

e) Nail-Biting
Nail-biting is mentioned frequently as a cause of tooth mal-
positions. High-strung, nervous children most often display this
habit, and not infrequently their social and psycho logic malad-
justment is of greater clinical importance than the habit, which is
nothing but a symptom of their basic problem. It seems generally
to be harder on the nails than it is on the teeth.

f) Other Habits
The constant holding of a very young baby supine on a hard,
flat surface can mold and shape the head by flattening the occiput
or producing facial asymmetry. The significance of pillowing and
sleeping on the arm, though, is thought to be greatly exaggerated.
The habitual sucking of pencils, pacifiers, or other hard objects
can be just as deleterious to facial growth as thumb-sucking and FIG 7-16.
finger-sucking. 15-IS Open bites associated with tongue posture. A, mild and more com-
Head posture and craniofacial morphology have been exten- mon form. The condition shown persisted after full-bracketed edge-
sively studied. Solow and Tallgren21 found that the craniocervical wise treatment and two retreatments. B, a more severe case.

FIG 7-17.
Malocclusion and mouth-breathing. A, face of a mouth-breather. B,
hypertrophied tonsils, which may result in an alteration in tongue
posture, mandibular posture, the action· of the tongue during the
part, though, systemic disease is more likely to have an effect on
the quality rather than the quantity of dentitional development.
Malocclusion may be a secondary result of some neuropathies and
neuromuscular disorders and it may be one of the sequelae of
treatment of such problems as scoliosis by prolonged wearing of
appliances for immobilizing the spine. The dentist must seek pe-
diatric consultation when the child with a malocclusion has any
systemic problem that might influence the course of orthodontic
therapy. No mal occlusion is known to be pathognomonic of any
usual childhood disease.
b) Endocrine Disorders
Endocrine dysfunction prenatally may be manifest in hypo-
plasia of the teeth. Postnatally, endocrine disturbances may retard
or hasten, but ordinarily they do not distort, the direction of facial
growth. They may affect the rate of ossification of the bones, the
time of suture closure, the time of eruption of the teeth, and the
rate of re sorption of the primary teeth. The periodontal membrane
and gingivae are extremely sensitive to some endocrine dysfunc-
tions and the teeth thus are affected indirectly. No malocclusion
is known to be pathognomonic of any specific endocrine disturb-
ance. It is my opinion that any professional discussion of the effects
of endocrinopathies on the child's growth should be presented by
a pediatrician.
c) Local Diseases
, ,
1) Nasopharyngeal Diseases and Disturbed Respiratory
Function.- The allegations that nasopharyngeal disease and/or
disturbed respiratory function affect craniofacial growth and pro-
duce malocclusion have been argued for over 100 years. Linder-
Aronson 12 presented and Bushey3 discussed three hypotheses which
bring the matter into focus: (I) adenoid enlargement leads to mouth-
breathing, resulting in a particular type of facial form and dentition;
(2) enlarged adenoids, though they may lead to mouth-breathing,
do not influence facial form and the type of dentition; and (3)
Eti%gy of Ma/occlusion 157
swallOW,and the mode of breathing. C, hypertrophied adenoid mass.
Such enlarged adenoids usually make necessary increased breath-
ing through the mouth. (B and C courtesy of Dr. Robert Aldrich.)
enlarged adenoids in certain types of faces and dentitions lead to
mouth-breathing. Much research now focuses on this complicated
problem which is of interest to speech scientists, otolaryngologists,
allergists, and pediatricians as well as orthodontists .. Although
there is extensive literature on the possible association between
mode of respiration and facial form and occlusion, the evidence
is simply neither complete nor explanations clear how growth and
development are modified in humans by variations in air flow.
There seem to be at least two fundamental problems in the research
thus far, whether in animal experimentation or hU})l.anclinical
studies: (I) the lack of a precise definition of what is meant by
"mouth-breathing;" and (2) the failure to use adequate cephalo-
metric methods to test rigorously the hypotheses of interest. The
following summary of the current state of our knowledge should
be read with these two methodologic limitations in mind. The
basic assumption is that enlarged adenoids obstruct the airway,
causing mouth-breathing, which necessitates changes in tongue,
lip, and mandibular posture. These upsets in "soft-tissue balance"
lead to alterations in craniofacial form and to malocclusion, in-
,\Juding increased anterior face height, narrow and high palate,
retroclined incisors, increased lower face height, open bite, and a
tendency to crossbite (Fig 7-17). These changes are thought to
be brought about by compression, disuse atrophy, and altered air
pressure.
In .a series. of classic studies, Harvold8 restricted the airway
iir Jllcin~eys, producing:" a variety of responses in electromy-
ographic, cephalometric, and occlusal findings, but always leading
to serious malocclusion. After resumption of normal breathing,
though the lips and tongue usually returned to normal, th~!lljll-
occlusion remained (Fig 7-18).
Linder-Aronson's studiesl2 are the most detailed research on
humans. His reports on the relationship between reduced respi-
ratory function and facial type and dentition are of interest, but
his reports on the effects of a change from mouth-breathing to
nose-breathing are compelling.
He studied children who had undergone adenoidectomies to
158 Growth and Development

.~~.
-....
'\

FIG 7-18.
Young adult animal with (A) normal occlusion and (B) normal tongue
position. C, the tongue moved forward in response to nasal obstruc-
tion. D, three years later an effective oral airway was well established.
Six months after nasal respiration was resumed the lips (E) and the
tongue (F) were again pqsitioned normally. G, the acquired dental
malocclusion, however, was retained. (From Harvold EP: Neuro-
.,
muscular and morphological adaptations in experimentally induced
oral respiration, in McNamaca JA Jr (ed): Nasa-Respiratory Function
and·'c~~niofacial Growth, monograph 9. Craniofacial Growth Series.
Ann Arbor, Mich, Center for Human Growth and Development, Uni-
versity of Michigan, 1979. Used by permission.)

clear nasal passages, finding that 5 years after the change from
mouth-breathing to nose-breathing there was a normalization of
the upper incisor inclination, an improvement in the lower incisor
inclination during the first year, a return to normal bimolar arch
width, a normal depth of the nasal pharynx, .lmd an improvement
in the mandibular plane and lower face height. Furthermore, the
head posture, which was altered prior to surgery, returned to nor-
mal later.
Warren23 and colleagues have studied extensively the aero-
dynamics of the upper airway. They conclude that the present
studies do not support the assumption that nasal airway inadequacy
produces dental facial deformities. They document well, however,
that abnormalities of oral and nasal structures can seriously com-
promise speech performance. Hershey et aI., colleagues of War-
11
ren, reported a marked reduction in nasal airway resistance after
rapid maxillary expansion.
Bluestone2 pointed out that upper-airway obstruction can be
caused by tonsils and/or adenoids and can result in serious car-
diorespiratory complications. However, he felt that the effects of
respiratory obstruction on craniofacial and occlusal development
remain to be shown.
In my opinion, the hypothesis that impaired nasal respiratory
function affects dentitional and craniofacial development is at least
somewhat correct since the anecdotal observations are so volu-
minous and the research findings support in an erratic and incon-
clusive way the supposition. However, the details of the relationship
between impaired nasal respiratory function and craniofacial growth
await results of research under way.
2) Gingival and Periodontal Diseases.- Infections and other
disorders of the periodontal membrane and gingivae have a direct
and highly localized effect on the teeth. They may cause loss of
teeth, changes in the closure patterns of the mandible to avoid
trauma to sensitive areas, ankylosis of the teeth, and other con-
ditions that influence the position of the teeth (Fig 7-19).
3) Tumors.- Tumors in the dental area may cause maloc-
clusion (Fig 7-20). Severe malfunction will result when they are
found in the articulatory region.
4) Caries.- The greatest single cause of localized maloc-
clusion undoubtedly is dental caries. Caries may be responsible
for early loss of primary teeth, drifting of permanent teeth, pre-
FIG 7-19.
Hypertrophy of the gingivae and incisal malalignment.
Etiology of Malocclusion 159
FIG 7-20.
Fibroma at maxillary midline causing diastema.
mature eruption of permanent teeth, and so forth. Although caries
is not the sole cause of these conditions, it is responsible for most
of them.
(a) Premature Loss of Primary Teeth.- In this instance,
the word "premature" refers to the child's own dental develop-
ment, not to population standards. Specifically, it refers to the
stage of development of the permanent tooth that will succeed the
lost primary tooth. When a primary tooth is lost before the per-
manent successor has started to erupt (crown formation completed
and root formation begun), bone may re-form atop the permanent
tooth, delaying its eruption. When its eruption is delayed, more
time is available for other teeth to drift into space that would have
been occupied by the delayed tooth (see Chapter 6).
Of importance in this connection is not only the total loss of
the primary teeth (Fig 7-21) but partial loss of crown substance
to caries as well. Interproximal caries plays a most important role
in shortening of arch length. Any decrease in the mesiodistal width
of a primary molar may result in the forward drifting of the first
permanent molar.
Since the last edition of this book two excellent studies of
the effects of caries and premature loss of primary teeth have been
completed and reported, by Ronnermanl9 in Sweden and Northwayl7
in Canada. Northway17 found that the space occupied by the pri-
mary molars closed as a consequence of caries or loss of the
primary teeth. The rate of loss of space was related to extraction-
age in the maxilla but not in the mandible. Loss of the first primary
molar in the maxilla blocks out the permanent cuspids (Fig 7-22)
FIG 7-21.
Drifting of primary teeth due to early loss of a primary incisor.
 160 Growth and Development

AGE AT LOSS
6 YR 5 .0. .0.

l
..J
7 YRS 0----0
0-
6 0
<f) UJ
0u
..•
::l' --
>E
U
:0
..•
:0
UJ
E
~>-
..•
..J
>=
<f)
UJ
-I82
--3
-4
-5
II A'
8
9
10
YRS 0------0
VRS.--.&
YRS ----
li I I Y RS .--.

I
I
I
I
9 10 11 12 13
CHRONOLOGICAL AGE
FIG 7-22.
Blocked-out maxillary permanent cuspids and mandibular second FIG 7-24.
bicuspids. Changes in anterior and posterior limits of 0 E space, upper. (From
Northway WM: Antero-posterior Arch Dimension Changes in French-
while loss of the maxillary second primary molar tends to impact Canadian Children: A Study of the Effects of Dental Caries and
the second premolar. Lower primary molar extractions prematurely Premature Extraction, thesis. Quebec, Canada, University of Mon-
tend to cause mal eruption of the second premolar. Most space loss treal, 1977. Used by permission.)
is due to mesial movement of the molars, but distal migration of
need for more orthodontic treatment in those cases in which pri-
the cuspids occurs (Figs 7-23 and 7-24). Molar and canine oc-
mary molars had been lost early and that it was necessary to extract
clusal relationships are significantly affected by premature loss of
more permanent teeth in the treatment of such cases.
primary molars in either arch. Ronnerman'9 found that the early The loss of primary INCISORS ordinarily is not a matter of
loss of the primary second molar resulted in the earlier eruption
concern; however, should a primary incisor be lost before the
of the second permanent molar. He also noted that there was a
crowns of the permanent incisors are in a position to prevent
drifting of the more distally placed primary teeth, malocclusion
~ of the primary dentition may result (see Fig 7-21). If a primary
'" ~
"u
Q,
E
19
16
15
incisor is lost before age 4, radiographs should be taken of the
E

17 -
developing permanent incisor and the space observed regularly.
18
12
13 14-
Primary CUSPIDS, when lost, may be a matter of great con-
cern. In the maxilla, the permanent cuspid erupts so late that if
the primary cuspid is removed before the central and lateral incisors
have been moved together, it may permit permanent spacing of
a
the anterior teeth. Strange as it seems, incisor spacing and la-
bioversion of the cuspid may occur in the same case (Fig 7-25).
Pri{llary cuspid loss in the mandible is more frequent and more
serious. The untimely loss of these teeth may result in lingual
tipping of the four mandibular incisors if there is abnormal activity
of the mentalis muscle. It has been widely recommended that the
------ NON·MUT primary cuspid be extracted to facilitate the alignment of the per-
.--e SEVERE CARIES
0-------<> D- LO SS
6· ..... ·6- E· LOS S
manent incisors in the man~ible (see Chapter 15). Removal of the
0-·-0 D+E LOSS ,. primarY cuspid to achieve' incisal alignment sometimes must be
accompanied by an appliance to prevent lingual tipping of the
incisors (see Chapter IS). Many a blocked-out mandibular cuspid
6 7 8 9 10 11 12 13 14 owes its position to the ill-planned removal of the primary cuspid,
DENTAL AGE
just as many an anterior malalignment is due to the prolonged
FIG 7-23. retention of the same tooth.
Changes in anterior and posterior limits of 0 E space, lower. (From The lost of FIRST PRIMARY MOLARS is not thought by
Northway WM: Antero-posterior Arch Dimension Changes in French- some to be of clinical import. This is because the problem does
Canadian Children: A Study of the Effects of Dental Caries and not manifest itself for some time after the tooth's removal. Study
Premature Extraction, thesis. Quebec, Canada, University of Mon- of Figures 7-22 and 7-26 reveals that the loss of the primary first
treal, 1977. Reproduced by permission.) molar will cause the permanent canine to move mesially and the

FIG 7-25.
Labioversion of maxillary cuspids with spacing between incisors.
first permanent molar to do the same. In the maxilla the effects
are not so profound. The first bicuspid is not misplaced during its
eruption, since it is a bit narrower mesiodistally than is the first
primary molar. If the first mandibular primary molar is lost very
early, the second primary molar may shift forward at the time the
first permanent molar is erupting (see Fig 7-26).
The early loss of the SECOND PRIMARY MOLAR will
allow the first permanent molar to drift forward at once (see Figs
FIG 7-26.
A, crossbite caused by unilateral loss of a mandibular first primary
molar. Loss of the tooth allowed drifting of other teeth, causing tooth
interferences, and the muscles shifted the mandible to achieve an
adequate occlusal relationship. B, effects of premature loss of first
Etiology of Malocclusion 161
7-23 and 7-24):The second primary molar is wider mesiodistally
than its successor, but the difference in their widths is utilized in
the anterior part of the arch to provide space for the permanent
cuspids. Therefore, when the second primary molar is lost early
not only does the first permanent molar move directly forward but
the canine drifts distally. The incisors often follow altering the
midline, and the canine consequently erupts with no space to
occupy (see Fig 7-22). In the mandible, where the second bicuspid
is the last of the canine and bicuspids to arrive, it is the tooth
blocked out of position (see Fig 7-22). Too much emphasis cannot
be placed on the importance of the second primary molar during
the mixed dentition stage. Loss of crown substance to caries in
this tooth may be more serious than the loss of an entire other
tooth. It plays an important role in the establishment of occlusal
relationships and in the maintenance of arch perimeter (Chapter
6).
When TWO OR MORE PRIMARY MOLARS are lost early
in the development of the dentition there is, in addition to the
accumulated effects of drifting already noted, the opportunity for
other changes to take place. With the loss of posterior dental
support, the mandible may be held in a position to provide some
sort of adaptive occlusal function and a resulting accommodative
posterior crossbite (see Fig 7-26). These positional crossbites"have
primary molar at an early age. C, effects of loss of primary second
molar prior to the eruption of the first permanent molar. Note the
mesial position of the right first molar and earlier eruption of the right
second molar. (B and C courtesy of Or. Sheldon Rosenstein.)
162 Growth and Development

TABLE 7-1.
Variations in Sequence of Eruptions'
MAXILLA MANDIBLE

SEQUENCE gASES % SEQUENCE CASES %

1.6124537 115 48.72 1.6123457 108 45.77

2. 6124357 38 16.01 2. 6123475 44 18.64
3.6124573 28 11.87 3.6124357 20 8.47
4.6123457 14 5.93 4.6123745 14 5.93
5.6124375 13 5.51 5.6124537 14 5.93
6. remaining 13 6. remaining 12
sequences 28 11.87 sequences 36 15.26
• Adapted from Lo R, Moyers RE: Sequence of eruption of permanent dentition. Am J Orthod 1953; 39:460.

far-reaching effects on the temporomandibular joints, the mus-
culature, the growth of the facial bones, and the final positions of
the permanent teeth.
Davey,' in a study of the loss of maxillary primary molars,
concluded that the factors related to migration of the first per-
manent molar after loss of the second or first and second primary
molars were (I) the amount of leeway space-more drift occurred
in arches with less leeway space, (2) cusp height-high permanent
molar cusps inhibit drifting, and (3) age when the primary teeth
are lost-the greatest loss occurred when the primary molars were
lost prior to the eruption of the first permanent molars.
(b) Disturbances in Sequence of Eruption of Permanent
Teeth.- Lo and Moyers13 have shown that the normal sequence
of eruption of the permanent teeth will provide the highest per-
centage of normal occlusions (Table 7-1). Abnormal orders of
arrival may permit shifting of the teeth, with resultant space loss.
The premature loss of any primary tooth may allow the earlier
arrival of its permanent successor or it may delay it, according to
the stage of dental development. Periapical pathology of the pri-
mary teeth particularly hastens eruption of the successor due to
loss of bone and increased vascularity of the region. In severe
cases, the permanent crown may erupt into position before there
is sufficient root development to stabilize the tooth's position.
Tumors and supernumerary teeth may deflect or impede the course
of eruption and thus upset the order of arrival. Prolonged retention
of primary teeth, either because of failure of the roots to resorb
or because of ankylosis of the root with the alveolar process, is a
common factor that disturbs the sequence of eruption. One of the
most important sequences to observe is that of early arrival of the
second permanent molar. When this tooth develops ahead of any
anterior teeth, it may have a dramatic effect in shortening arch
perimeter (see Chapter 15).
(c) Loss of Permanent Teeth.-- The loss of a permanent
tooth results in a major upset in the physiologic functioning of the
dentition, since the break in mesiodistal contacts permits shifting
of the teeth. Because of their susceptibility to caries, the first
permanent molars are of particular interest (see Chapter 15).
7. Malnutrition
Malnutrition is more likely to affect the quality of tissues
being formed and the rates of calcification than it is the size of
parts (although the latter has been demonstrated in animals). In-
sofar as local effects are concerned, the roles of fluoride intake
and refined carbohydrates in caries production are well known.
Although there is no malocclusion that is pathognomonic of any
typical and common nutritional deficiency, good nutrition plays
an important role in growth and in the maintenance of good bodily
health and oral hygiene.
SUMMARY
Very few malocclusions are the result of a single specific
cause. For example, there is no virus that produces Class n, Di-
vision I malocclusion or an organism that specifically causes cross-
bite; even thumb-sucking does not always cause the same
malocclusion. Rather, mal occlusion is a clinically significant var-
iation from normal growth resulting from the interaction of many
factors during development. However, there is a tendency for some
malocclusions to originate within a single tissue system and to
affect other tissue systems secondarily as they, in turn, adapt.
Most severe types are osseous in origin, on which are superimposed
dental and muscular features.
Malocclusions originate because of imbalances among the
developing systems that form the craniofacial complex, imbalances
with which the growing face cannot cope.
REFERENCES
I. Benjamin L: Non-nutritive sucking and dental malocclusion
in the deciduous and permanent teeth of Rhesus monkey.
" Child Dev 1962; 3:29.
2. Bluestone CD: The role of tonsils and adenoids in the ob-
struction of respiration, in McNamara JA Jr (ed): Naso-Res-
piratory Function and Craniofacial Growth, monograph 9.
Craniofacial Growth Series. Ann Arbor Mich, Center for
Human Growth and Development, University of Michigan,
• 1979. ~~.
3."Bushey RS: Adenoid obstruction of the nasopharynx, in
McNamara JA Jr (ed): Naso~Respiratory Function and
Craniofacial Growth, monograph 9. Craniofacial Growth
Series. Ann Arbor, Mich, Center for Human Growth and
Development, University of Michigan, 1979.
4. Cook J: Intraoral Pressures Involved in' Thumb and Finger
Sucking, master's thesis, Horace H Rockham School of
Graduate Studies, University of Michigan, Ann Arbor,
1958.
5. Davey KW: Effect of premature loss of primary molars on
the anteroposterior position of maxillary first permanent

molars and other teeth. J Dent Child 1967; 34:383.
6. Dockrell R: Classifying etiology of malocclusion. Dent Rec
1952; 72:25.
7. 'Freud S: Three Contributions to the Theory of Sex, 3rd ed.
New York, Nervous and Mental Disease Publishing Co,
1919 .•
8. Harvold EP: Neuromuscular and morphological adaptations
in experimentally induced oral respiration, in McNamara lA
lr (ed): Naso-Respiratory Function and Craniofacial
Growth, monograph 9. Craniofacial Growth Series. Ann
Arbor, Mich, Center for Human Growth and Development,
University of Michigan, 1979.
9. Haryett R, et al: Chronic thumb-sucking: The psychologic
effects and the relative effectiveness of various methods of
treatment. Am J Orthod 1957; 53:569.
10. Haryett RD, Hansen FC, Davidson PO: Chronic thumb-
sucking: Second report on treatment and its psychologic ef-
fects. Am J Orthod 1970; 57:164-178.
11. Hershey HG, Steward BL, Warren DW: Changes in nasal
airway resistance associated with rapid maxillary expansion.
Am J Orthod 1976; 69:274-284.
12. Linder-Aronson S: Adenoids-their effect on mode of
breathing and nasal air flow and their relationship to char-
acteristics of the facial skeleton and the dentition. Acta
Otolaryngol 1970; 265(suppl):3-132.
13. Lo R, Moyers RE: Sequence of eruption of permanent den-
tition. Am J Orthod 1953; 39:460.
14. Mayne W: Serial extraction, in Graber TM (ed): Current
Orthodontic Concepts and Techniques. Philadelphia, WB
'I Saunders Co, 1969.
15. Melson B, Stensgaard K, Pedersen l: Sucking habits and
their influence on swallowing pattern and prevalence of
malocclusion. Eur J Orthod 1979; 1(4):271-280.
16. Moore A: Critique of orthodontic dogma. Angle Orthod
1969; 39:69.
17. Northway WM: Antero-posterior Arch Dimension Changes
in French-Canadian Children: A Study of the Effects of
Dental Caries and Premature Extractions, thesis. School of
Dentistry, University of Montreal, Quebec, Canada,. 1977.
18. Popovitch F, Thompson GW: Evaluation of preventive and
interceptive orthodontic treatment between three and eight-
een years of age, in Cook l: Transactions of the Third In-
ternational Orthodontic Congress. St Louis, CV Mosby
Co, 1975.
,.
Etiology of Malocclusion 163
19. Ronnerman A: Early extraction of deciduous molars: Effect
on dental development and need for orthodontic treatment.
Swed Dent J 1974; 67:327-337.
20. Sears R, Wise G: Relation of cup-feeding in infancy to
thumb-sucking and the oral drive. Am J Orthopsychiatry
1950; 20:123.
21. Solow B, Tallgren A: Head posture and craniofacial mor-
phology. Am J Phys Anthropol1976; 44:417-436.
22. Svedmyr B: Dummy sucking: Study of its prevalence, dura-
tion and malocclusion consequences. Swed Dent J 1979;
3:25-210.
23. Warren DW: Aerodynamic studies of upper airway: Impli-
cations for growth, breathing and speech, in McNamara lA
lr (ed): Naso-Respiratory Function and Craniofacial
Growth, monograph 9. Craniofacial Growth Series. Ann
Arbor, Mich, Center for Human Growth and Development,
University of Michigan, 1979.
SUGGESTED READINGS
I. Dockrell R: Classifying etiology of malocclusion. Dent Rec
1952; 72:25.
2. Haryett R, et al: Chronic thumb-sucking: The psycho logic
effects and the relative effectiveness of various methods of
treatment. Am J Orthod 1957; 53:569.
3. Haryett RD, Hansen FC, Davidson PO: Chronic thumb-suck-
ing: Second report on treatment and its psychologic effects.
Am J Orthod 1970; 57:164-178 ..
4. Melson B, Stensgaard K, Pedersen l: Sucking habits and
their influence on swallowing pattern and prevalence on mal-
occlusion. Eur J Orthod 1979; 1(4):271-280.
5. McNamara lA lr (ed): Naso-Respiratory Function and Cranio-
facial Growth, monograph 9. Craniofacial Growth Series.
Ann Arbor, Mich, Center for Human Growth and Develop-
ment, University of Michigan, 1979.
6. Popovitch F, Thompson GW: Evaluation of preventive and
interceptive orthodontic treatment between three and eighteen
years of age, in Cook l: Transactions of the Third Interna-
tional Orthodontic Congress. St Louis, CV Mosby Co,
1975.
SECTION 11
Diagnosis
Robert E. Moyers, D.D.S., Ph.D.
DIAGNOSIS
To treat any malocclusion well one must first recognize it iD
all its forms and stages of development: such recognition consti-
tutes the diagnosis. Orthodontic diagnosis is systematic, tentative,
accurate guessing directed to two ends: classification (naming the
clinical problem, if possible) and planning consequent actions made
necessary by its recognition. Some diagnoses are easy, many are
difficult, and a few are impossible-yet all are important, for
diagnosis is the trump factor in providing orthodontic care.
Orthodontic diagnosis is completed in several stages: the ex-
amination, when one gathers cursory data from observations of
and listening to the patient; a tentative assignment or classification;
testing the validity of initial perceptions with more definitive data
(e.g., cephalograms); and placing the diagnosis in the total per-
spective of the patient's age, needs, self image, and other factors
as the prelude to treatment planning.
Orthodontic diagnostic mistakes can be made in several ways:
a) By misunderstanding the role of diagnosis in orthodon-
tics.-Diagnosis is a Greek word (MArNOEIE) meaning to dis-
cern among, to know differences between; therefore, diagnosis is
the determination of the presence or absence of the abnormal or
undesired. Diagnosis is thinking about a problem, classification is
naming it, treatment is acting on it.
b) By attaching too little significance to il.-In dentistry
diagnosis is frequently simple, requiring little thought or reflec-
tion-as in diagnosing a carious lesion or the absence of teeth. In
these instances, a single clinical observation places immediate
emphasis on the techniques required. Few such observations, dur-
ing an orthodontic examination, lead to immediate thoughts of
treatment techniques. Rather, initial signs prompt the search for
related indicators: one question brings more. Soon, unless the
whole procedure is systematic, confusion reigns.
c) By resorting to intuition.-Diagnosis by intuition or hunch
is the swiftest way to orthodontic disaster. Habitual guessing about
mal occlusions or random selection of treatment methods are equally
defeating. A certain conceit causes us to prefer our own ideas or
theories to the truth because they are our private property whereas
the truth belongs to everyone. Further, the truth about a difficult
problem often makes us uncomfortable whereas hunches seem
certain. But to be certain is sometimes ridiculous and to depend
on personal hunches is to disavow the rich accumulation of clinical
wisdom in our literature, to deny the research of many great minds,
and to repudiate science itself while substituting arrogant whim
for all this loss.
d) By undue reliance on simplistic formula.-A friend once
said to me, in response to a query about a colleague, "He's the
kind of person who removes four second molars and then begins
the diagnosis." All of us may wish all malocclusions to yield to
simple formulary-a single cephalometric measure, one appli-
ance, or routine removal of the same teeth in all patients-but it
is much more complicated. In orthodontics only blind fools or
inexperienced and gullible clinicians think a simple formula com-
petent to deal with variability, and a thorough diagnosis protects
even them. Remember diagnosis derives from the Greek word for
knowledge (rNOEIE): we must know before we treat.
'.
, ~. e) By insufficient·individualization.-Classification is the
naming of typical malocclusions. When one substitutes classifi-
cation for differential diagnosis one depends on the rule, whereas
every patient is a particular example. How is it possible to sub-
stitute such a coarse system of sifting as The Angle Classification
or the ANB angle for thoughtful, judicious diagnostics? The ap-
preciation of subtle, minor differences is the essential factor in all
successful orthodontic diagnoses. But their systematic cataloging
is not enough, for they must be related to each other, to their
impact on the patient, and compared to similar situations seen in
the past. We seek simple rules or labels to avoid thinking; but a
165
166 Diagnosis

classifier is not always a good clinician, whereas a thorough diag~ diagnosis is the prelude to practice.
nostician is bound to be. Classification can be an end in itself, but
CHAPTER 8

The Cursory Orthodontic

Examination

Robert E. Moyers, D.D.S., Ph.D.

More mistakes are made from want of a proper examination

than for any other reason.-DR. RUSSELL JOHN HOWARD,
quoted by F.G. ST. CLAIR STRANGE,in The Hip, Chapter 5.

The first step toward cure is to know what the disease is. (Ad
sanitatem gradus est novisse morbum.)-Latin Proverb

KEY POINTS OUTLINE

A. Before the examination

1. The purpose of the cursory examination is to reach a
B. The cursory examination
tentative diagnosis and classification quickly from
facts gathered in a single brief appointment. I. Consideration of general health, appearance, and
attitude
2. The cursory examination provides clues to possible 2. Examination of external facial features
treatment plans.
a) Position and posture of lips
3. The cursory examination defines the need for more b) Col or and texture of lips
definitive diagnostic data. c) Method of breathing
4. The cursory examination includes, in order: d) Soft -tissue profile
a) Consideration of general health, appearance, and attitude, e) Swallow
b) Examination of the external facial features, 3. Analysis of facial form
c) Analysis of the facial f9rm, 4. Description of intraoral features
d) Description of intraoral features, a) Gingivae
e) Classification of the occlusion, b) Faucial pillars and throat
f) Evaluation of available space in the dental arch, c) Tongue
g) Study of the functional occlusal relationships and d) Number of teeth
temporomandibular joints, e) Size of teeth
h) Completion of part of the permanent record, including case f) Sequence and position of erupting teeth
history, dental casts, and radiographs. g) Malposed individual teeth
h) Occlusal relationships of the teeth

167
168 Diagnosis

5. Classification of the occlusion

6. Evaluation of the available space
7. Study of the functional occlusal relationships and the
temporomandibular joints
8. Completion of the permanent record
a) The case history
b) Record casts
c) Radiographic record
Often one sees the terms "examination," "diagnosis,"
"classification," and "treatment planning" used interchangeably.
Since each term has its own precise meaning, these should not be
substituted for one another. Such misusage is semantic proof of
confused thinking!
, The cursory examination is a procedure for gathering initial
data-the compilation of sufficient facts to permit a tentative di-
agnosis (Fig 8-1). Diagnosis is the study and interpretation of
data concerning a clinical problem in order to determine the pres-
ence or absense of abnormality. In orthodontics, the diagnosis
establishes or denies the existence and character of dentofacial
deformity. Once the presence of an abnormality has been deter-
mined, similar abnormalities often are grouped together for con- FIG 8-1.
venience in discussion; this process is the classification. After the Flow chart of the orthodontic examination.
data have been gathered, studied, and interpreted and the problem
named, the treatment must be planned. Treatment planning is
strategy; the treatment itself is the tactics. A necessary sequential
dependence will be seen: we examine, we diagnose, we classify,
we plan, we treat. Logic points to this sequence; practice man-
agement demands it.
ORTHODONTIC PATIENT INFORMATION Present drugs or medication: _
Birth Defects:
Welcome to our office. Has the patient reached puberty (menstruation, hair)? Yes No

The following information is requested to enable me to give you the best Does the patient:
consideration of your orthodontic problem during your initial examination in 1. Have allergies to: Seasonal grasses Food _
our office. In order for me to diagnose thoroughly any condition, I must have Drugs Other _
accurate background and health information on which to base my decisions. 2. Snore when sleeping? Yes No
This information, which is important for my records and your health, is 3. Breath through mouth? Usually Sometimes Seldom
confidential. Please circle the appropriate response where indicated. Thank 4. Have frequent colds? Yes No
you. 5 Have frequent "stuffy nose"? Yes No
6. Have frequent sore throat or tonsilitis? Yes No
7. Have chewing or swallowing difficulty? Yes No

:~:~e~~~;e~:me Age_ Birt~~::ep~ Sex_ Has the patient received medical treatment from an allergist or an ear, nose and
Street City Zip Code throat specialist? Yes No
Patient's Occupation or School Level Business Phone If YES: When Treated by Whom _
Employer or School ~ Nasal Surgery Tonsils removed Adenoids removed
Person Responsible for Account Home Phone _
Relationship Occupation Employer _ Dental History
Is patient covered by insurance for orthodontic treatment? Yes No
If YES, by which company? _ Does the patient have pain or clicking in jaw joints? Yes No
Name of person to be contacted if patient cannot be reached: Have any teeth been injured by accidents or blows to the mouth? Yes No
Name Relationship _ Has the patient received or been requested to receive speech correction? Yes No
Address Phone _ The following habits are of interest. List information as it pertains to this
Family Dentist Family Physician Referred by _ patient: •
thumb sucking until age Grinding of teeth Yes No when?
Family History Finger sucking until age- Tongue thrusting Yes No
Lip-biting or sucking Y~o Other habits Yes No
Father's Name Living? Yes No
Mother's Name ~ Living? Yes No Has the patient had any unusual dental experiences?
Siblings None Nwnber of Brothers Nwnber of Sisters Specify: of;

Patient's Marital Status _ Date of last dental check up Were the patient's teeth cleaned? Yes 1\0
Patient Living with: Mother Father Spouse Self Other
Spouse's Name _ Orthodontic History

Medical History Has ,the patient had a previous o~tD-pdontic consultation? Yes No or treatment? Yes No
Has the patie!)t ever had: Dat"e;...• Dr.' ~ _
Asthma Diabetes Heart Disease Hepatitis Present orthodontic consultation prompted by:'~ Patient Dentist Mother Father
Anemia Epilepsy Hearing Disorder Rheumatic Fever Spouse Sibling Physician Friend Other (specify): _
Blood Disease Endocrine Problem Head or Face Injury Other (describe beloH)
Bone Disorders Emotional Problems Herpes Patient's interest in orthodontic treatment:
Wants Treatment Treatment If Necessary Unwilling But Agrees Uncooperative
COMMENTS:
Why did patient seek this consultation? _
What is the primary probl~m? _

Has the patient been under the care of a physician during the past two years, other What is expected from orthodontic treatment? _
than for routine examination? Yes No Additional comments you wish to make:

Condition:

Signature of individual completing this form: _

Relationship to patient Today's Date _
FIG 8-2.
Questionnaire to be filled out by the patient or patient's parent.

A. BEFORE THE EXAMINATION
Much has been written concerning the preparation for a dental
examination and the psychology of "handling" children in the
dental office. Elaborate parental preparation. of the child's mind
for a visit to the dentist is to be discouraged lest the child become
unduly apprehensive. Most children are naturally relaxed. If they
are tense in the dental office, it is important to learn the source
of the tension. If the child is anxious while still in the waiting
room, it may help to ask the parent to remain outside during the
examination. While the dentist is showing the patient to the chair,
the assistant may say to the parent, "We have a rule that parents
wait outside during the examination. You know how some parents
are. Doctor lones will want to talk with you later." Few parents
fail to respond to this approach. Not all children should be seen
alone; this procedure has proved successful in instances in which
the child's fears had their origins in the parent's attitude. The
parent may complete a health record and questionnaire (Fig 8-2)
while waiting for the discussion with the dentist if the patient is
not old enough to do so. It is advantageous to have the patient
complete the questionnaire as far as possible, since it enables the
dentist to direct his questions, based on the answers, directly to
the patient. Thus a cooperative dialogue is set up between child
and dentist with the parent in the role of observer not that of
explainer, advocate, or protector.
A child usually will respond casually if treated casually. A
good relationship will be established with most children by being
busy at your work and slightly indifferent to them. Too much
attention should be avoided. Often it is the dentist who is nervous,
and the child quickly realizes this. The orthodontic examination
is not painful and as soon as this is learned, cooperation of most
young patients is ensured.
B. THE CURSORY EXAMINATION
The purpose of the cursory examination is to provide the
minimal necessary facts on which a tentative diagnosis and clas-
sification can be made. The detailed analysis on which treatment
planning is based is done later (see Chapter IQ through 12). The
difference between the cursory examination and the detailed anal-
ysis-treatment plan is a matter of economics. One cannot afford
to do a detailed analysis of every child seen, nor do most require
such attention. On the other hand, neither can one afford to un-
dertake extended orthodontic therapy with only the facts acquired
in the cursory examination. Considerable clinical skill is required
to make quick, correct initial examinations of potential orthodontic
patients in order to know which will require further diagnostic
data before such decisions can be made.
The steps to be described provide a satisfactory cursory or-
thodontic examination easily managed in the office of the typical
family dentist. No use is made in the cursory examination of
elaborate diagnostic aids (e.g., cephalograms). Such procedures
are, however, described in Chapters 10 through 12. Each step
should be in sequence and all observations written down. The
orthodontic appraisal of a patient cannot be reduced to such simple
systems of notations as those used for charting cavities and plan-
ning restorative dentistry. Furthermore, the details of a developing
The Cursory Orthodontic Examination 169
FIG 8-3.
Instruments used for the cursory orthodontic examination. Left to
right: mouth mirror, explorer, tooth-measuring
gauge, dividers, and
tongue depressor.
occlusion change so rapidly from one observation to the next that
they cannot be remembered. It is helpful to have a recent periapical
radiographic survey while making the cursory examination. If such
a radiographic survey is not available, securing it becomes part of
the examination.
The following instruments should be in place on the bracket
table (Fig 8-3); mouth mirror, explorer, gauge for measuring
teeth, dividers, and tongue depressor.
1. Consideration of General Health, Appearance, and
Attitude
The first step in any orthodontic examination is to form a
general idea of the patient's health status, physical appearance,
and attitude toward orthodontics. Actually, the examination should
begin the moment the patient is first seen. Often it is possible to
'team much concerning his/her general appearance, stature, pos-
ture, attitude, and the parent-child relationship as the child walks
into the examination room and ·:Sits. The child with an extensive
medical history or an unfortunate previous dental experience may
be unduly apprehensive. First questions serve not only to inform
t\1e examiner but to ease the mind of the child. It may be useful
fofthe dentist to ask the usual questions necessary for completion
of the record card as the child tells his or her name, age, street
address, school, family physician, etc. An opportunity is given to
observe the child's facial features, speech mannerisms, attitude
toward you, and other clues. General questions concerning the
child's health and past illnesses may be asked and related to the
questionnaire completed by a parent, although, of course, a com-
plete physical examination is the responsibility of the physician.
Of particular interest to the dentist are data about allergies and
chronic nasorespiratory disorders. Do not hesitate to ask the child
 170 Diagnosis

TABLE 8-1.
Growth Charts. Stature and Weights Are Given by Age Percentiles (2 to 18 years) A, boys' stature; B, boys' weights. C, girls' stature; 0, girls'
weights'

A B

f- ] -~
44.1
........
.........
........
.........
:::::~: W
:::::;::::::::::::::::::
!55.1 -W
:c: ~~
I4/"lf"'
f- .~::.:.:~ ;·;·:s :.;.:,
.........
:;:·;·t ::;::N.........
......
i~ :::::v r yI v
1:::::]::::::!:::::::t::::::!:::::::I::::::t::::::[:::::[::::::!::::::::!::::::::r::::j;!' :;:;:;:;
v··:·····51.2
;:,:::,:
er I~1'd AG
A: X (/)
Y"1;~:;:;:;;1:
47.:> =>
;:
1 98.2

D
E (yearsl

0
22.0 66.1

f- AGE (years) ~ I"

'W
;t
I.
eo18
It····' 12
"
r
-
:::::1:::1::::::1:::::::1:::::::1::::::::1::::::::1::::':'I: :':]::::1 ::::1:;>'1
1
,~
88.2
.... i;;;f 10
};;;;}} }} ...
.;{ .,,::::::::::;:;:::::::
ti;i;;
130 5 ..... 49.2 044'.1
70
~ ;i;):
53.1
57.1 66.1
22.0

8 10 12 14 16 18

AGE (years)

'Courtesy National Center for Health Statistics, Health Resources Administration, US Department of Health, Education and Welfare. Monthly Vital Statistics Report
25(3, suppl): June 22, 1976.

any question that seems necessary or pertinent. The child's answers Frankfurt Plane should be roughly parallel to the floor. This po-
frequently are more enlightening than' those of the parents. sition in the chair, althougll not usual for intra-oral dental exam-
For appraising the child's physical development, the stature inations, is more useful for examining the external facial features,
and weight charts (Table 8-1) are useful. (The relationship be- jaw functions, and occlusal relationships (Fig 8-4).
tween facial and bodily growth is discussed in Chapter 4.) Begin
the examination by forming a general impression of the child's a) Position and Posture of Lips
health and appearance. Lip posture is best studied during normal head and mandibular
posture (see Fig 8-4). Normally, the lips meet each other in an
un strained relationship at the level of the occlusal plane (Fig 8-
2. Examination of External Facial Features
5). Palpate the lips to ascertain whether they are of equal tonus
The patient should be seated in the chair so that the spine is and muscular development. Study the role of each lip during the
erect and the head is placed well over the vertebral column. The unconscious swallow. A detailed analysis of lip function is given
 The Cursory Orthodontic Examination 171

FIG 8-4.
A, improper position of the head for orthodontic examination. 8, to the floor. Note the difference in the patient's profile in these two
proper position of the head. The Frankfurt plane should be parallel views.

in Chapter 10; however, in the cursory examination, the posture
of the lips, their relative size, and their role in swallowing should
be noted.
b) Calor and Texture of Lips
When one lip is of a color or texture different from the other,
there is a reason. If, for example, the lower lip rests beneath the
upper incisors during a swallow, it usually is redder, heavier, and
more likely to be moist and smooth (see Fig 10-3). The less active
upper lip more frequently is chapped and lighter in color.
c) Method of Breathing
It is easiest to study the method of breathing while the patient
is unaware that he is being observed. The mouth-breather's lips
are separated at rest to allow inspiration, whereas the nasal-breath-
er's lips are held lightly together. After a general impression of
the breathing method is formed, ask the patient to take a deep
breath and then blow it out. Most children, given such a command,
will inspire through the mouth, although an occasional nasal-breather
will inspire through the nose with the lips tightly closed. Then ask
the patient to close his or her lips and take a deep breath through
the nose. A child who is a normal nasal-breather has good reflex
control of the alar muscles, which control the size and shape of
the external nares. Therefore, the nasal-breather dilates the external
nares reflexly during inspiration. On the other hand, although all
mouth-breathers (except rare ones with nasal stenosis or conges-
tion) can breathe through their noses, they usually do not change
the size or shape of the external nares during inspiration (see Fig
10-13). Occasionally, mouth-breathers actually contract the nares
while inspiring. Even the nasal-breather who has temporary nasal
congestion will demonstrate alar contraction reflexly when asked
to take a breath while keeping the lips closed. Unilateral nasal
function may be diagnosed by placing a small mirror on the upper
lip, which will cloud with condensed moisture from the nasal
breathing, or by use of a cotton "butterfly" (see Fig 10-14).

d) Soft-Tissue Profile
"'Observation of the superficjal facial features at rest and in
action complements greatly our knowledge of the occlusal rela-
tionships and the positions of the teeth. Extreme malpositions of
teeth rarely are seen without accompanying muscle imbalances.
The important questions are "Do the muscles of the lips and face
contribute to any tooth malpositions, or are they accommodating
to the malpositions?" and "How might they adapt to any corrective
movements of the incisors?" Detailed analysis of the facial mus-
FIG 8-5. culature is discussed in Chapter 10, but the role of the facial
Normal lip posture. muscles must be noted in the cursory examination.
172 Diagnosis

FIG 8-6.
Use of a tongue depressor on the lower lip to check the type of
swallow.
FIG 8-7.
Palpation of the temporal muscle for checking the swallow.

e) Swallow
It is important in the cursory examination to learn how the
patient swallows. Observe the patient swallowing unconsciously,
noting whether the lips contract. Then gently place a mouth mirror
or tongue depressor on the lower lip and ask the patient to swallow
(Fig 8-6). Normal (teeth-together) swallows are completed, whereas
teeth-apart swallows are inhibited, since mandibular lips and men-
talis contractions are necessary in teeth-apart swallows. Palpate
the temporal muscle during command swallows of saliva or a small
amount of water (Fig 8-7). Teeth-together swallowers must con-
tract this muscle to elevate the mandible and hold the teeth in
occlusion; teeth-apart swallowers do not have to contract the el-
evator muscles. Further methods of analyzing swallowing are given
in Chapter 10.
3. Analysis of Facial Form
Even though detailed analysis of the craniofacial skeleton can
only be done by use of the cephalogram, an appraisal of the facial
form is an absolute necessity for even the shortest examination.
(Detailed cephalometric analyses of the facial skeleton are given
in Chapter 12.)
The Facial Form Analysis method* outlined in this chapter
has proved practical and worthwhile. It is subjective, therefore not
* The Facial Form Analysis was developed by E.A. Cheney and
J.F. Mortell to teach students at The University of Michigan to evaluate
craniofacial morphology in an efficient systematic way. It is not a sub-
stitute for a cephalometric analysis, only a careful procedure for exam-
ining the patient's facial features.

FIG 8-8.
The planes of the Facial Form Analysis. A, lateral view; B. frontal view.

NASION
PLANE
FRANKFURT
PLA~
FIG 8-9.
Landmarks of the Facial Form Analysis. The midfacial point is anal-
ogous to the cephalometric A point and may be estimated by using
ihe ala of the nose. The maxillary alveolar point is analogous to
superior prosthion and is found at the interseptal gingival tip between
quantitative, and is suggested for use only when radiographic
cephalometry is not available. The Facial Form Analysis provides,
however, a quick, systematic evaluation of the relationship of the
various parts of the facial skeleton.
The Facial Form Analysis relates the facial parts to two planes,
the Frankfurt and the Nasion, in the lateral view. The Frankfurt
Plane (Fig 8-8), on the living, joins the tragus (representing the
external auditory meatus) and the orbitale (the lowest point in the
bony orbit). The Nasion Plane (Izard's plane) is erected perpen-
dicularly to the Frankfurt Plane and passes through the Nasion
point (Fig 8-9). The deepest point in the bony profile of the
frontonasal curvature is taken on the living as Nasion. These two
planes in combination have limitations for cephalometric use (see
Chapter 12, Requisites of a Cephalometric Analysis) since there
are clinically significant sex and age differences in the relationship
of skeletal landmarks to the Nasion Plane. They are useful, how-
ever, in the Facial Form Analysis as a crude, clinical evaluation
of one face without metric reference to population norms. The
face is related to the Midsagittal Plane alone in the frontal view
(see Fig 8-8). In Figure 8-10 the landmarks used for recording
findings of the Facial Form Analysis are illustrated. The locations
of the landmarks on the patient, as shown for a typical case (Figs
8-10 and 8-11), are marked directly on the form, and the soft-
tissue profile may be drawn. To make it easier to visualize the
exact placement of the landmarks as they appear in the patient,
vertical dotted lines are used to represent the distance between
perpendiculars erected to Frankfurt at orbitale and nasion, and that
same distance anterior to the Nasion Plane. The questions asked
are pertinent and useful to an understanding of the clinical sig-
nificance of the relationships noted. The Facial Form Analysis
does not provide answers; it simply makes it easier for the clinician
to identify any gross malrelationship of parts and to pose the most
critical questions that must be asked before treatment is begun.
4. Description of Intraoral Features
a) Gingivae
Localized gingival lesions may be symptomatic of trauma-
The Cursory Orthodontic Examination 173
MIDFACIAL POINT
MAXILLARY ALVEOLAR POINT
MANDIBULAR ALVEOLAR POINT
CHIN POINT
the maxillary central incisors. The mandibular alveolar point, anal-
ogous to the cephalometric inferior prosthion, is found at the inter-
septal gingival tip between the mandibular central incisors. The chin
point is the most protrusive point of the skin overlying the chin.
togenic occlusion, poor oral hygiene, delayed eruption of per-
manent teeth, hyperactivity of the mentalis muscle (see Fig 10-
6), mouth-breathing, or other conditions. The appearance and health
of the gingival tissues is an index of periodontal health.
b) Faucial Pillars and Throat
Oral health is closely related to pharyngeal conditions. In-
flamed, hypertrophied, or infected tonsils may give rise to alter-
ations in the tongue posture, mandibular posture, swallowing, or
breathing reflexes (see Chapters 7 and 10).
c) Tongue
Study of tongue activity is difficult because the tongue or-
dinarily is not clearly visible. Since most tongue functions are
synchronized well with the circumoral muscles and the muscles
of mastication, abnormal function in one will result in associative
or accommodative abnormal function in the others. Abnormal
function of the tongue often is first suggested when one notes
abnormal function of the lips. When the lips are parted by a mouth
mirror or the cheeks are withdrawn by retractors so that the mouth
may be viewed better, normal tongue activity is inhibited and
tannot be observed. The diagnostic trick is to examine the tongue
in its normal functions without displacement of the lips and cheeks.
Much has been written concerning the tongue as a gauge of oral
health. From an orthodontic point of view, considerations other
than its color and texture are perhaps more important, for example,
its relative size, its posttfral position, and its role and positions in
s~veral reflex functions. An assessment of lingual motor skills
must also be a part of any orthodontic diagnostic examination (see
Chapter 10).
I) Study the posture of the tongue while the mandible is in
its postural position. Sometimes this can be done if the lips rest
apart, or tongue. posture can be noted in the lateral cephalogram
of mandibular posture. If neither ?f the procedures is fruitful,
gently part the lips after cautioning the patient not to move.
2) Observe the tongue during various swallowing procedures:
the unconscious. swallow, the command swallow of saliva, the
174 Diagnosis

¥)!.
Patient' 5 Name, Date

FACIAL FORM ANALYSIS

L Lateral View

INasion
Po I I II
IIIOrI I...L.
Frankfurt ~ :fX
Midfacial

Maxillary alveolar
Mandibular alveolar

Chin point

Draw in the profile from Nasion to chin point.

1. What molar relationship is indicated by facial Bkele~ VJJ::.

2. a. What is the overjet? 9,0 b. What is the overbite? (... I fl101f.

3. What 1Sthe significance of the lOC1sorrel~'ti~

4. What IS molar relationshIp? &J'£ What is the cuspid
relationship? ~ JI:
5. Is mandible shifted in A-P on closure? Yes No

6. Angle between Frankfurt horizontal and occlusal plane;

flat, normal, ~
7. Obtusity of gonial angle, less than normal, normal.
weater than norma!.)
8. hlclination of maxillary central incisors relative to
nasion plane; anteriorlv inclined, normal, vertical,
posteriorly inclined.

9. m.clination of mandibular central incisors relative to

nasion plane;anteriorly inclined, normal, vertical,
posteriorly inclined ..

Summary: ~.~~7TT~
~~~.
FIG 8-10.
An example of a completed Facial Form Analysis, lateral view.

command swallow of water, and the unconscious swallow during
chewing. Do not separate the lips to see what the tongue is doing;
rather, observe the contractions of the orbicularis oris and men.talis
muscles and deduce from their activity the tongue's positions dur-
ing swallowing. Complete details Of the analysis of the swallow
are given in Chapter 10.
3) Observe the role of the tongue during mastication.
4) Observe the role of the tongue during speech. Some have
overstated the relationship between speech and malocclusion. Many
patients with gross malocclusions have excellent speech because
they have great motor skills ~nd can adapt the lips and tongue well
to mal positions of the teeth and malrelationships of the jaw. Very
few mal occlusions are the result of abnormal tongue function pres-
ent only during speech. However, observation of abnormal use of
the tongue during speech may beqof use in. analyzing other mal-
functions of the tongue (see Chapter 10).
, d) Number of Teeth~'
't'ounting the number of teeth 9ften is forgotten. The examiner
must account for 52 teeth-20 deciduous and the 32 permanent
teeth, which are developing at the time of the usual orthodontic
examination. For this reason, a complete standard periapical or
panoramic survey is necessary.
e) Size of Teeth
Like all other biologic forms, teeth come in different sizes.
From an orthodontic point of view, their most important mea-
surement is their mesiodistal width. The tooth-measuring gauge
 The Cursory Orthodontic Examination 175
n. Frontal view

Are the following landmarks symmetric?

If not, indicate location.

I
I

Orbitale

Malar
(Or)

bones
---O-1-Q--
I \. I
I
I
Occlusal Plane: -- _ _____
4tn _
Midlines. (Draw in maxillary QJO
and mandibular central incisors) I
Gonial Angles -- - - - - - - --- ----'r----
I
Chin point - Occlusal
Postural - Draw in
Path of

Maxillary arch form; (taperinwtrapezoid, ovoid, liD" - type.

Mandibular arch form; tapering, ,trapezoid, (Ovoid) IID" - type ..

Summary:
iJwvmO/U<JuO 4~"~~"'~~-~
~~2-~,V~~w<-d ~~.
FIG 8-11.
An example of a completed Facial Form Analysis, frontal view,

(see Fig 8-3), or a Boley gauge that has been reduced in size,
provides a simple and accurate method of measuring teeth: In Table
8-2 the mean mesiodistal widths of various permanent teeth are
shown for purposes of comparison. There are important and sig-
nificant racial differences in tooth dimensions. Table 8-2 data
reveal the distribution of sizes for the two most common racial
groups in North America. The problem of tooth size and maloc-
clusion is always a relative one, since teeth accommodated nicely
in one mouth are crowded in another.
f) Sequence and Position of Erupting Teeth
During development there are changes in the apparent sequence
of eruption and relative positions of the teeth. There are also
clinically important variations in sequence and eruptive positions
(see Chapters 6 and 11). Radiogr~hs provide a static "snapshot"
at a single moment, but our minds must visualize dental development
as a constantly shifting and changing series of events, a "movie"
of the forming occlusion. One must note, during the cursory
examination, any deviations of sequence and position which must
be observed later or are symptomatic of developing malocclusion.
g) Malposed Individual Teeth
Malpositions of teeth must be evaluated according to their
developmental status, not by their ultimate position in the line of
the arch. For example, maxillary cuspids usually erupt high in the
alveolar process, point mesially and labially, and temporarily look
a bit unsightly to patient and parent. Such a position is normal
only if there is adequate space in the arch for the tooth and if the
examiner can visualize this position as part of normal eruption.
Later, the same position is a malposition.
h) Occlusal Relationships of the Teeth
With the mandible in the retruded contact position or the ideal
.occlusal position (see Chapter 10 and 11), the examiner should
'(;onsider the occlusal relationships of the teeth in detail, beginning
at one side in the molar region and advancing around the arch to
the opposite side. (I) Note the precise il)tercuspation of each of
the posterior teeth and whether the intercuspation is symmetric.
(2) Determine precisely the anteroposterior relationship of the molars
and cuspids, and deterrtline any reasons for dissimilarity between
their intercuspation. (3) Study the effects of tipped and rotated
permanent teeth. (4) Measure the incisor relationships, both vertical
and horizontal (Fig 8-13). (5) Note any lack of occlusal stops, as
in an open bite, and find an explanation for their absence. There
are two definitions of open bite in current orthodontic usage. The
first defines open bite as the absence of vertical incisal overlap
(Fig 8-14); the second defines open bite as the absence of an
occlusal stop (Fig 8-14). It is most important to use the latter
definition. Some cases, for example, Class n, Division 1, may
show incisal overlap and what seems to be an unimportant lack
 .
• >

176
MALE
172
136
127
102
125
148
147
160
161
156
143
100
122
MEAN so
11.76
9.50
11.04
10.74
10.57
11.23
10.35
10.94
10.71
10.58
191
150
158
192
189
6.78
5.92
6.60
6.13
0.70
0.73
0.37
6.67
0.71
9.50
0.40
6.96
0.63
6.89
0.47
7.22
0.46
7.07
0.67
9.98
6.86
9.12
7.26
0.59
0.57
8.67
0.64
8.19
7.25
8.72
7.08
7.37
0.34
5.46
7.85
5.38
5.99
7.41
7.61
7.99
0.36
7.49
6.76
5.53
6.88
6.04
7.74
5.54
80
92
0.74
0.60
0.58
0.56so
so
11.539.4-14.0
10.18
6.5-9.0
6.0-8.2
6.1-9.3
4.6-6.5
6.4-8.7
7.0-8.8
7.5-10.8
5.5-8.7
7.1-9.3
6.0-8.5
7.3-10.0
6.2-8.4
6.0-8.0
5.0-7.1
6.3-9.0
6.50
8.79
196
159
134
6.58
N 9.1-13.0
9.4-12.2
9.1-12.0
8.7-12.1
9.3-12.5
N
7.76
6.64
0.32
0.42
7.66
8.91
99
153
146
142
104
156
145
148
138
140
112 0.67
0.49
0.38
0.64
0.63
0.52
0.73
0.53
0.58
0.56
0.43
0.39
0.51
0.42
0.57
0.55
0.46
0.50
0.62
0.44
0.86
0.72
4.5-6.6
5.0-7.5
6.2-8.6
10.0-13.7
5.8-8.3
10.299.7-12.5
159RANGE
6.2-9.4
Diagnosis 121N
201
212
216
208
152
157
214
215
170
159
132
115 FEMALE MANDIBLE

Development,
1976.
5, Central
Craniofacial
Table
Negroes.
Mesiodistal
Monograph
BJ.from
AmincisorGrowth
Richardson
Orthod
Crown
Series. Ann
-ER,MAXILLA
Arbor,
Malhotra
1975; 68:157-164
Diameters, . Michigan,
Permanent
SK: Mesiodistal
Center for crown
Dentition'
Humandimension
Growth and
of the '.permanent
Development, University
dentition ofof American
Michigan,
A, North American Whites
TABLE 8-2.
 The Cursory Orthodontic Examination 177

7354216 6124537
7543216 6123457

??? ???
7354216 6124573
3574216 6124735
??? ???
FIG 8-12.
Symbolization of the sequence of eruption. A, normal sequence; B, abnormal sequence.

FIG 8 •.....
:13.
Method of measuring overjet. The Boley gauge is placed against the
labial surface of the lower incisor, the sliding portion of the gauge is
moved back to touch the labial surface of the upper incisor, and the
distance is then read off directly.
178 Diagnosis
FIG 8-14.
Definition of open bite. Left, the no.rmal incisor relationship showing
contact between upper and lower incisors. Middle, an open bite with-
out overlap of the incisors. Right, an open bite with overlap of the
incisors. Often, only the middle figure is described as an open bite.
of intermaxillary incisal contact. However, as treatment proceeds,
and after the incisors are retracted and the occlusal plane leveled,
the open bite becomes more obvious (Fig 8-15). In such instances,
incisal retraction encroaches on the tongue's functional space,
dramatizing with treatment a condition that was present but
undiagnosed at the start.
5. Classification of Occlusion
It is not enough to classify the occlusion on the basis of the
first permanent molar relationship alone. The skeletal profile must
be classified, the cuspid relationship noted, the incisor relationship
studied, the position of the dentures to their bases observed, etc.
Study carefully Chapter 9 on Classification of mal occlusion for
the classification procedure is one of the most misused and mis-
understood procedures in orthodontics.
FIG 8-15.
Mild open bites, often undiagnosed at the start of treatment, are
dramatized during treatment if the incisors are retracted into the
functional space of the tongue.
The condition at the right also is an open bite, as there are no
functional or occlusal stops present. The absence of occlusal contact
with antagonistic teeth (functional stops) is proof of an open bite.
6. Evaluation of the Available Space
One of the most important steps in the cursory orthodontic
examination is the evaluation of the space available to achieve
desired tooth positions and occlusal corrections. Before all of the
permanent teeth are present in the mouth, this procedure is called
the Mixed Dentition Analysis, details of which will be found in
Chapter 11. When the permanent dentition is completed as far as
the second molars, space analysis often is more critical and dif-
ficult, and the diagnostic setup (see Chapter 11) may be utilized.
Perhaps evaluation of the available space is the most difficult
task during the cursory examination, since a quantitative estimate
of the amount of space available and needed is necessary. Most
parts of the cursory examination are qualitative and subjective
judgments; space analysis, even at the start, is based on precise
measurements. One may be tempted to make quick, crude esti-
mates by visual observations alone, or by ratings as "very crowded,"
"moderately crowded," "spaced," etc. Unless one's retinas are
calibrated in millimeters, casual inspection is insufficient even for
the cursory examination. The Mixed Dentition Analysis described
in Chapter 1I is intended for use on dental casts. If casts are
available, the Mixed Dentition Analysis should be completed on
th'em during the cursory examination. Often, however, a cursory
examination is done before record casts are obtained. It is better,
under such circumstances, to doa Mixed Dentition Analysis di-
rectly in the mouth (Fig 8~ 16) than to make casual guesses that
may bias incorrectly all other initial thoughts concerning the case.
Th,e Mixed Dentition Apalysis obtained directly in the mouth is
helpfHl at this time but must b~ verified later when casts are
available.
7. Study of the Functional Relationships and the
Temporomandibular Joints
There is a possible or potential functional element in every
malocclusion. The patient's usual occlusal position may be due to
occlusal interferences in the undeviated path of closure, that is,
interferences .may prompt a reflex shifting of the mandible during

FIG 8-16.
The Mixed Dentition Analysis directly in the mouth. A, measuring the
lower incisor width. B, ascertaining the amount of space needed to
closure to an occlusal position dictated by the cusps and forcing
an imbalance on the musculature (see Chapter 5); such malocclu-
sions have been termed "functional malocclusions" (although they
more properly should be labeled malfunctional occlusions). Such
"slides into centric" (aren't they really slides out of centric?) may
be seen at any age, but the functional slides into occlusion in the
primary and mixed dentitions are of a grosser nature than those
ordinarily seen in the completed, permanent dentition. They are
also more important because of their potential for affecting future
growth and imbalance in the craniofacial skeleton as well as dis-
torting the form of the alveolar arches.
Detailed procedures for analyzing occlusal interferences and
registering'jaw relationships are given in Chapter 11. Since a brief
functional analysis of the occlusion must be a part of the cursory
examination, the following procedures are suggested:
a) With the patient sitting upright in such a way that the head
The Cursory Orthodontic Examination 179
align two of the lower incisors. (See Chapter 11 for details of the
Mixed Dentition Analysis.)
is unsupported by the headrest, or supported in such a way that
the Frankfurt Plane is parallel to the floor, have the patient open
and close the jaws slowly. Pay particular attention to the chin and
mandibular inc.isors during the last stages of closing. Changes in
the overjet relationship as the teeth come into occlusion are typ-
ically noted. The use o( dots marked on the midlines of the face,
or'i-straight edge held to the midlines, is useful in diagnosing
lateral shifts of the jaws (Fig 8-17). The Facial Form Analysis
makes use of such a functional evaluation (see Fig 8-10).
b) Correlate the two denture midlines, asking the patient to
move the mandible forward gently while you guide it so that the
midlines still coincide (Fig 8-18). As the patient moves the jaw
gently forward and backward with the midlines coincident, a quick
and clear view of cuspal interferences and lack of coordination
between the shapes of the two arch forms sometimes can be noted.
Often they are found in the primary cuspid region during the mixed
180 Diagnosis
FIG 8-17.
Extra-oral testing for a functional slide into occlusion. Dots are placed
at selected points on the midline and the patient is asked to open
and close the jaw gently. A, the jaw is wide open. Note that the dots
are now aligned. B, the mandible is in a postural position. Note that
dentition. Have the patient tap the incisors together, noting whether
or not incisal guidance and tapping provides complete posterior
disclusion.
c) Gently guide the mandible into its retruded contact position
and note any cuspal interferences between the retruded contact
position and the usual occlusal position.
cl) Place the jaw in the retruded contact position and guide
the patient slightly into lateral occlusion on either side to observe
occlusal impedance to lateral function (Fig 8-19).
e) Observe carefully jaw movements during the unconscious
swallow (q. v.) to ascertain whether it is completed with the teeth
together or the teeth apart.
/) Ascertain any abnormal movements of the jaw during speech
and mastication.
g) Even during this quick, functional analysis of the occlusion,
one may mark any interfering cusps with articulation paper, noting
in the written record the teeth involved.
The temporomandibular joints should be studied for evidence
FIG 8-18.
Checking for occlusal interferences during protrusion.
the dots are still aligned. C, the teeth are in occlusion. In this instance,
as the teeth came together, the mandible was guided by cuspal
interferences into a functional crossbite and was forced to swing to
the left on closure. Note the malalignment of the dots in C.
of dysfunction, pain, or other abnormal signs and symptoms. De-
tails are provided in Chapters 10 and 11. Most books and articles
on temporomandibular dysfunction and analysis are written from
a geriatric not a developmental viewpoint. Definitive studies of
the early stages of temporomandibular dysfunction are lacking,
but it is obvious the problem has an earlier start than is usually
assumed and that many adult diagnostic criteria are inappropriate
for the child.
I) Place your fingers lightly over both joints and feel the
condylar-meniscus relationships during opening and closing.
2) Note the amount of maximal opening.
3) Palpate individually the temporal (particularly its attach-
ment), medial pterygoid, lateral pterygoid, masseter, and infra-
mandibular muscles. Ask the patient to note left-right differences
and score each muscle on the crude tenderness scale explained in
Chapter 10.
4) Palpate the joints intra-orally, noting intercapsular pain and
any loss of intimacy between meniscus and condyle.
FIG 8-19.
Checking for occlusal interferences in lateral excursive occlusion.
 CLINICAL EXAMINATION
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TONSILS. ADENOIOS'
GENER ..••lEVAlU ..••T10N
SHORT INFLAMED NOT VISIBLE
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BROAD MODERATE REMOVED
PATIENT ATTITUDE: ENTHUSIASTIC

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_______________ PROGNATH~ _ FUNCTIONAL ANALYSIS

MENTOLABIAL
CLICKING ON LEFT CREPITUS ON LEFT
SULCUS:
CLICKING ON RIGHT CREPITUS ON RIGHT

""
AT REST:
INTEROCCLUSAL CLEARANCE, mm

MANDIBULAR PATH OF CLOSURE IREST TO OCCLUSION),

DEVIATION DISTAL
INTRA·ORAl DEVIATION RIGHT DEVIATION MESIAL
OCCLUSAL INTERFERENCES

OVERJET: mm DVERBIT£: mm
MUSCLE FUNCTION
IMPINGING
Cl ••• '

EMOoE"" MOl.' C•••••

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DEGLUTlTlON, NORMAL SIMPLE TONGUE THRUST (TEETH TOGETHER I
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''''''.D''~O '''''AY
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FIG 8-20.
A, cursory examination form; e, case history form.

The Cursory Orthodontic Examination 181

182 Diagnosis
8. Completion of the Permanent Record
Three permanent records are derived from the cursory ex-
amination: the case history, record casts, and radiographs. Memory
cannot be trusted to recall minute details at a later date. Further-
more, subsequent problems missed in the initiar examination but
observed later may be clarified by referral to the original record.
Many problems in dental practice are reasonably static and can be
expected to remain unchanged until corrected. The early signs and
symptoms of malocclusion often are subtle, fleeting, and ever
changing; therefore, it is essential that a continuous record be kept
of changes in the developing dentition.
a) The Case History
,The case history (Fig 8-20) should include all of the infor-
mation gathered in the cursory examination as well as the usual
data concerning the patient's age, parents' names, address, family
physician, school, siblings, and so forth. The case history may
include, as well, any questions that arise and must be answered
later.
Factors to be studied in detail before treatment can be begun
should be mentioned. The orthodontic case history must be written
out and thus resembles more a medical case history than it does
the usual codified representation of teeth and cavities used in
restorative dentistry. Time spent in compiling a complete ortho-
dontic case history is time productively invested, for this record
is of continuing assistance during subsequent observations of de-
velopment of the dentition during treatment. No dentist treating
mal occlusion can afford to have an inadequate or improper case
history.
b) Record Casts
It is difficult to recall minute occlusal details of every patient.
It is even more difficult for the parents who see their child con-
stantly to realize the important changes that take place with growth
and orthodontic treatment. For these and obvious legal reasons, a
carefully prepared set of record casts is a part of the cursory
examination. Procedures for taking impressions and preparing re-
cord casts are given in Chapter 18; for their detailed analysis, see
Chapter 11.
c) Radiographic Record
Ifthe necessary radiographs are not available, their acquisition
and study becomes the last step in the cursory examination. A
discussion of the several radiographic projections of use in analysis
of the occlusion will be found in Chapter 11. A discussion of
cephalometric analysis is contained in Chapter 12.
SUMMARY
The cursory examination is a brief gathering of sufficient data
to permit a tentative diagnosis and classification. It consists of (I)
gathering a health history, (2) examination of external facial form,
intra-oral features, the static occlusion, and occlusal and jaw-joint
functional relationships, and (3) completing part of the permanent
record for the patient.
SUGGESTED READINGS
I. Feinstein AR: The clinician as scientist, in Vig PS, Ribbens
KA (eds): Science and Clinical Judgment in .orthodontics,
monograph 19. Craniofacial Growth Series. Ann Arbor,
Mich, Center for Human Growth and Development, The
University of Michigan, 1986.
2. Horowitz SL, Hixon EH: The Nature of .orthodontic Diag-
nosis. St Louis, CV Mosby Co, 1966.
3. Jacquez JA: The diagnostic process: problems and perspec-
tives, in Jacquez JA (ed): The Diagnosis Process. Ann Ar-
bor, Mich, University of Michigan Press, 1964.
4. Johnson AL: Basic principles of orthodontics. Dental Cod-
mos 1923; 65:379-, 503-,596-,719-, 845-,957-.
5. Proffit WR, Ackerman JL: Diagnosis and Treatment Plan-
ning, in Graber TM, Swain BF: .orthodontics, Current Prin-
ciples and Techniques. St Louis, CV Mosby Co, 1985.
6. Proffit WR, Ackerman JL: Rating the characteristics of mal-
occlusion: A systematic approach for planning treatment. Am
J .orthod 1973; 64:258.
7. Sackett D: The Science of the Art of Clinical Management,
in Vig PS, Ribbens KA (eds): Science and Clinical Judg-
ment in .orthodontics, Monograph 19. Craniofacial Growth
Series. Ann Arbor, Mich, Center for Human Growth and
Development, The University of Michigan, 1986.
8. Vig PS, Ribbens KA (eds): Science and Clinical Judgment
in .orthodontics, Monograph 19. Craniofacial Growth Series.
.,Ann Arbor, Mich, Center for Human Growth and Develop-
ment, The University of Michigan, 1986.
CHAPTER 9

Classification and Terminology of

Malocclusion

Robert E. Moyers, D.D.S., Ph.D.

The beginning of wisdom is to call things by their right names.-Chinese Proverb

KEY POINTS • Muscular: abnormal function of craniofacial musculature

contributing to malocclusion.
1. Classification is a grouping of clinical cases of similar • Dental: abnormal malpositions, number, size, shape, or
appearance for ease in comparison, handling, and texture of teeth.
discussion. e) Syndromes of malocclusion
• Class I: the features associated with a Class I malocclusion.
2. Systems of classification and terminology:
• Class II: several malocclusion syndromes provide typical
a) Angle
sub-set types of Class II.
• Based on the anteroposterior relations of the jaws.
• Class Ill: a few malocclusion syndromes make up Class
• Class I (neutroclusion): normal anteroposterior jaw Ill.
relationship.
• Other syndromes are outside the Angle classification.
• Class 11 (distoclusion): the maxilla and/or its dentition are
1) Limitations
prognathic and/or the mandible and its dentition are
• No system is truly inclusive.
retrognathic.
• All are static in concept, most are narrow in focus, and
• Class III (mesioclusion): the mandible is prognathic and/or
most are traditionally misapplied.
the maxilla is retrognathic.
• Most commonly used system.
b) Simon
• Based on'three planes of head (orbital, midsagittal, and
Frankfurt).
• Little used in its entirety, but useful terminology persists. OUTLINE
c) Naming mal positions of teeth
• "Version" is added to the pirection of misplacement (e.g., }\~ What is a c1assii'ication system?
linguoversion) . B.' Purposes of classifying>
cl) Naming misplacement of groups of teeth C. When to classify
I) Vertical D. Systems of classification and terminology
• Deep overbite-excessive vertical overlap. I. Angle system
• Open bite-localized lack of occlusal contact. a) Class I (neutroclusion)
2) Transverse b) Class 11 (distoclusion)
• Crossbite-abnormal buccolingual relationships. I) Division I
3) Etiologic classification (according to primary tissue site) 2) Division 2
• Osseous: abnormal size, shape, position, or proportion of 3) Subdivisions
bones. c) Class III (mesioclusion)

183
184 Diagnosis
2. Simon system
a) Anteroposterior relationships (Orbital Plane)
b) Mediolateral relationships (Midsagittal Plane)
c) Vertical relationships (Frankfurt Plane)
3. Naming malpositions of individual-teeth and groups
of teeth
a) Individual teeth
b) Vertical variations of groups of teeth
c) Transverse variations of groups of teeth
4. Etiologic classification; its effect on diagnosis
a) Osseous (problems in abnormal growth of bones
of the face)
b) Muscular (problems in malfunction of den to-
facial musculature)
c) Dental (problems involving primarily the teeth
and their supporting structures)
d) Comment
5. Ackerman-Proffit system
E. The Class I syndrome
F. The Class 11syndrome
G. The Class III syndrome
H. Limitations of classification systems
It has been said that the introduction of the Angle system of
classification of malocclusions was the principal step in turning
disorganized clinical concepts into the disciplined science. of or-
thodontics. This may be true. But it also is true that no phase of
orthodontics is less understood or more misused. Many new and
simplified systems for classifying malocclusions have been intro-
duced, and each new system soon has many modifications. The
reason for this constant search for an unfailing method of cate-
gorizing cases is due not only to inadequacies in systems already
presented but to their misuse as well. Someone once said that 5%
of us think, 15% of us think we think, and the other 80% are
looking for rules so that we won't have to think. Those who strive
to devise a perfect formula that will enable them to put each case
into a carefully numbered pigeonhole where all will be precisely
alike and treated in exactly the same fashion obviously are in the
80% group. Unfortunately, malocclusions are not so easily sorted
and typed. There is a need for clinicians in the 5% group who
think, because orthodontics cannot be practiced primarily by any
set of rules, however cleverly devised.
A. WHAT IS A CLASSIFICATION SYSTEM?
To classify malocclusion, one must have a concept of normal
occlusion. Since normal occlusion is the composite of many fac-
tors, some of which, if measured separately, might be outside the
expected normal range, the simple chissification of normal or ab-
normal occlusion is difficult. A pe~~on with abnormally I~rge teeth
may have a normal occlusion, provided other features are suffi-
ciently large to compensate for the large teeth. Occlusion may be
best conceptualized for classification purposes as a frequency dis-
tribution with a range of features typically found in Class I, Class
11, and Class Ill. No single feature measured is a valid clue to any
class because of the overlap of the class distributions for single
measurements. Certain signs and symptoms tend to cluster in typ-
ical malocclusions, producing syndromes or classes whose iden-
tification and labeling are useful.
Each time that a patient is examined, he or she is classified
subconsciously by the examiner in many different ways. We say,
for example, that this patient is an 8-year-old boy who has not yet
acquired his maxillary permanent central incisors. In one sen-
tence we have classified our patient by three different stan-
dards-sex, age, and time of eruption of permanent teeth. But
this classification tells us nothing concerning the plan of treatment
and the prognosis. In Chapter 7 on Etiology, care was taken to
differentiate several factors involved: (I) the cause, (2) the time
it was acting, (3) the site where its effect was felt, and (4) the
resulting orthodontic problem. Classification systems, to be usa-
ble, must confine themselves to the last-the resulting malocclu-
sion, as determined for a specific developmental age.
A classification system is a grouping of clinical cases of
similar appearance for ease in handling and discussion; it is not a
system of diagnosis, method for determining prognosis, or a way
of defining treatment.
B. PURPOSES OF CLASSIFYING
One well may ask, then, "Why does one classify?" There
are several practical reasons for so doing. Historically, certain
types always have been grouped together; thus, the literature con-
tains many articles confined, for example, to "The Treatment of
Angle Class 11, Division 1 Malocclusions." It is necessary, if we
are to appreciate such an article, to have a clear concept of just
how an Angle Class 11, Division I case appears. All Class n,
Division 1 malocclusions are not exactly alike, their etiology is
not necessarily identical, their prognoses are not similar, nor do
they all demand precisely the same treatment; still, it is traditional
to group them together. A second reason for classifying is ease of
reference. It is much easier to call a case a Class III malocclusion
than to go into all of the detail necessary to describe the cranio-
facial morphology of mandibular prognathism. The listener will
have a rough idea of the problem simply from the label "Class
Ill" even though he or she does not know the etiology, the prog-
nosis, or the best treatment procedure. Experience with previous
cases bearing the same label facilitates understanding of problems
that may be encountered in treatment; thus, classification aids
comparison. There also is a reflexive or self-communicative reason
for classification. When we name a malocclusion a severe Class
1I,'we are (I) identifying problems of which we must be wary,
(2) recalling past difficulties with similar cases, and (3) alerting
ourselves to possible strategies and· appliances that may be needed
in treatment.
Classification is done for traditional reasons, for ease of ref-
ere'J,lc.e, for purposes o.f~·comparison, and for ease in self-
communication.
C. WHEN TO CLASSIFY
One of the most common mistakes is that of trying to label
each case immediately. Do not be to hasty to categorize. The
classification is not the diagnosis. It is far better first to describe
that which is wrong in a complete and precise manner. If, at the
end of the examination, the case falls into a certain usable group,
 Classification and Terminology of Malocclusion 185

A
CLASS IT CLASS I CLASS :m:
~-_.
~
\
j)
\) \'"

FIG 9-1.
A, angle classification. Facial profile and molar relationship; note
how the two change together. It would be difficult, for example, to
have a Class III molar relationship in a Class 11profile. S, the rela-
tionship of the soft-tissue profile to the occlusion. A, a balanced profile
with a Class I malocclusion. S, a retrognathic profile and the Class
11malocclusion. Note how the lips reflect the overjet of the incisors.
C, a Class III malocclusion. Here, the lip posture clearly indicates
the presence of a Class III malocclusion.
 186 Diagnosis
it should then be named. If it does not fit easily into any of the
classic groupings, do not worry. Do not, in any circumstance,
strain to put a case in a given classification; the fit seldom is
perfect. There was good reason in Chapter 8 for leaving the process
of classification until the fifth step of the cursory examination.
Immediate classification may prejudice later thinking. Study the
malocclusion carefully; describe it in detail; then, if possible, clas-
sify it.
D. SYSTEMS OF CLASSIFICATION AND
TERMINOLOGY
Of all the many methods of classifying mal occlusions pre-
sented to the profession, only two persist and are widely used
today. One of these, the Angle system,2 is used intact, but the
other, the Simon system,. is used in its entirety by very few
clinicians. However, certain fundamental concepts contained in
FIG 9-2.
A Class I malocclusion. (See also Figures 9-1 and 9-9.)
the Simon system have had a great influence, and for that reason
it will be described briefly.
1. Angle System
The Angle system is based on the anteroposterior relationships
of the jaws with each other (Fig 9-1). Angle originally presented
his classification on the theory that the maxillary first permanent
molar invariably was in correct position. Subsequent cephalometric
research has not substantiated this hypothesis. Emphasis on the
relationship of the first permanent molars caused clinicians to
ignore the facial skeleton itself and to think solely in terms of the
position of the teeth. Therefore, malfunction of muscles and prob-
lems of growth of bones often were overlooked. Even today, there
is a tendency in the inexperienced to center too much attention on
this one tooth relationship. The first molar relationship changes
during the various stages of development of the dentition (see
Chapter 6). A better correlation between Angle's concepts and
/
186 Diagnosis
it should then be named. If it does not fit easily into any of the
classic groupings, do not worry. Do not, in any circumstance,
strain to put a case in a given classification; the fit seldom is
perfect. There was good reason in Chapter 8 for leaving the process
of classification until the fifth step of the corsory examination.
Immediate classification may prejudice later thinking. Study the
malocclusion carefully; describe it in detail; then, if possible, clas-
sify it.
D. SYSTEMS OF CLASSIFICATION AND
TERMINOLOGY
Of all the many methods of classifying mal occlusions pre-
sented to the profession, only two persist and are widely used
today. One of these, the Angle system,2 is used intact, but the
other, the Simon system: is used in its entirety by very few
clinicians. However, certain fundamental concepts contained in
FIG 9-2.
A Class I malocclusion. (See also Figures 9-1 and 9-9.)
the Simon system have had a great influence, and for that reason
it will be described briefly.
1. Angle System
The Angle system is based on the anteroposterior relationships
of the jaws with each other (Fig 9-1). Angle originally presented
his classification on the theory that the maxillary first permanent
molar invariably was in correct position. Subsequent cephalometric
research has not substantiated this hypothesis. Emphasis on the
relationship of the first permanent molars caused clinicians to
ignore the facial skeleton itself and to think solely in terms of the
position of the teeth. Therefore, malfunction of muscles and prob-
lems of growth of bones often were overlooked. Even today, there
is a tendency in the inexperienced to center too much attention on
this one tooth relationship. The first molar relationship changes
during the various stages of development of the dentition (see
Chapter 6). A better correlation between Angle's concepts and

FIG 9-3.
A, typical Class 11,Division 1 malocclusion as shown in dental casts.
treatment is obtained if one uses the Angle groups to classify
skeletal relationships. A Class II molar relationship may result in
several different ways, each requiring a different strategy in treat-
ment, but a Class II skeletal pattern is not misunderstood, since
it dominates the occlusion and its treatment. Clinicians now use
the Angle system differently than)t was originally presented, for
the basis of the classification has shifted from the molars to skeletal
relationships.
The Angle system does not itself take into account discrep-
ancies in a vertical or lateral plane. Although the anteroposterior
relationship of the teeth may be the most important single consid-
eration, this classification system sometimes causes the uninitiated
to overlook such problems as overbite and narrowness of the arches.
Despite these and other criticisms, the Angle method of classifying
cases is the most traditional, most practical, and hence the most
popular in use at present.
Classification and Terminology of Malocclusion 187
ES 8-8
S, cephalometric tracing of a Class I malocclusion.
a) Class I (Neutroclusion)
Those malocclusions in which there is a normal anteropos-
terior relationship between the maxilla and the mandible fall in
this class. The triangular- ridge of the mesiobuccal cusp of the
maxillary first permanent molar articulates in the buccal groove
of't2e mandibular first petmanent molar. The bony base supporting
the mandibular dentition is direct1y beneath that of the maxillary,
and neither is too far anterior or posterior in relation to the cranium
(Fig 9-2). The malocclusion therefore is confined to malpositions
of the teeth themselves which may be misaligned, malplaced on
their boney bases, (dentoalveolar protrusion), etc.
b) Class II (Distoclusion)
Those malocclusions in which there is a "distal" relationship
of mandible to maxilla make up Class II. The nomenclature of the
Angle classification emphasizes the "distal" positioning of the
188 Diagnosis
posteriorly to the mesiobuccal cusp of the maxillary first permanent
molar (Fig 9-3). Although the word distal is commonly used in
this manner to describe Class n, it is of course wrong! Distal refers
. the relationship of the mandible to the cranial base, for example,
FIG 9-4.
A typical Class 11,Division 2 malocclusion. Class 11,Division 2 mal-
occlusions ordinarily do not show the basic skeletal retrognathism
seen in Class 11,Division 1. The maxillary central incisors seem to
be tipped lingually and the lateral incisors are in labioversion. This
incisal relationship is the most typical diagnostic sign for Class 11,
Division 2, although the lingual tipping of the central incisors is more
apparent than real. The skeletal mal relationship is rarely as severe
anteroposteriorly in Division 2 as in Division 1. (See Fig 9-11 for
other records of this same patient.)
mandible to the maxilla in Class n malocclusion, but of course
many Class n cases are seen in which the maxilla is prog-
nathic-quite a different craniofacial morphology but producing
a similar molar relationship and hence the same classification. The
mesial groove of the mandibular first permanent molar articulates
FIG 9-5.
A, a Class III malocclusion. The mesiobuccal cusp of the maxillary
first permanent molar occludes posteriorly to the buccal groove of
the mandibular first permanent molar and the mandibular incisors
occlude outside the maxillary incisors. Such an occlusal configuration
may be the result of marked skeletal mandibular prognathism or
midface deficiency. B, a cephalometric tracing of a Class III mal-
occlusion due to mandibular prognathism (this is not the same patient
as 9-5A). (See Fig 16-13 for more details of this patient.)
solely to teeth surfaces or directions and the Class n malocclusion
involves primarily the bony skeleton. If one wishes to describe
words such as posterior or dorsal are more correct.
Divisions are as follows:
I) DIVISIONI.-Distoclusion in which the maxillary incisors
are typically in extreme labioversion (Fig 9-3).
2) DIVISION2.-Distoclusion in which the maxillary central
incisors are near normal anteroposteriorly or slightly in linguo-
version, whereas the maxillary lateral incisors have tipped labially
and mesially (Fig 9-4).
3) SUBDIVISIONS.-When the distoclusion occurs on one side
of the dental arch only, the unilaterality is referred to as a sub-
division of its division.
c) Class III (Mesioclusion)
Those malocclusions in which there is a "mesial, i.e., a
ventral," relationship of mandible to maxilla make up Class Ill.
The mesial groove of the mandibular first permanent molar artic-
ulates anteriorly to the mesiobuccal cusp of the maxillary first
permanent molar (Figs 9-1 and 9-5).
2. Simon System
The dental arches in the Simon system are related to three
anthropologic planes based on craniallandmarks4 (Fig 9-6). The
planes are the Frankfurt, the orbital, and the midsagittal. They are
used in cephalometric analyses frequently, but the only part of this
system in routine current usage is some of the terminology.
FIG 9-6.
The Simon system of classification of malocclusion. Tooth mal po-
sitions are related to three planes of space in the head.

a) Anteroposterior Relationships (Orbital Plane)
When the dental arch, or part of it, is more anteriorly placed
than, normal with respect to the orbital plane, it is said to be in
protraction. When the arch, or part of it, is more posteriorly placed
than normal with respect to the orbital plane, it is said to be
retraction.
b) Mediolateral Relationships (Midsagittal Plane)
When the dental arch, or part of it, is nearer to the midsagittal
plane than the normal position, it is said to be in contraction.
When the arch, or part of it, is farther away from the midsagittal
plane than the normal position, it is said to be in distraction.
c) Vertical Relationships (Frankfurt Plane)
When the dental arch, or part of it, is nearer to the Frankfurt
plane than the normal position, it is said to be in attraction. When
the dental arch, or part of it, is farther away from the Frankfurt
plane than the normal position, it is said to be in abstraction.
Only three of these terms are in frequent use-protraction,
retraction, and contraction. For example, an Angle Class II case
may be due to maxillary protraction, mandibular retraction, or
both. Similarly, a narrowed dental arch is said to be contracted.
The principal contribution of the Simon system is its emphasis on
the orientation of the dental arches to the facial skeleton. In addition
to this, it separates carefully, by means of its terminology, prob-
lems in mal positions of teeth from those of osseous dysplasia; for
example, maxillary dental protraction is differentiated from total
maxillary protraction. In the former, only the teeth are anteriorly
placed, whereas, in the latter, the entire maxilla and its teeth are
protracted. This system probably is capable of more precision than
the Angle system, and it is three-dimensional. However, in truth,
it is cumbersome, confusing at times (e.g., attraction is intrusion
of the maxillary teeth and extrusion of mandibular teeth), and little
used in practice. Simon's concepts, however, have had a great
impact on orthodontic thinking and even have altered the fashion
in which the Angle system is used.
3. Naming Malpositions of Individual Teeth and Groups of
Teeth
a) Individual Teeth
Lischer's nomenclature' to describe malpositions of indi-
vidual teeth is in general use. It simply involves adding the suffix
"-version" to a word to indicate the direction from' the normal
position:
I) Mesioversion-mesial to the normal position.
FIG 9-7.
Crossbite. A, the normal buccolingual relationship of molars. B, buccal crossbite. C, lingual crossbite. D, complete lingual crossbite.
Classification and Terminology of Malocclusion 189
2) Distoversion-distal to the normal position.
3) Linguoversion-lingual to the normal position.
4) Labioversion or buccoversion-toward the lip or cheek.
S) Infraversion-away from the line of occlusion.
6) Supraversion-extended past the line of occlusion (i.e.,
below in the maxilla and above in the mandible.)
7) Axiversion-tipped; the wrong axial inclination.
8) Torsiversion-rotated on its long axis.
9) Transversion-wrong order in the arch; transposition.
The terms are combined when a tooth assumes a malposition
involving more than one direction from the normal. Thus, for
example, sometimes it is said that a tooth is in mesiolabioversion.
b) Vertical Variations of Groups of Teeth
Deep overbite is a term applied when there is excessive ver-
tical overlap of the incisors. Just what is excessive overlap is
difficult to define, but when the soft tissue of the palate is im-
pinged, or the health of the supporting structures is endangered,
certainly that bite is excessively deep. Wide variations in depth
of the bite may be seen, however, with no danger to the occlusion
or health of the supporting structures.
Open bite is a term applied when there is localized absence
of occlusion while the remaining teeth are in occlusion (see Fig
8-14). Open bite is seen most frequently in the anterior part of
the mouth, although posterior open bites are encountered also.
c) Transverse Variations of Groups of Teeth
Crossbite is a term used to indicate an abnormal buccolingual
(Iabiolingual) relationship of the teeth (Fig 9-7). The most com-
mon cross bite is that seen when buccal cusps of some of the
maxillary posterior teeth occlude lingually to the buccal cusps of
the lower teeth. When one or more maxillary teeth are in crossbite
toward the midline, it is termed lingual crossbite. When the lingual
cusps of upper posterior teeth occlude completely buccally of the
buccal cusps of the lower teeth, it is termed buccal crossbite.
4. Etiologic Classification; Its Effect on Diagnosis
Although it is handy to be able to group cases easily, it is
more important and practical to learn their origin. There is, for
example, a wide diversity of malocclusions that must bear the label
<'Class II," yet they may have differing geneses and varying
prognoses and may require diverse appliances. It will be easier to
clarify this situation by a retUQ1 for a moment to the etiologic
concepts outlined in Chapter 7. We have seen that there are several
190 Diagnosis
primary tissue sites in which orthodontic problems may originate.
Indeed, one may classify cases according to the tissue primarily
involved, for the soundest method of precisely determining dif-
ferences in similar clinical problems is to study each on the basis
of the probable site of origin.
a) Osseous
This category includes problems in abnormal growth, size,
shape, or proportion of any of the bones of the craniofacial com-
plex. When any bone of the face develops in a perverted, delayed,
advanced, or otherwise asynchronous manner, the aberration may
be reflected in an orthodontic problem. Class III cases, for ex-
ample, may be due to mandibular hypertrophy and Class 11 to
mandibular inadequacy. The clinical condition may be ascribed to
a genetic cause or severe malfunctions. Each region has a potential
for growth that may be altered by environment. The pattern of
bony development may express itself somewhat independently of
the dental area. The terms "basal bone" and "apical base" have
been coined to describe the areas involved in osseous dysplasias.
The remaining bone, the alveolar process, reacts largely to the
needs of the dentition it supports. The alveolar process can easily
be shaped and altered by tooth movements; the basal bone is less
responsive to the forces of orthodontic appliances. Abnormal or
perverted muscle contractions readily alter the conformation of the
alveolar process, but it takes a greater muscular abnormality acting
longer to affect the basal bone areas.
Cephalometric analysis provides the best means of studying
variations of the craniofacial skeleton. It should be remembered
that other parts always are affected secondarily. Malpositions of
teeth in such cases are mostly the result of abnormal growth of
bone, an expression or symptom of the principal fault. Orthodontic
treatment may be planned to correct the fundamental osseous dys-
plasia or to accommodate the 'dentition to it. Some orthodontic
appliances influence the dentoalveolar area; others have a profound
"orthopedic" effect on basal bone as well.
Osseous dysplasia or skeletal disharmony, unfortunately, is
a component of many of the malocclusions seen most frequently.
Only the most naive clinician avoids analysis of the skeletal aspects
of craniofacial deformity. Correction or camouflage of skeletal
disharmonies of the face is one of the primary tasks of dentists
who would treat any but the most simple malocclusions. The
adjective "skeletal" is applied to a high percentage of Class 11
problems, indicating significant osseous involvement. Most Class
III malocclusions are skeletal in origin and even such apparently
localized matters as deep bite or crossbite may have a skeletal
basis.
b) Muscular
This group includes all probleI£s in malfunction of the den-
tofacial musculature. Any persistent alteration in the normal syn-
chrony of the mandibular movements or muscle contra.ctions may
result in distorted growth of the facial bones or abnormal positions
of teeth. ~ simple lip-sucking habit may give rise to a Class 11
dentition and profile. Sometimes several habit patterns combine
to make a complicated syndrome; for' example, thumb-sucking.
The sucking habit itself is a complicated neuromuscular reflex
involving many muscles of the face, the temporomandibular ar-
ticulation, throat, tongue, and arm. Continued sucking may narrow
the maxillary dental arch. This contraction of the maxillary arch
gives rise to another complicated neuromuscular habit pattern,
mandibular retraction. The narrowing of the maxillary arch results
'in tooth interference, and the mandible is then shifted p~steriorly
by the muscles to a position of better occlusal function. (Hotz calls
this "compulsive distoclusion, "). A Class 11 molar relationship
results, but each molar may be well related to its supporting bone
and neither the mandible nor the maxilla may be abnormal in size
or conformation, In other words, the size of the bones and the
positioning of the molars can be near normal and still a Class 11
relationship eventually obtains because the mandible is held by
the muscles in a retruded position. In time, the upset of forces
acting within the entire system produces the syndrome we call
Class 11 (see Chapters 4, 6, and 7).
Since such neuromuscular patterns of behavior are habits,
they were once learned and hence are capable of being altered.
Treatment is directed toward understanding the complete habit
reflex, then removing precipitating influences or substituting other
habits that are less detrimental. The prognosis usually is excellent
if care is taken to learn well the entire syndrome and if treatment
is begun early. Neuromuscular' or ' 'functional" malocclusions al-
ways eventually bring about dental, dentoalveolar, or skeletal man-
ifestations that are not as easily reversible as the original reflex.
There is near unanimity (a rare thing in orthodontics) that neu-
romuscular features of malocclusion should be treated as early as
possible.
The role of the muscles in etiology will be found in Chapter
7, their part in dentitional and occlusal development in Chapter
6, and in skeletal growth in Chapter 4. Maturation of the neuro-
musculature is described in Chapter 5, analysis in Chapter 10, and
treatment of the functional aspects of malocclusion in Chapter 15.
This category includes:
• Functional "slides into occlusion" due to occlusal
int~rferences .
• Detrimental sucking habits (e,g., th@1b, finger, lip, etc).
• Abnormal patterns of mandibular closure.
• Incompetent normal reflexes (e.g., lip posture).
• Abnormal muscular contractions (e.g., tongue-thrusting
during swallowing, mouth breathing, etc).
c) Dental
" Dental problems involve primarily the teeth and their sup-
porting structures. The malposition of a tooth on a bone is a totally
different consideration from the growth of that bone or the mus-
cular contractions that move bones. It is fortunate, indeed, that
many clinical cases primarily involve the teeth, for they often are
the ..~asiest to intercept and'retain. Care must be exercised, though,
to det~nnine whether the dental abnprmality is the primary problem
or whether it is secondary to aberrations in osseous growth or
malfunction of muscles. Treatment is aimed at moving the teeth
to their normal positions, replacing lost teeth, or fitting the den-
tition's abnormalities to the facial skeleton and its musculature.
This category includes:
• Malpositions of teeth.
• Abnormal numbers of teeth.
• Abnormal size of teeth.
• Abnormal conformation or texture of teeth.

-IDEAL
- CROWDING
- SPACING
FIG 9-8.
Diagram of the Ackerman-Proffit classification system. (From Ack-
erman JL, Proffit WR: Characteristics of malocclusion: A modern
approach to classification and diagnoses. Am J Orthod 1969; 56:443-
454. Used by permission.)
d) Comment
One rarely encounters a malocclusion that is solely a dental,
a muscular, or an osseous problem. So intimate are the interactions
of growth that a change in one tissue easily affects another. Al-
though all three tissues (bone, muscle, and teeth) usually are in~
volved in all dentofacial deformities, one is dominant~one is
most likely the primary etiologic tissue site. It is this one that
largely determines the final treatment plan and prognosis, and on
it we should focus our attention.
The simple classification has purposes other than providing
a convenient tag for designating clinical problems. When thought-
fully applied, it also may help in understanding basic differences
among cases that at first glance look similar.
S. Ackerman-Proffit System
Because the much-used, traditional Angle classification dis-
regards certain essential factors of malocclusion, Ackerman and
Proffit' proposed a scheme which embodies the Angle classifi-
cation and five characteristics of ~alocclusion within a Venn dia-
gram (Fig 9-8). Since the degree of alignment and symmetry of
the teeth within the arches is common to all dentitions, it is rep-
resented as the universe (group I). Their profile is represented as
a major set (group 2) within the universe. Lateral, anteroposterior,
and vertical are depicted as deviations from the normal with their
interrelationships as interlocking subsets (groups 3 through 9) within
the profile set. In this system any malocclusion can thus be de-
scribed by five or fewer characteristics.
When one is classifying using this method, the alignment and
Classification and Terminology of Malocclusion 191
symmetry of the teeth in the dental arches are analyzed, the pa-
tient's profile is viewed, the dental arches are studied with regard
to the lateral dimensions, and the buccolingual relationships to the
posterior teeth are noted. The patient and the dental arches are
viewed in the saggital plane using the Angle system-noting whether
the deviation is skeletal, dentoalveolar, or a combination-and
the patient and dentition are viewed with regard to the vertical
dimension. Obviously Group 9, which combines elements of all
of the interlocking sets, represents the most complex malocclu-
sions. The system has some advantages particularly for the student
or beginner in orthodontics for it teaches a perspective about the
complexities of malocclusion. All three planes of space and the
influence of the dentition on the profile are considered. The dif-
ferentiation between skeletal and dental problems is made at the
appropriate level, and arch length problems with or without an
influence on the profile are recognized. Furthermore, this classi-
fying scheme leads one convincingly to the diagnosis and to dif-
ferential treatment planning since homologous malocclusions
probably would require similar treatment plans, whereas analogous
malocclusions may require different treatment strategies. This sys-
tem has not been widely adopted for clinical use, but I include it
here since I think it has great merit for the student wishing to gain
an integrated perspective of classification in practice.
E. CLASS I SYNDROME
Class I (neutroclusion) malocclusions are characterized by a
normal molar and skeletal relationship. The skeletal profile is
straight, and therefore the problem usually is dental in origin. Such
problems as large teeth, open bite, and deep bite, are typical of
Class I malocclusion. The lips and tongue are more likely to
function normally than in Class II or Class Ill. A typical Class I
malocclusion is shown in Figure 9-9. Treatment of Class I mal-
occlusions is described in Chapters 15, 16, and 17.
F. CLASS 11 SYNDROME
Class II (distoclusion, postnormal occlusion) is the most fre-
quently encountered severe malocclusion. It is characterized by a
mandibular dentition "distal" to the maxillary, the malrelationship
of which may be due to a basic osseous dysplasia or to forward
movement of the maxillary dental arch and alveolar processes or
a combination of skeletal and dental factors. The overjet is ex-
cessive in Class I1, Division I, and the bite is likely to be deep.
T):1~ retrognathic profile:- and excessive overjet demand that the
facial muscles and tongue adapt Jhemselves by abnormal contrac-
tion patterns. Typically, there is a hyperactive mentalis muscle,
which contracts strongly to elevate the orbicularis oris and effect
the lip seal. Figure 9-10 illustrates a typical Class I1, Division I
malocclusion.
Class I1, Division 2 is characterized by distoclusion, abnormal
depth of bite, labioversion of the maxillary lateral incisors, and
more normal lip function. The Class I1, Division 2 facial skeleton
usually is not as dramatically retrognathic as that of Class I1,
Division I. Figure 9-11 shows a typical Class 11, Division 2 case.
192 Diagnosis

FIG 9-9.
A Class I malocclusion. A-C, before treatment. D-F, after treatment.,

-
.,..",
.
 Classification and Terminology of MaloccLusion 193

FIG 9-10.
Casts of a Class 11,Division 1 malocclusion. A, before treatment. S, after treatment. (See other such cases in Chapters 15 and 16.)

,-
194 Diagnosis

(fl/'

FIG 9-11.
A typical Class 11, Division 2 malocclusion treated in the permanent
dentition. A, the casts before treatment. B, the casts after treatment.
C, cephalometric tracings before treatment (dotted lines) and after
treatment (solid lines). Note that the response is primarily dental and
that the distal movement of the maxillary first molar also opened the
bite. Further, note that the maxillary central incisors were not moved
labially during treatment. D, intra-oral photograph after the retention
period was over.

Class I1, although described here as a single syndrome, is
really a large grouping with many subtypes. Help in differentiation
of the features of Class II will be found in Chapters 12, 15, and
16. It is unfortunate that so many important and disparate mal-
occlusion types have been found to lie within the Angle Class 11
category. The best cephalometric analyses permit their discrimi-
nation. Only the most naive clinicians now would presume to treat
all Class 11problems in the same way.
G. CLASS III SYNDROME
Class III (Mesioclusion, prenorrnal occlusion) is characterized
by mandibular prognathism and/or maxillary deficiency, a Class
III molar relationship, and the mandibular incisors labially placed
to the maxillary incisors. Most frequently it is a deep-seated skel-
etal dysplasia, although functional Class Ills are seen. In the adult,
orthodontic treatment is aimed at camouflage of the skeletal pattern

(511
AK
(525)
-12-0
--13-1
(50
M.R
(47.7)
7-0

FIG 9-12.
A, cephalogram of a Class IIImalocclusion. B, superimposed cepha- Solid lines, before treatment; dotted lines, after treatment. See Chap-
lometric tracings of an adult Class III before and after treatment. ter 12 for an explanation of the cephalometric findings noted.

to improve esthetics and function, but in the young child, growth
may be directed to obtain a correction. Occasionally, surgery must
be resorted to in order to treat well the severe Class Ill. Figure
9-12 illustrates a typical Class III syndrome treated in a child.
Figure 9-12B shows a well treated adult'case. See Chapters
15, 16, and 17 for a discussion of the possibilities of treatment of
Class III malocclusion.
H. LIMITATIONS OF CLASSIFICATION
SYSTEMS
Though the classification systems which have been described
in'this chapter are in everyday use and practice it is prudent to
remember some of their limitations. Most originated at a time in
the development of orthodontics when our knowledge was less
complete and our concepts were more simplistic, yet they survive.
The field of orthodontics is alive today, with frequent improve-
ments in clinical treatment, important new contributions to our
knowledge of craniofacial growth, and significant changing de-
mands on the profession's ability to deliver treatment to those who
need it. However useful, classification schemes must not impede
our flexibility to adapt new knowledge.
a) None are truly inclusive.
Most classification schemes omit entire regions which are
now known to be an indigenous and integral part of the
malocclusion, for example, the temporomandibular
articulation.
Most omit dimensions. For example, the Angle classifica-
tion provides essentially an anteroposterior view of the face
with little or no emphasis on either the vertical or lateral
contributions to malocclusion.
Most omit entire syndromes or malocclusion types. We
now know, for example, that the simple term, Class II, in-
Classification and Terminology of Malocclusion 195
cludes a wide variety of quite disparate malocclusion types
which probably never should have been included under a
single general classification.
b) All are static in concept.-Classification is done at one
moment in time, and allowance is not made for future changes
which might occur with growth or the removal of etiologic factors.
Malocclusions adapt and change through time, yet most classifi-
cation schemes do not encourage us to think in terms of such
changes.
c) Most are narrow in focus and perspective.-It is very
difficult to fit new findings or ideas into a classification scheme
or framework. Furthermore, the very simplicity of the classifi-
cation, which admittedly contributes to its utility, causes us to
place too much emphasis on one aspect of the total malocclusion
syndrome, (e.g., the molar relationship in the Angle classification
scheme).
d) There is a tradition of misuse and misapplication.- This
problem is not just a semantic one; rather, misunderstanding about
the role of classification leads to real and practical problems in
diagnosis and treatment planning.
REFERENCES
I. Ackerman JL, Proffit WR: Characteristics of malocclusion:
A modem approach to classification and diagnosis, Am J Or-
thod 1969; 56:443-454.
2. Angle EH: Malocclusion of the Teeth, 7th ed. Philadelphia,
SS White Dental Mfg Co, 1907.
3. Lischer BE: Principles and Methods of Orthodontics. Phila-
delphia, Lea & Febiger, 1912.
4. Simon P: Grundzuge einer systematischen Diagnostik der
Gebiss-Anomalien. Berlin, Meusser, 1922.
CHAPTER 10
Analysis of the Orofacial and
Jaw Musculature
Robert E. Moyers, D.D.S.,Ph.D.
By examining the tongue of the patient, physicians find out
the diseases of the body, and philosophers the diseases of the
mind.-ST. JUSTIN
KEY POINTS
1. Concepts of occlusion must include not only the
relationships of teeth and morphology of the
craniofacial skeleton but also neuromuscular activities
of the jaw and face region.
2. Sensory or motor inabilities may be involved in the
etiology of malocclusion and may affect orthodontic
treatment and prognosis.
3. Abnormal lip morphology or function may be
identified with specific malocclusions.
4. Morphologically inadequate lips are rarer than
functionally inadequate or functionally abnormal lips.
Functional lip problems are more apt to respond to
treatment.
5. Abnormal tongue posture is a more frequent problem
than abnormal tongue size.
6. Muscle tenderness and malfunction are more
clinically significant to dentists than is variation in
morphology of the jaw, head, or neck muscles.
7. Both general and head posture may reveal
dysfunctions of orthodontic importance.
8. Interferences with normal respiration affect head and
mandibular posture and may affect craniofacial
growth.
9. Though there are problems in our understanding of
swallowing malfunction, the role of normal
swallowing in the maintenance of occlusal stability is
clear.
10. The normal infantile swallow is characterized by
contractions of the facial muscles and tongue and the
positioning of the tongue between the gum pads.
11. Beginning with the eruption of the teeth a transitional
period occurs in which elements of infantile and
mature swallowing are both observed.
12. The normal mature swallow is characterized by
contractions of the mandibular elevators, occlusal
contact, and little facial muscle activity.
13. The simple tongue~thrust swallow combines a teeth-
together swallow with excessive facial contractions
" • necessary to aid.the tongue in sealing off a well-
"'circumscribed open bite. ,It is usually associated with
earlier digital sucking.
14. The complex tongue-thrust is a tongue-thrust with a
teeth-apart swallow. It is often associated with
chronic nasorespiratory difficulties and displays an
ill-defined open bite.
15. The infantile swallow on rare occasions persists past
childhood and constitutes then a serious clinical
problem.
196
 Analysis of the Orofacial and Jaw Musculature 197

16. Since the prognosis varies greatly for treatment of 2) Semantics

open bites resulting from abnormal tongue posture, a 3) Differing goals of treatment
simple tongue-thrust, a complex tongue-thrust, and a b) Methods of examination
retained infantile swallow, their differential diagnosis c) Differential diagnosis
is important. - I) Normal infantile swallow
17. Malocclusion does not ordinarily impair masticatory 2) Normal mature swallow
efficiency. 3) Simple tongue-thrust swallow
4) Complex tongue-thrust swallow
18. Malocclusion does not necessarily produce poor
5) Retained infantile swallowing behavior
speech. 4. Mastication
19. Because some speech difficulties, mostly of 5. Speech
articulation, may be associated with some 6. Jaw relationships
malocclusions, a simple speech screening test is D. Analysis of the temporomandibular joints
useful to the dentist. I. Jaw movements, path of closure, and joint sounds
20. Temporomandibular dysfunction is related to 2. Occlusal interferences
functional occlusal developmental disorders, 3. Palpation of muscles and ligaments
particularly interferences; therefore, careful analysis 4. Palpation of joint capsule
of the' temporomandibular joints is an imperative part 5. Registration of jaw relationships in the presence of
of the complete orthodontic diagnosis. pain or limited jaw movement
The concept of normal occlusion includes the relationships
of the teeth to one another, to the supporting bony structures, and
to the surrounding musculature, and the functional movements of
OUTLINE the mandible and temporomandibular joints.
Occlusion should not be judged solely by the static relation-
A. Evaluation of sensory and motor abilities ships of the teeth in casts or the cephalogram, for what is apparently
I. Sensory evaluation of the mouth normal in the cephalogram or casts can be malrelated during func-
2. Evaluation of orofacial motor skills tion. Analysis of neuromuscular function is as critical to ortho-
B. Muscle Groups dontic diagnosis as is the study of teeth or bones. The purpose of
I. Muscles of the face and lips this chapter is to describe a series of examination procedures for
a) Morphologic examination clinical analysis of the orofacial jaw musculature and its functions.
b) Functional examination
c) Differential diagnosis of lips
I) Morphologically inadequate lips A. EVALUATION OF SENSORY AND
2) Functionally inadequate lips MOTOR ABILITIES
3) Functionally abnormal lips
2. Tongue Analysis of the orofacial and jaw musculature is complicated
a) Morphologic examination by the many sensory and motor interrelationships among the teeth,
b) Functional examination tongue, lips, oral mucosa, jaw muscles, and pharynx. The clinical
c) Differential diagnosis of abnormal tongue signs and symptoms arising from this elaborate multisensory sys-
posture tem consequently are difficult to segregate and identify. The face
3. Muscle of mastication is a region of great and varied sensory input, and dentists who are
a) Morphologic examination skiJled in locating sites of pain and in testing the vitality of the
b) Functional examination pulp are often less able to evaluate systematically other important
c) Pain and tenderness sources of sensory input. Examination procedures outlined herein
4. Muscles of neck and head support are not as sophisticated in sensory evaluation as in motor analysis.
a) Morphology Since there is an intimate relationship between sensory input and
b) Function motor activity, deficiencies in psychosensory evaluation hamper
c) Pain and tenderness the 'd~gnosis of functional capability. We shall describe simple
C. Examination of specific neuromuscular functions but useful methods for orofacial sensory evaluation and motor skills
I. Posture
testing. The reader should realize that they are intended solely for
2. Respiration cursory clinical examination, not for research.
a) Methods of examination
b) Differential diagnosis
I) Nasal-breathers 1. Sensory Evaluation of the Mouth
2) Mouth-breathers Several tests of lingual tactile discrimination have been de-
3. Swallowing vised and are used for research purposes by oral and speech phys-
a) Role in etiology of malocclusion iologists.3 One of these can be simplified for use in dental practice.
I) Misinformation Several familiar geometric forms of identical size are presented to
 .- •..
198 Diagnosis
FIG 10-1.
Plastic geametric figures ta test .oral tactile perception. Twa sets .of
figures are used. One set is placed in the patient's view, then the
clinician selects a figure from the secand set and places it in the
patient's mauth in a manner unseen by the patient. Maving the figure
araund in the mauth with tangue and lips, the patient then paints ta
the matching figure befare him/her. Patients wha have great difficulty
with such tactile, discriminatary functians may nat be gaad candi-
dates far certain speech therapies .or tangue training.
the patient ta .observe (Fig 10-1). An unknawn farm from a
duplicate set is slipped unseen inta the patient's mauth and he .or
she is asked ta identify it with the tangue. The test may be made
mare difficult by using small, medium, and large squares, circles,
triangles, and .other farms. Patients whase lingual tactile discrim-
inatary abilities are limited have trouble discerning even simple
differences in shape and size. There is evidence that individuals
with such sensory limitatians have difficulty learning new .oral
neuramuscular skills-such as thase invalved in speech-using
an intraaral arthadantic appliance .or arofacial myatherapy.
In anather simple test, tactile and simple matar skills are
cambined by asking the patient ta use the tip .of the tangue ta
caunt the number .of teeth in each arch. The dentist shauld nate
nat .only the carrectness .of the caunt but alsa the ease and speed
.of campleting the task:
2. Evaluation of Orofacial Motor Skills
Variatians in the use .of the tangue, lips, and jaw muscles are
just as naticeable as differences in muscle skills at the ballet class
.or an the Little League baseball diamand. Na .one has yet develaped
a simple, orderly test .of lingual, lip, and jaw muscle matar abil-
ities, althaugh such a test is much needed. What is desired is a
test .of the patential far better perfarmance .of such campi ex psy-
chaneuromuscular activities as speech, swallawing, and masti-
catian. The dentist .often natices haw easily same patients adapt
ta a new intraaral appliance and haw difficult it is far .others, sa
the new appliance itself is a sart .of test .of .oral mator adapatability.
But .one wauld like ta knaw the ~otor skills .of the patient befare
inserting a new appliance, since such knawledge might affect the
design .or chaice .of appliance.
If narmal hearing and appartunity ta learn are assumed, speech
itself is such a test and sa is swallawing. Blaamer] has suggested
diadachakinetic perfarmance as a test .of .oral mator skills and
patential. The child repeats each .of the failawing sau[1ds, first
slawly ta achieve perfect farmatian and then with gradually in-
creased speed until he .or she is repeating them as rapidly as possible:
I. "puh, puh, puh " screening mechanism ta identify gross matar inadequacies, far they
2. "tah, tah, tah " have an impact an arthadantic therapy and prognasis.
3. "kuh, kuh, kuh "
4. "puh-tah-kuh," "puh-tah-kuh," "puh-tah-kuh ..... "
Age* affects diadachakinetic perfarmance.2 Children whase
.oral mavements are belaw the narmal range far their age usually
are defective speakers, .often shaw patterns .of swallawing abnor-
mality, and give evidence .of dysdiadachakinesia. The child wha
has defective speech and/ar swallawing abnarmalities withaut dys-
diadachakinesia has a better prognasis far speech therapy and .oral
myatherapy.
B. MUSCLE GROUPS
1. Muscles of the face and lips
a) Morphologic Examination
The marphalagic relatianships .of the lips are determined, ta
an extent, by the skeletal prafile (Fig 10-2). When the mandible
is in its pastural pasitian, the lips narmally tauch lightly, effecting
an .oral seal (Fig IO-3,A and B). In mauth-breathers and a few
nasal-breathers, the lips will be parted at rest (Fig IO-3,E). Same
campetent lips will have adapted ta the malacclusian; thus, al-
thaugh a seal is present, it is nat a lip-lip seal but a lip-taath-lip
arrangement (Fig 1O-3,C and D). Differences in calar, texture,
and size .of lips .often are related ta lip malfunctian. Hyperactive
lips may be larger (Fig IO-3,E) and mare red and maist then
hypaactive .or narmal lips.
b) Functional Examination
I. Observe the lip and facial muscle cantractians during the
variaus swallaws (see B-2-b, item 2, and C-3-c, item 2).
2. Observe lip functian during masticatian. Bite-size dry
breakfast faad may be used ta study masticatian. During narmal
masticatian, the lips are held lightly tagether. Strong cantractians
.of the mentalis and circumoral muscles will be seen in teeth-apart
swallawers. These same muscles alsa cantract strongly in severe
Class 11malacclusians where there is large .overjet and averbite.
3. Study lip functian during speech (see belaw). Mast ab-
narmal lip functian during speech .of children with malacclusians
i.~an adaptatian .or accammadatian ta taath pasitians, not an eti-
alagic factar in the malpasitianing .of the teeth.
4. Palpate the jaw elevatars (e.g., the masseters). Palpatian
is a rather crude way by which to identify,hypa- and hyperactive
muscles, althaugh masseters sametimes enlarge remarkably with
chronic hyperactivity (see Fig 10-10). It is, hawever, a gaad way
t<j,identify.asymmetric muscle functian and tanicity. Palpating bath
right'and left muscles during simple functians such as jaw .opening,
tapping the teeth, .or swallawing pravides a surprisingly sensitive
means .of nating asym'metric muscle activities.
*Rate narms far chronalagic ages have been develaped" Hawever,
speed .of mavement is .only 'ane factar. Accuracy, patteming .of lingual
mavement, and independence .of linguamandibular actian are thaught ta
be .of equal significance in distinguishing narmal from abnarmal actian.
Far .our use such narms are nat needed. We require .only a simple

FIG 10-2.
Relationship of the soft tissue profile to occlusion. A, Class I malocclusion; B, Class 11malocclusion; C, Class III malocclusion.
c) Differential Diagnosis of Lips
1) Morphologically inadequate Iips.- On rare occasions
the upper lip is morphologically short (Fig 10-4). The significance
of the morphologically short upper lip to malocclusion, speech
disorders, and retention of orthodontically treated cases often is
overstated. Lips originally diagnosed as morphologically inade-
quate may be found satisfactory later qecause the tooth movements
allow normal lip function to return. ,Modem orthodontic techniques
involving bodily retraction of maxillary incisors and midface or-
thopedics provide the opportunity for many an alleged short upper
lip to fall into position and function normally. Surgical intervention
for supposedly short upper lips is to be discouraged except in rare
cases and then undertaken only after orthodontic therapy is com-
pleted. In my experience, it has not often been necessary, except
for cleft lip.
2) Functionally inadequate Iips.- Sometimes lips are ad-
equate in size but fail to function properly; for example, the max-
Analysis of the Orofacial and Jaw Musculature 199
illary lip in extreme Class Il, Division I malocclusion. A hyperactive
lower lip seals against the lingual surfaces of the maxillary incisors
while the maxillary lip scarcely functions at all (see Fig 10-3 ,C).
After retraction and proper positioning of the incisors, spontaneous
normal lip function usually occurs (Fig 10-5). If it does not, a
regimen of lip exercises may be prescribedj (see Chapter 18).
'. ,,3) Functionally abh'&rmallips.- One of the most frequent
abnormal lip functions is associated with tongue-thrust swallowing
(see Section C3). The mentalis muscle and the inferior orbicularis
oris muscle are enlarged, causing the gingivae to be rubefacient
and hypertrophied. Gingivitis in the mandibular incisor region in
the absence of maxillary gingivitis may be indicative of hyperactive
mentalis function (Fig 1O-6,A), whereas gingivitis in both anterior
regions may be associated with mouth-breathing (Fig 1O-6,B).
Methods for correction of abnormal n,.;ntalis muscle and lip func-
tion will De found in Chapter 18.
Posen22 has invented a device, the "Pommeter," for
200 Diagnosis

FIG 10-3.
A, relaxed, normal lips. S, the same subject swallowing. Note that a swallow is occurring. C and 0, adaptation of the lips to a severe
the lip posture position does not change markedly during a normal skeletal Class 11malocclusion. E; lips part(3d at rest in a mouth-
swallow. Only the contraction of the muscles in the neck betrays that breather.
 Analysis of the Orofacial and Jaw Musculature 201

FIG 10-4.
A and e, an anatomically short upper lip prior to orthodontic treatment several years after orthodontic therapy. Note the position of the lip
and the malocclusion associated with it. C and D, the same patient posture, even though orthodontics is completed.
202 Diagnosis

FIG 10-5.
Change in lips with treatment. A-1, before treatment; A-2, after treat- dramatic example of a change in functionally inadequate lips with
ment. Notice that as the mild Class III dental correction occurred an treatment. B-1, before treatment; B-2, after treatment
anteroposterior adaptation took place in the lip posture. B, more

FIG 10-6.
A, gingivitis associated with hypertrophy and hyperactivity of the mentalis muscle. B, gingivitis associated with mouth-breathing.

quantitative perioral muscle assessment. He advocates using the
measured maximum tonicity of the lips for both diagnosis and
assessment of muscle response to treatment.
2. Tongue
a) Morphologic Examination
The tongue should be examined for size and shape, though
both are subjective observations. "Large" applied to a specific
tongue has only relevant meaning for a tongue which is "large"
in one mouth is not in another. The best clinical sign of a tongue
too large for its dental arch is the presence of scalloping on the
lateral borders. Only on rare occasions is the tongue too small.
Asymmetry of the tongue is more apt to be a functional than a
morphologic matter. Ask the patient to protrude the tongue and
note the symmetry of its position. Then ask the patient to relax
the tongue, allowing it to drape over the lower lip. Functional
asymmetries of the tongue change from one position to the other.
Morphologic asymmetries will persist in the draped position. Any
asymmetry of the tongue has important clinical implications to
dental arch symmetry, dental midlines, maintenance of treated
incisal relationships, open bites, etc. Neither asymmetry is easily
"corrected" and treatment planning may thus often involve some
sort of compromise.
b) Functional Examination
The tongue and lips are often integrated and synchronized in
their activity; thus, one may sometimes infer tongue malfunction
FIG 10-7.
Variations in tongue posture. A and B, variations in normal tongue
posture. C, retracted tongue posture. D, the retained infantile tongue posture.
Analysis of the Orofacial and Jaw Musculature 203
from observed lip and facial muscle malfunction. When the lips
are parted by the mouth mirror or the cheeks are withdrawn by
retractors, normal tongue activity may be inhibited and what is
observed is accommodation to the stretching of the lips and cheeks.
The paradoxic problem of the tongue examination is to study the
tongue's normal functions without displacing it or the lips.
I. Observe the posture of the tongue while the mandible is
in its postural position. This may be done in a cephalogram taken
at the mandibular postural position or it may be done by gently
and casually examining the tongue-lip relationship while the patient
is seated in an upright position. During mandibular posture, the
dorsum touches the palate lightly, and the tongue tip normally is
at rest in the lingual fossae or at the crevices of the mandibular
incisors (Fig 1O-7,A and B).
2. Observe the tongue during the various swallows-the un-
conscious swallow, the command swallow of saliva, the command
swallow of water, and the unconscious swallow during mastication
(see Section C3, later in this Chapter). The tongue tip during the
normal mature swallow touches the curvature of the palate just
behind the maxillary incisors.
3. Observe the role of the tongue during mastication-a dif-
ficult procedure except for obvious abnormalities associated with
neurologic problems. This observation may be combined with
those of swallowing during chewing (see Section C4).
4. Observe the role of the tongue in speech (see Section CS).
c) Differential Diagnosis of Abnormal Tongue Posture
Tongue posture is related to skeletal morphology; for ex-
 204 Diagnosis

FIG 10-8.
A, tongue posture in Class III malocclusion. The tongue is postured occlusal level. e, typical tongue posture associated with a Class 11
lower than normal. Note that the dorsum is below the incisal tip and malocclusion that has a steep mandibular plane relationship.

ample, in severe Class III skeletons, the tongue tends to lie below
the plane of occlusion (Fig 10-8,A), and in Class 11facial skeletons
with a short mandible and steep mandibular plane, the tongue may
be positioned forward (Fig 1O-8,B). Two significant variations
from the normal tongue posture can be seen: (I) the retracted or
"cocked" tongue, in which the tongue tip is withdrawn from all
the anterior teeth (see Fig 1O-7,C), and (2) the protracted tongue
posture, in which the resting tongue is between the incisors (see
Fig 1O-7,D). The retracted tongue posture is seen in less than
10% of all children, but it is often associated with a posterior open
bite since the tongue may spread laterally. The retracted tongue
posture is more frequent in edentulous adults or those who have
bilateral loss of several posterior teeth. Undoubtedly the tongue
has lost some of its positional sense with the removal of teeth and
periodontal ligaments and it retracts itself in order to establish
tactile contact laterally with the alveolar mucosa for a better seal
during the swallow. The retracted tongue is unsettling to mandi-
bular artificial dentures.
The protracted tongue posture may be a serious problem, since
it usually results in an open bite. There are two forms of the
protracted tongue posture (Table 10-1): (I) the endogenous; and
(2) the acquired adaptive. The endogenous protracted tongue pos-
ture may be a retention of the infantile postural pattern. 19 Some
persons, for reasons not yet clear, do not change their tongue

TABLE 10-1.
Causative and Adaptive Features of Open Bite
f- -<
<w
Uz -
Forward
0~ 0~
+
f-f-
~u+
+?
??ZLL
Nw <
?-'<
:J-'
Simple
Retained -'
f-
(/)
f-
tongue
0<
tongue
infantile
posture
thrust
swallow'
.
ADAPTIVE FEATURES >w >-z
r<
"-0 <>-
W-' "- w(/)
, ~ TO
< LL(/)a:
OWW
a:oa: < 0 w0
-ZW:::;:'
w> -u w!!l
>-'
:J
(/)
"- t;:::;:
:::;:ID
Complex
<::>
Skeletal
Simple a: or
< tongue
open
0complexbite thrust
tongue
AN OPEN
§;«
f-z-,
-0>
Wa:Q
zXo
~u!z ±
w(/)W
a:(/)a: 0~5 (iio
"-
+
COMMON
ID(/) CLINICAL
ffi:::;: NAME
BITE
+ ;.+ swallow)
-.thrust (depends on the
?

f-
::>
a:
r
~
(/) LL"-
::>
Ul
w
~f-
~
f-
z +?a:
a:(/)
°w+
0
a:
<::> -+?f-
::>
z 00+
~ Thumb-sucking tonsils
Hypertrophied

• Also seen with various neural deficits and certain severe craniofacial developmental syndromes;
- not ordinarily associated; + typically associated; ? can be associated.
 Analysis of the Orofacial and Jaw Musculature 205

since it usually' is a transitory adaptation to enlarged tonsils,

pharyngitis, or tonsillitis. The latter two may be verified by swabbing
the throat with a viscous topical anesthetic and allowing the patient
to swallow a tiny bit of the material. When the acutely inflamed
throat is thus anesthetized, the adaptive protracted posture of the
tongue may spontaneously correct to a more normal position. As
long as the precipitating pain mechanism is present, the tongue
will posture itself forward, and repositioning of the incisors will
not be stable. Therefore, it is best to refer such patients to a
physician for correlative therapy. Dramatic changes in tongue and
mandibular posture often follow a tonsillectomy and/or adenoid-
ectomy.'4 Such changes in posture may then result in signifi-
cant alterations in the growth of the face." Occasionally, the
nasopharyngeal condition no longer exists but the tongue reflexly
remains in a forward position.
To summarize, there are two clinically significant problems
in abnormal tongue posture: (I) endogenous protracted tongue
posture for which the prognosis is poor and around which,
unfortunately, the occlusion must be built, and (2) the acquired
protracted tongue posture, which usually can be corrected.

3. Muscles of Mastication
a) Morphologic Examination
There is no satisfactory quantitative way to study the mor-
FIG 10-9. phology of muscles of mastication and it probably is not a,s im-
Open bites associated with abnormal tongue posture. A, Class 11, portant as their function. However, the relationship between
Division 1 malocclusion 2 years out of orthodontic retention. Note "squarish" faces (see Chapter 12, Analysis of the Cranio-
the return of a very mild open bite. This patient was treated twice facial Skeleton, Section G-7-b-2, Vertical Type 2) and powerful
more and each time the bite returned to this incisal relationship. Note masseter function and size has long been known (Fig 10-10).
the absence of functional occlusal stops in the entire incisor and Palpation of each jaw muscle at rest and in function is often useful
cuspid region. e, a severe open bite resulting from abnormal tongue to reveal asymmetries of muscle size and placement.
posture. In this instance there was no tongue-thrust on swallowing;
rather, the tongue remained in this position most of the time.
b) Functional Examination
Functional analysis of the jaw musculature is best carried out
posture during the arrival of the primary incisors, and the tongue with each particular synchronized function in mind (see Section
tip persists between the incisors. 17. ]9 For the great majority of C, Examination of Specific Neuromuscular Functions). Individual
patients with endogenous protracted tongue posture, the open bite muscles may be lightly touched during specific functions as part
is mild and not a serious clinical problem, but, on rare occasions, of the functional analysis (see Fig 10-11).
quite serious open bites are present (Fig 10-9). Protracted tongue
postures are frequently adaptations to excessive anterior facial
height, a condition which predisposes to open bite, the tongue
posture necessarily adapting to enforce an anterior seal during the
swallow. Proffit23.24 has drawn attention to the fact that tongue
posture is far more apt to cause an open bite than tongue-thrusting
simply because the tongue is always there exerting a mild contin-
uous force. So the old question is raised again-which came first,
the endogenous protracted tongue poSture creating an anterior open
bite and excessive vertical anterior face height, or the skeletal
pattern which predisposes to the tongue protraction? There is sup-
port for both positions. (See Chapter 4, The Growth of the Cra-
niofacial Skeleton, and Chapter 7, The Etiology of Malocclusion).
There is no known certain treatment for all problems of endogenous
tongue posture.24 Surgical correction of severe skeletal dysplasia
is often successful, yet the literature also reports relapse alleged
to be the result of failure of the tongue to adapt to the altered FIG 10-10.
skeletal morphology. 24 Masseteric hypertrophy and facial form. A, note the relationship of
The acquired protracted tongue posture is a more simple matter, facial breadth to facial height. e, cephalogram of the same subject.
206 Diagnosis
FIG 10-11.
Palpation of the temporal muscle to ascertain its activity during the
swallow.
c) Pain and Tenderness
Localized myalgia is an important diagnostic sign and symp-
tom of temporomandibular joint dysfunction. Identification of pain
of capsular origin is also important (see Section D, Analysis of
Temporomandibular Joints).
4. Muscles of Neck and Head Support
a) Morphology
Only on rare occasions does one encounter atypical mor-
phologies of the neck and head support muscles, and then they
are obvious and associated with far more serious neuromuscular
disorders than those primarily related to malocclusion.
b) Function
The role of these muscles in head posture is often revealed
even in a casual glance at patients as they walk into the examination
room and seat themselves. Observations of head posture are often
more diagnostic than the patient's ability to produce extreme po-
sitions of head rotation, elevation, etc.26. 27
c) Pain and Tenderness
Myalgia of the neck muscles m'ay be associated with tem-
poromandibular dysfunction, sponct'ylitis, or other functional dis-
orders of the region. Pain and tenderness of the neck muscles are
less often encountered in children and adolescents than in adults,
but when seen are of diagnostic significance. Inquire about pain
in the region and palpate thoroughly all of the neck muscles,
particularly those originating at the occiput and the sternocleido-
mastoid. It may be necessary to refer the patient to an attending
physician before beginning orthodontic treatment. In milder in-
stances such pain may diminish and cease with orthodontic therapy.
Special mention must be made of the stylomandibular liga-
FIG 10-12.
Calcified stylomandibular ligament. This condition, also known as
Eagle syndrome, induces limitation of head movements and pain;
which sometimes are confused with temporomandibular joint
symptoms.
ment, which on rare occasions becomes calcified (Fig 10-12).
Calcification of this ligament produces atypical head posture, re-
straint of head movements, and acute pain on rotation of the head.
The symptoms obfuscate diagnosis of more common problems
(e.g., temporomandibular disorders). It may be diagnosed by the
case history, by palpation, and by analysis of the radiograph (see
Fig 10-12). The condition is even rarer in children and adoles-
cents. When encountered, irrespective of the age of the patient,
consultation with an oral surgeon is advised prior to beginning
orthodontic therapy.
C. EXAMINATION OF SPECIFIC
NEUROMUSCULAR FUNCTIONS
1. Posture
Generally bodily posture, and head posture in particular, are
often of diagnostic significance. The general posture should first
be studied unobtrusively, observing the patient sitting in the wait-
ing room and walking to the dental chair to be seated. A particularly
g;)od time to make postural observations is during weighing and
the measuring of stature. Note asymmetries of shoulder position,
spinal curvature, and the natural placement of the head atop the
vertebral column. Posture is a reflection of the body's efficiency
to maintain joints in relationships which require the least energy
for. (pe furrctions imposed' on them28 Head posture is altered in
moutli-breathers (see Section 2, which follows) as body posture
adapts to congenital dysplasias, after accidents, or to trauma. Body
posture also conveys subtle messages about self image, particularly
during the gangling growing-up stages of adolescence.
Solow and Tallgren26.27 have shown a relationship between
facial proportions and head posture on a population basis in adults,
and similar findings have been demonstrated in children. 28 A head-
up and chin-up posture is more associated with disproportionate
anterior facial height, while posturing the head back and the chin
down is more associated with shorter anterior face height.

FIG 10-13.
Effect of mouth-breathing on control of the alar musculature. A and
B, mouth-breather inhaling and exhaling through the nose. Although
the patient can breathe through his nose, the diameters of the ex-
2. Respiration
It has long been claimed in orthodontic circles that mouth-
breathing or interference with nasal respiration could have im-
portant effects on craniofacial growth and the positions ofthe teeth.
Recent research in several laboratories has shown that, in exper-
imental animals, this is definitely true. ]0-12. ]6 Research on human
subjects has shown favorable alterations in posture and changes
in craniofacial dimensions after adenoidectomies and restoration
of normal nasal function5. 13-]5 Details of the significance of this
research can be found in Chapters 4, 6, and 7. Since the mech-
anisms by which altered respiration affects facial growth has been
clarified by this research-most likely due to alteration in the
posture of the head, tongue, and mandible-it is important to
combine the examination of posture with a study of the patient's
patterns of respiration.
Sometimes the literature. speaks as if all of mankind were
divided into nasal-breathers and mouth-breathers. Very few per-
sons breath .solely in one manner:29 Normal "nasal-breathers"
quickly change to mouth breathing during strenuous exercise or
exertive running. Herein, the term "nasal-breather" is used to
mean a person who breathes mostly through the nose except during
exertion. Mouth-breathers are those who breath orally even in
relaxed and restful situations.
a) Methods of Examination
I. Study the patient's breathing unobserved. -Nasal-breath-
ers usually show the lips touching lightly during relaxed breathing,
Analysis of the Orofacial and Jaw Musculature 207
ternal nares do not change. C and D, nasal-breather inhaling and
exhaling. Note that the size and shape of the external nares change
during inhalation.
whereas mouth-breathers must keep the lips parted (Fig 1O-l3,A
and B).
2. Ask the patient to take a deep breath.-Most respond to
such a request by inspiring through the mouth, although an oc-
casional nasal-breather will inspire through the nose with the lips
lightly closed.
3. Ask the patient to close the lips and take a deep breath
through the nose.-Nasal breathers normally demonstrate good
reflex control of the alar muscles, which control the size and shape
of the external nares; therefore, they dilate the external nares on
inspiration (Fig 1O-l3,C and D). Mouth-breathers, even though
th"y are capable of breathing through the nose, do not change the
size or shape of the external nares (Fig 1O-13,A and B) and
occasionally actually contract the nasal orifices while inspiring.
Even nasal-breathers with temporary nasal 'Congestion will dem-
onstrate reflex alar contraction and dilation of the nares during
voluntary inspiration. Unil';lteral nasal function may be diagnosed
by Phl~ing a small, two-surfaced steel mirror on the patient's upper
lip (Fig IQ-14,A). The mirror will'cloud with condensed moisture
during breathing. A cotton butterfly (Fig 1O-14,B and C) may
be used also.
b) Differential Diagnosis
1) Nasal-breathers.- Lips touch lightly at rest, nares dilate
on command inspiration.
2) Mouth-breathers.- Lips are parted at rest. Nares main-
tain size or contract on command inspiration with lips held together.
208 Diagnosis
FIG 10-14.
A, use of a two-surfaced steel mirror to check the method of breath-
ing. When the mirror is held in this position, if the child is a nasal-
breather, the upper surface will cloud; if a mouth-breather, the lower
3. Swallowing
c) Role in Etiology of Malocclusion
Misunderstanding about the role of swallowing in the etiology
of malocclusion has lead to disagreements and affects our ability
to diagnose clearly and treat properly. This misunderstanding comes
from three major sources: (I) the abundance of misinformation in
the literature, (2) semantic problems, and (3) differing goals of
treatment. Certain aspects of these matters are also discussed in
Chapters 5, Maturation of the Orofacial Musculature; Chapter 7,
Etiology of Malocclusion; and Chapters 14, 15, and 18 in the third
section of this book, TREATMENT.
Misinformation.- There are many varying origins of our
concepts and "facts" about swaliowing6 The variance is due to
the several fields interested in the problem: dentistry, oral phys-
iology, speech, otolaryngology, and others. Research on the tongue'
and the swallow is technically an extremely difficult matter. Cli-
nicians began by relating variations in orofacial muscle behavior
to different types of swallows. Speculation about the etiology of
abnormal swallowing has been rampant, and articles abound in
which certain etiologies are assumed but not tested. Serial devel-
surface will cloud. 8 and C, use of a cotton butterfly to diagnose
nasal-breathing: 8, bilateral use of nostrils; C, breathing through only
one nostril.
opmental studies of the normal changes in the swallow are very
few. In fact the normal change from the infantile to transitional
IR
to . mature swallowing behavior seems not to be recognized by
some. Knowledge of normal development and the normal range
of variability is essential as a basis for treatment of any part of
the facial or occlusal systems. Racial differences in the normal
---incisor relationship have been noted. The skeletal predisposition
to open bite is well recognized by clinicians, but studies of the
incidence of various swallowing behaviors in correlated studies
with skeletal variability are rare. t
Clinicians diagnosing possible abnormal swallowing are in a
,very difficult position.at this stage of our knowledge, for they
milst orient themselv~; among the well-intentioned, often-mis-
leading, enthusiastic claims of'some; the abundant naive misin-
terpretation of "facts"; and the insecure, hesitant conclusions of
the conscientious research scientist. But diagnoses and treatments
must continue while better data are developed and our knowledge
is advancing.
Semantics.- Even a casual reading of the literature reveals
many articles written without defining the terms of reference.
Improper or slovenly use of words is both a reflection of inaccurate

thinking and a predisposition to illogical diagnosis and treatment.
Some of the misuse of terms in this field is worthy of specific
discussinn.
The word normal means the common and most representative
observation. Normal is not a rigid rule for all, -but a range of
expected behavior. The normal height of adult men in the United
States is said to be approximately 168 centimeters. Everyone does
not have to be 168 centimeters, for there is a normal range around
that mean or norm. At some distance from it, however, one must
decide what is short and what is tall. Just as the normal height
varies with age so the normal swallow varies with maturation, and
the range of atypical swallowing behavior changes too. What is
normal in a neonate is abnormal in an adolescent.
f-. variety of adjectives have been used to describe atypical
or abnormal swallows, for example, "reverse swallow" (surely
that is regurgitation), "perverse swallow" (carrying unwarranted
implications of depravity), "tongue-thrust swallow," etc. It must
be clear that an atypical swallowing behavior is of clinical interest
to the dentist only when it is related to malocclusion, mastication,
or feeding. The speech therapist has different clinical responsi-
bilities and may logically adopt different working definitions and
goals of therapy. A child with a "tongue-thrust swallow" and a
perfect occlusion but a speech problem undoubtedly might be
described as abnormal, but that abnormality is of more interest to
the speech therapist than to the orthodontist.
Differing Goals of Treatment.- Given the problems of
scarcity of dependable information and the semantic variations, it
is difficult for dentists to define goals of treatment. Many questions
come to mind. Which diagnostic signs are important for dentists
to note? How can one separate etiologic factors from diagnostic
signs and symptoms? Which reflexes can be conditioned? And by
which of the many therapies proposed? What should be the goals
of orthodontic treatment of a patient with abnormal swallowing
behavior? Many of these matters are discussed in detail elsewhere
in this book, particularly in the section on TREATMENT, (Chap-
ters 15, 16, and 17) and Chapter 18. But the goals of orthodontic
treatment must be clearly in mind during the diagnostic evaluation
of the swallow. They are the attainment of occlusal stability and
securing the best possible occlusal function and facial esthetics.
Correction of an abnormal swallow is a proper treatment goal for
TABLE 10-2.
Differential Diagnosis of Swallowing Types
SWALLOWING
Yes
NoYes
No MATURE No
SIGNS AND ' SYMPTOMS
;'~IMPLE Yes
INFANTILE
Teeth-together
Enlarged tonsilsswallow
Low gag reflex and
threshold
Analysis of the Orofacial and Jaw Musculature 209
the dentist only if abnormal swallowing is directly related to the
etiology of the malocclusion and these treatment goals.
b) Methods of Examination"
It is imperative that the patient be seated upright in the dental
chair with the vertebral column vertical and the Frankfurt Plane
parallel to the floor. Try to observe, unnoticed, several unconscious
swallows. Then place a small amount of tepid water beneath the
patient's tongue tip and ask the patient to swallow, noting man-
dibular movements. In the normal mature swallow, the mandible
rises as the teeth are brought together during the swallow, and the
lips touch lightly, showing scarcely any contractions. The facial
muscles ordinarily do not show marked contractions in the normal
mature swallow (Figs 10-3 and 10-15). Next, place the hand
over the temporal muscle, pressing lightly with the fingertips against
the patient's head (see Fig 10-11). With the hand in this position,
give the patient more water and ask for a repeat swallow. During
the normal swallow, the temporal muscle can be felt to contract
as the mandible is elevated and the teeth are held together: during
teeth-apart swallows, no contraction of the temporal muscle will
be noticed. Place a tongue depressor or mouth mirror on the lower
lip or hold the lower lip lightly with thumb and forefingers and
ask the patient to swallow (Fig 10-16). Patients with a normal
swallow can complete a command swallow of saliva while the lip
is so held. Those with a teeth-apart swallow will have the swallow
inhibited by depression of the lip, since strong mentalis and lip
contractions are needed for mandibular stabilization in the teeth-
apart swallow.
The unconscious swallow my be examined more specifically
as follows: place more water in the patient's mouth, and, with the
hand on the temporal muscle, ask the patient to swallow one more
"last time." After the swallow is completed, turn away from the
patient as if the examination were over, but retain the hand against
the head. Most patients will, in a few moments, produce an un-
conscious clearing swallow. Unconscious swallowing behavior is
not always the same as on command, particularly in those patients
who have had some form of tongue-thrust therapy or whose at-
tention has been called to an abnormal swallow.
It is common practice for the clinician to part the lips to
determine whether or not the tongue is really thrusting forward.
Sometimes parting the lips elicits a type of swallow which is not
TONGUE-THRUSTING
INFANTILESWALLOWING
RETAINED
Yes
No
COMPLEX ,.
No Yes
Yes
Yes
No
210 Diagnosis

R.
L.

R.

L.

R. Mentalis

R.
L.

L.

FIG 10-15.
Electromyographic comparison of teeth-together and teeth-apart the swallow. The record at the top (E. B.) is of a child of the same
swallows. The record at the bottom (R. G.) is that of a typical mature age. Note, however, that this child has a teeth-apart swallow, since
swallow. Note the strong contractions of the temporal muscles, which there is little or no activity of mandibular elevators and a far greater
indicate that the mandible has been elevated into occlusion during relative activity of the facial muscles.

FIG 10-16. /-
Use of a tongue depressor to check the role of the lower lip during
the swallow.
 Analysis of the Orofacial and Jaw Musculature 211

otherwise there. If all of the signs or symptoms of one of the

swallowing atypicalities is present, I do not hesitate to part the
lips gently to seek confirmatory visualization of the thrust itself,
but the use of visual observation alone will produce a higher rate
of tongue-thrusts than is the true case. Think llot in terms of one
sign or symptom but of the constellation of signs. and symptoms
which constitute the typical etiology and clinical designation (Ta-
bles 10-1 and 10-2).

c) Differential Diagnosis

I) Normal Infantile Swallow.- During the normal infantile

swallow, the tongue lies between the gum pads and the mandible
is stabilized by obvious contractions of the facial muscles. The
buccinator muscle is particularly strong in the infantile swallow
as it is during infantile nursing. The normal infantile swallow is
seen in the neon ate and gradually disappears with the eruption of
the buccal· teeth in the primary dentition.'8 It, therefore, is less
often seen in the dental examination of children. The cessation of
the infantile swallow and the appearance of the mature swallow
are not a simple on-and-off phenomenon. Rather, elements of both
intermix during the primary dentition and sometimes even into the
early mixed dentition. This normal appearance of features of both
the infantile and mature swallow is termed the "transitional
swallow." Diminishing of buccinator activity is part of the
transitional period, but the most characteristic feature of the start
of cessation of the infantile swallow is the appearance of contractions
of the mandibular elevators during the swallow as they stabilize
the teeth in occlusion. 18

2) Normal Mature Swallow.- The normal mature swallow

is characterized by very little lip and cheek activity, and the
contraction of the mandibular elevators bringing the teeth into
occlusion. 19 The amount of lip activity during the normal mature
swallow depends on the ability of the tongue to effect a complete
valve seal against the teeth and alveolar processes. During the
mixed dentition, when some teeth are llJissing and there is normal
interdental spacing, the lips may contract a bit to secure the seal.
All of these features are not seen all of the time in all kinds of
swallows in young children during the transitional period.9 For
this reason it is important to study several swallows-the command FIG 10-17.
swallow of saliva, the command swallow of water, the unconscious Examples of open bites associated with a simple tongue-thrust. Note
swallow of saliva, and swallowing during mastication. The most in'each instance that there is a highly circumscribed open bite and
important and discriminative of these is the unconscious swallow. good occlusal fit posteriorly even if the molar relationship is not
correct. A, B, and Care examples before treatment; D is the same
The one most apt to mislead is the command swallow of water,
subject shown in C but after correction of the molar relationship and
and the one most apt to be occasionally observed with "tongue-
retraction of the incisors. Although correction of the malocclusion is
thrust" is the swallow during mastication.
not yet complete, the opeO. bite has been corrected spontaneously
withq~t tongue therapy. ,.
3) Simple Tongue-thrust Swallow.- The simple tongue-
thrust swallow typically displays contractions of the lips, mentalis
muscle, and mandibular elevators (see Fig 10- 15); and the teeth
are in occlusion as the tongue protrudes into an open bite. There (Fig 10- 17). When a patient is observed with a simple tongue-
is a normal teeth-together swallow, but a "tongue-thrust" is present thrust, check carefully for an history of chronic digital pacifier
to seal the open bite. The so called "tongue-thrust" is simply an sucking, for that is the most frequent primary etiologic factor. A
adaptive mechanism to maintain an open bite created by something simple tongue-thrust swallow may also be found with hypertrophied
else, usually thumb-sucking. The open bite in a simple tongue- tonsils which are not enlarged and/or inflamed sufficiently to prompt
thrust is well circumscribed; that is, if one studies the teeth or the a tooth-apart swallow. Problems in respiration are usually not
casts in occlusion, the open bite has a definite beginning "andending associated with a simple tongue-thrust. When one fits together
212 Diagnosis
FIG 10-18.
OpE!.nbite associated with complex tongue-thrust.
the dental casts of a patient with a simple tongue thrust, they have
a precise and secure intercuspation, even though a malocclusion
may be present, because the occlusal position is continually
reinforced by the teeth-together swallow.
Some who write about "tongue-thrusting" group simple and
complex tongue thrusting together and seem not to recognize their
differences in etiology and orthodontic prognosis. It is true that
the incidence of simple tongue thrusts diminishes with increasing
age, its treatment is simpler and its prognosis more certain; but
none of these are reasons for postponing treatment of the associated
malocclusion and swallowing misbehavior (see Chapters 15 and
18).
4) Complex Tongue-thrust Swallow.- The complex tongue-
thrust swallow is defined as a tongue-thrust with a teeth-apart
swallow. Patients with a complex tongue-thrust combine
contractions of the lip, facial, and mentalis muscles, lack of
contraction of the mandibular elevators (see Fig 10- 15), a tongue-
thrust between the teeth, and a teeth-apart swallow. The open bite
associated with a complex tongue-thrust usually is more diffuse
and difficult to define than that seen with a simple tongue thrust
(Fig 10-18). Indeed, on occasion, complex tongue-thrusters have
no open bite at all! Examination of the dental casts typically reveals
a poor occlusal fit and instability of intercuspation, because the
intercuspal position is not repeatedly reinforced during the swallow.
This point may not be of interest to speech therapists, but it surely
is important to dentists, since persistent teeth-apart swallows do
not stabilize the occlusion. Swallows of water or food may produce
teeth-apart swallows, so it is important to test the patient's
unconscious swallow carefully when a complex tongue-thrust is
suspected. Patients with a complex tongue-thrust usually
demonstrate ,occlusal interferences in the retruded contact position.
They also are far more likely to be- mouth-breathers and to have
a history of chronic nasorespiratory disease or allergies. The
incidence of complex tongue-thrusting does not diminish as much
with age as does the simple tongue-thrust. Treatment of the complex
tongue-thrust is described in Chapter 18.
5) Retained Infantile Swallowing Behavior.- Retained
infantile swallowing behavior is defined as predominant persistence
of the infantile swallowing reflex after the arrival of permanent
teeth. Fortunately, very few people have a true retained infantile
FIG 10-19.
An open bite due to a retained infantile swallow. Usually, the teeth
occlude on the last molar in each quadrant. This patient was treated
by a very competent orthodontist who had banded all of the patient's
teeth with an edgewise mechanism. These photographs were taken
1 month after removal of the retainers.
swallow. Those who do demonstrate very strong contractions of
the lips and facial musculature, even a massive grimace. The
tongue thrusts strongly between the teeth in front and on both
sides: Particularly noticeable are contractions of the buccinator
muscle. Such patients may have inexpressive faces, since the seventh
cranial nerve muscles are not being used for the delicate purposes
of facial expression but rather for the massive effort of stabilizing
the mandible during the swallow. Patients with a retained infantile
swallow have serious difficulties in mastication, for ordinarily they
occlude on only one molar in each quadrapt (Fig 10-19). The
gag threshold is typically low. These patients may restrict themselves
to a soft diet and state frankly that they do not enjoy eating. Food
oftt;n is placed on the dotsum of the tongue and "mastication"
occurs between the tongue tip and PJllate because of the inadequacy
of occlusal contacts. The prognosis for conditioning of such a
primitive reflex is very poor. The retained infantile swallow may
be associated with skeletal craniofacial development syndromes
and/or neural deficits. True retained infantile swallowing behavior
is, fortunately, rare.
Excessive anterior face height often produces severe frontal
open bites and extremes of adaptive swallowing behavior as the
neuromusculature attempts to cope with the skeletal imbalance (Fig
10-20)24 Such strained adaptive swallowing behavior must be
 Analysis of the Orofacial and Jaw Musculature 213

TABLE 10-3.
Place and Manner of Articulatory Valving*

y.~ m
~ (n2)
(NASALS) VALVE
PV-c
PV-o(FRICATIVES)
CONSTRICTED
(AFFRICATES)
(STOPS)
S
ARTICULATORY
tf dz ~(~)
f(sh) t(GLIDES)
M(hw) dPV-c
PV-c
I NARROWED
'!'!. CLOSED fh
VALVE MANNER
e(th) {l(th)p~
OF ARTICULATORY VALVING
!l ~ j(y) k 9
A (ch) Ult ARTICULATORY

Notes: 1. Palatopharyngeal valve closed and open are indicated by PV-c and PV-o, respectively. 2. The presence of
voicing is indicated by underlining. 3. The English spelling equivalents of phonetic symbols are indicated in parentheses.
'Adapted from Bloomer HH: Speech defects associated with dental abnormalities and related abnormalities, in Travis
LE: Handbook of Speech Pathology and Audiology. New York, Appleton-Century-Crofts, 1971, pp 715-765.
tNote that although the phonetic symbol Ul as in "yell" and the English sound Ul (as in "judge") are orthographically
the same, they are acoustically different. -

TABLE 10-4.
Mini-test of Speech Articulation

By place of articulation We ~ought my father/ two

1. Bilabials-hw '!'!.i!:! p ~ 1 1 1 2 3 4
2. Labiodentals-f V
.Qew sun lamps.
3. Linguodentals-th!b 4 4 4
4. Linguoalveolars-t Q .Ql s ~
5. Linguopalatals-:\" sh zh tsh dzh! You should choose a red

6. Linguovelars-k 2 ng 5 5 5 5
7. Glottopharyngeal-h coat ha~ger.
676
By manner of articulation
A. Stops-p ~ tQk2 ~obby pulled Qown two go carts.

B. Fricatives-f V th s z sh zh h The tqing is very full. Send his shoe measure

C. Affricates-tsh dzh to Charlie Jones.

D. Glides-hw '!'!.I Y r Why '!'!.on't you let her !un?

E. Nasals--;i!:!.Q ng
214 Diagnosis

FIG 10-20.
Open bite associated with skeletal dysplasia. A, lateral cephalograms after treatment. C, intra-oral views before and 2 years out of retention.
before and after orthodontic treatment. B, facial views before and Case treated without surgery. (Continued.) --->

,.
. i.. .•
214 Diagnosis

FIG 10-20.
Open bite associated with skeletal dysplasia, A, lateral cephalograms after treatment. C, intra-oral views b,efore and 2 years out of retention,
before and after orthodontic treatment. 8, facial views before and Case treated without surgery, (Continued.) -->

.-.
"

FIG 10-20 (cont.).
carefully discriminated from the complex and retained infantile'
swallow.
Table IQ-I summarizes the important differentiating char-
acteristics and symptoms of several problems, whereas Table
10-2 compares tongue-thrusting and swallowing functions.
4. Mastication
Patients with common malocclusions do not have impaired
masticatory efficiency to the extent that might be assumed; there-
fore, tests of mastication are not part of the routine orthodontic
examinations-though, as noted earlier, the swallow during mas-
tication may be of interest.
5. Speech*
Dentists are not speech pathologists, but they should be fa-
miliar with a few simple techniques of speech analysis in order
that children with obvious speech disorders may be referred to a
speech pathologist for diagnosis or therapy.
The fol\owing paragraphs in this section provide an orien-
tation to spe'ech production as it pertains to orthodontics. The
relationship between speech and malocclusion often is overstated,
since many patients with gross malocclusions have intelligible
speech. Because of the remarkably adaptive characteristics of the
lips and tongue, satisfactory speech can be produced in mouths
with severe malocclusions.
If abnormal tongue activity is noted during speech, there is
*Professor H. Harlan Bloomer, fonner Professor of Speech
Pathology and Director of the Speech Clinic, The University of Michi-
gan, helped in the writing of this section. He devised the ingenious
speech tests described herein.
Analysis of the Orafacial and Jaw Musculature 215
a basic question that must be answered: "Is the abnormal tongue
activity adaptive or etiologic to the malocclusion, is it attributable
to an etiology unrelated to either?" Usually it will be found to be
adaptive, but it may reflect an etiology that is common to both
the speech defect and the neuromuscular aspects of the malocclu-
sion. Maturational delays in development of oral motor coordi-
nations or neural pathologies affecting oral coordinations, though
not adaptive to the malocclusion, may contribute to it. On the
other hand, environment, or factors of learning or deafness (pe-
ripheral or central) may produce abnormal speech in a normally
formed mouth. The existence of a disorder of speech articulation
can be detected by having the patient repeat a few key sentences
designed to assist in the identification of defective consonants.
The basic units of American speech which contribute to mean-
ing are the 25 consonants, 14 vowels, and prosodic elements such
as melody, stress, and rhythm. Consonants and vowels are formed
by a complex series of oral pharyngeal and laryngeal movements
which create the musculoskeletal. valves that continually modulate
the sounds of speech. A critical phase of articulatory movements
in consonant production can be described as an "articulatory po-
sition" or "place" and the corresponding consonants can be class-
ifie.d in this context according to their "place of articulation."
~'However, "place of articulation" is significant only insofar
as it contributes to the' 'manner of articulation. " "Manner" refers
to the acoustic features which characterize speech sounds. In Table
10-3 a more complete classification of consonant phonemes is
presented according to: (I) the presence or absence of voicing; (2)
the anatomic structures by which the valves are created (place);
(3) the degree of (palatopharyngeal) valve closure required to pro-
duce the phoneme; and (4) the manner of articulation (glides,
fricatives, affricates, stops, nasals). Reference to such a table (and
to Table 10-4) can help us to understand how abnormalities of
216 Diagnosis

structure and maladaptive movements of the articulators may in~ lips and tongue function in nearly identical ways to produce the
terfere with the production of satisfactory consonant phonemes. sound. The audible distinction between them is created by the
Although this table is relatively simple, some tables and charts presence or absence of voicing. In the listing of the phonemes in
provide elaborate and detailed information concerning the phonetic the mini-test, the voiced member of each pair is underlined. In
parameters of speech. - the test sentences, the articulatory position being tested is indicated
A simple test the dentist may use to evaluate the relationship by a numeric subscript that identifies the "place of articulation"
between speech and malocclusion asks that the patient count from group to which the consonant belongs. There are, of course, other
1 to 10 or 1 to 20. The dentist (1) watches closely how the tongue instances of consonant occurrence, and the informed listener can
and lips adapt to the structures with which they are supposed to easily pick them out and listen for them as the speaker repeats the
articulate and (2) listens to how the consonants sound. sentence (for instance, the t in "bought," the z in "choose," the
d in "should").
The second group of sentences identifies the consonants by
Consonants Vowels
manner of articulation classified as (a) stops, (b) fricatives, (c)
One' tests wand n affricates, (d) glides, and (e) nasals. Instances of voiced consonants
w- and -n
are underlined, and each example of the consonant that illustrates
Two tests t- 00 the category is identified by a subscript asterisk. Whenever feasible,
Three tests th and r th- and -r ee words have been selected in which the initial consonant is illustrative
Four tests f and r f- and -r o of the sound to be tested.
Five tests f and v f- and -v Inasmuch as American orthography is only partially phonetic,
it is desirable to indicate the consonants by phonetic symbols, such
Six tests sand k s- and -ks (x) as those employed in the International Phonetic Alphabet. For
Seven tests s s-, -v-, and -n e readers who are not phonetically trained, the consonants have been
Eight tests! -t a paired with the equivalent English spellings to illustrate the
Nine tests n -n and -n pronounciation; for example, tsh for the ch in Charlie, zh for the
middle consonant in measure, and so forth. As in the first sentences,
Ten tests t and n -t and -n e
some consonants occur in several places, but only one instance· of
Eleven !, ~, and !! -1-, -v-, and -n e each has been identified by the asterisk.
Twelve !, ~, !, and ~ t/w-, -1-, and -v e Some patients, by concentrating, will produce perfect speech,
Etc. whereas, when speaking unobserved, they may make repeated
errors. Oral sensory deficits or lack of orofacial motor skills may
be common to both swallowing and speech disorders; however,
This simple procedure provides a test often consonants, seven the presence of abnormal tongue function during swallowing is
of which (th, r,f, v, s, I, k) are frequent offenders. It also includes not necessarily an indication that there will be abnormal tongue
eight of the 14 vowels and diphthongs common in American speech, function during speech.
listed with appropriate diacritical markings. In observing a patient's speech the dentist should be especially
The fricative consonants require very precise positioning of alert for articulatory error in cases of severe crossbite, severe
the speech organs and, consequently, are those sounds which are maxillary over-jet, anterior openbite, and visible interdental lingual
frequently defective. They may be affected in quality by maladaptive protrusion during speech. These are the malocclusions in which
placement of the tongue or lips or by malocclusion. Of these, the the sibilants's' and 'z' are most likely to be distorted. The patient's
sibilants, a subgroup of the fricatives, are the ones most likely to position in the dental chair provides a particularly good angle from
be distorted. which to observe lingual artigulatory positions and movements.
The proficiency of a patient to make such consonants can be
tested in various ways. The mini-test of speech articulation presented
in Table 10-4 was devised as a simple procedure to test speech
6. Jaw Relationships
articulation by place of articulation and by manner of articulation. Study of jaw relationships is an analysis of muscle function,
In this test, the subject is requested to read or to repeat after the but the technical and clinical procedures for such study are given
examiner a brief series of short sentences while the examiner in Chapter II since such registrations are used primarily for anal-
observes and ndtes whether the consonant failures or successes fall ysis,o.f occlusion. Section 5, which follows, is an analysis of the
into the numbered or lettered categories around which the sentences temporomandibular joints, includil)g specific techniques for jaw
are structured. Inasmuch as more than one instance of the articulatory registration when joint dysfunction is present or suspected.
category may be provided, it is suggested that the examiner listen
especially for the consonants underlined as belonging to the selected
category under test. D. ANALYSIS OF TEMPOROMANDIBULAR
The first test sentences identify consonants by place of JOINT DYSFUNCTION
articulation, that is, the position assumed by the oral articulators
at a critical point in the enunciation of the consonant. Many of There is increasing evidence that temporomandibular joint
the 25 consonant phonemes that occur in American English occur disorders may have origins early in development.4. 7. 20. 21 Epide-
in articulatory pairs; for example, p and b, sand z, in which the miologic studies show that a high percentage of children display

many of the signs and symptoms associated with temporomandib-
ular disturbances in adulthood4.7 It can no longer be assumed
that,temporomandibular dysfunction is solely a degenerative and
geriatic disorder. Furthermore, there is good evidence that these
early temporomandibular signs and symptoms"are often associated
with particular morphologic malocclusions, for example, Class II
(including end-to-end) malocclusions, crossbite, deep bite, and
perhaps open bite!' 7. 20. 21 Temporomandibular symptoms are en-
hanced when there is an occlusal interference.'
This section deals with the functional analysis of temporo-
mandibular joint disorders in children and adolescents. Such anal-
ysis must, of course, be supplemented by a thorough occlusal
analysis (Chapter 11) and a cephalometric analysis (Chapter 12).
1. Jaw Movements, Path of Closure, and Joint Sounds
When the head is in its natural postural position, the mandible
reflexly closes on a smooth arc with little deviation anteroposter-
iorly or mediolaterally (see Chapter 8). There are many reasons
for uneven or erratic jaw movements on closure-including past
trauma to the joint, occlusal interferences, an exfoliating primary
tooth, pain, etc. Observe the patient closing the jaw in a relaxed
manner without prompting or guidance on your part, noting the
amount, direction, and timing of any deviations from a smooth
closure path. Then, holding the fingers lightly over both jaw joints,
repeat the process to identify "clicks" or crepitus. A stethoscope
is particularly useful for identifying temporomandibular joint sounds:
One or both condyles may slide over the edge of the meniscus late
on jaw opening, slipping back into place after the initiation of
closure. In other instances, the condyle 'may be felt to move onto
the posterior edge of the meniscus very late in closure. All ab-
normal closure movements and joint sounds must be correlated
with occlusal interferences and muscle and joint pain.
The extent of maximal jaw opening should be measured.
Many authorities consider less than 40 mm to represent restricted
jaw opening. Brandt4 considers this an artificially high threshold
for determining restricted jaw movements, suggesting that 35 mm
is more appropriate for children and adolescents.
2. Occlusal Interferences
It is essential to check for interferences in the retruded contact
position and the intercuspal position, and during protrusive and
lateral occlusal contacts (see Chapters 8 and 11). Interferences
may be marked with articulation paper or registered in very thin
wax. Children with temporomandibular dysfunction may show
disharmonious occlusal interferences in either the retruded contact
position (centric relation) or the intercuspal position (centric oc-
clusion, uswll occlusal position)., WilliamsonJO has noted the im-
portance of posterior disclusion during incisal guidance. The patient
may be taught to move the jaw forward to edge-to-edge incisal
relationships. Interferences can be noted during this maneuver or
during tapping in the incisal position. Lateral working bite dis-
clusion may not be seen until the permanent cuspid is fully erupted,
and working side interferences of an irregular nature are frequently
observed in malocclusion. Balancing (nonworking side) interfer-
ences are particularly troublesome at all ages, irrespective of how
nice the morphologic occlusal relationship may seem in the inter-
cuspal position.
Analysis of the Orofacial and Jaw Musculature 217
3. Palpation of Muscles and Ligaments
Each muscle involved in mandibular movements should be
routinely palpated at rest and in isometric contractions (tell the
patient to clench the teeth) in an attempt to educe reflex responses
to pain. Often, unbeknownst to the patient, muscles or parts of
the muscles are painful upon palpation. The masseter, lateral pter-
ygoid, and temporal is are those which most frequently demonstrate
myalgia in patients with temporomandibular dysfunctions asso-
ciated with malocclusion.
Inform the patient that you are going to press several of the
muscles of the face and jaws and you want him or her to respond
if the pressure hurts. Then, with your finger, press on the muscle
at the base of the patient's thumb to show how pressure alone
feels. I use a four-point scale, asking the patient the score each
time I press a muscle site or tendinous attachment. The values are:
o pressure only, no pain;
I = pain on pressure only;
2 = chronic pain, pain prior to palpation-the pain is in-
creased with pressure;
, 3 = chronic pain-the patient flinches and/or grabs the den-
tist's hand.
Even though the patient acknowledges pain, it is necessary
to palpate carefully all muscles and their tendons in order to localize
and corroborate.
Wearing rubber gloves, systematically and evenly press the
bellies and then the attachments (as able) of the masseter, medial
pterygoid, temporalis, and lateral pterygoid muscles, in that order,
noting the patient's scoring for each muscle. It is especially im-
portant to separate temporal tendinous pain and lateral pterygoid
pain from joint capsular pain. Some patience and practice are
required to be certain of the anatomic site being pressed. For the
temporal is tendon it is easier if one begins by sliding the finger
along the anterior border of the ramus. As the coronoid process
is approached, ask the patient to open and close the jaw gently,
which movement reveals the exact site of the tendinous attachment.
When palpating the lateral pterygoid muscle and tendon, make
certain your finger is not pressing the joint itself. Palpation of the
temporomandibular joint and capsular ligament is also necessary
(see Section 4, Palpation of Joint Capsule, which follows).
'4. Palpation of Joint Capsule
Palpations of the joint capsllles may reveal intracapsular pain,
the timing of "clicks," and the nature of orepitus. Begin by touch-
ing lightly both joints during unguided opening and closure. Repeat
the procedure while the.)aw is moved into protrusive and lateral
eXj;~rsive positions. Next gently maneuver the jaw into the retruded
contact position with one hand 'lightly on the chin and the other
touching lightly each of the capsules (externally) in sequence. Then
palpate each of the joint capsules intraorally, noting the pain scores.
If specific occlusal interferences have been registered earlier, it is
often particularly revealing to have the patient tap lightly on the
noted interference while pressing the capsular ligament.
"Clicks" disclose a loss of intimacy of condyle and meniscus
relationships, and crepitus (rare in children) may point to early
arthritic symptoms. The significance of "clicking," though de-
bated, is far better understood in adults than in children. It is
/
218 Diagnosis
FIG'10-21.
Diagnostic splint. The flat bite plane allows the mandibular muscles
to position the mandible without afferent input from contacting cusps.
known that joint sounds in children are not closely associated with
pain, limited joint movements, and occlusal interferences.4
5. Registration of Jaw Relationships in the Presence of Pain
or Limited Movement
When any muscle or joint is painful, all of the muscles capable
of moving that joint display "splinting," the simultaneous con-
traction of all the muscles to reduce movement and further damage
to the joint. Splinting is sometimes called' 'guarding" in the dental
literature, and lay persons often speak of "stiff" joints after a
sprain. All these terms refer to a naturallJrotective reflex on the
part of the body which makes registration of jaw relationships
quite difficult. Splinting must be differentiated from anxiety or too
active attempts by the patient to cooperate during jaw registration.
If splinting is suspected, place a cotton roll between the molars
on each side and ask the patient to hold them lightly in place for
a few minutes. Then gently remove the cotton rolls, and obtain
the registration before the patient brings the teeth together. This
simple procedure temporarily "deprograms" the memory of the
occlusal interference which has been shunting the jaw away from
the reflexly determined position. When a serious and persistent
interference is present and temporomandibular dysfunction has
been positively identified, it is necessary to place a maxillary
diagnostic splint to relieve all occlusion for a period. For such
diagnostic (not treatment) purposes, I do not use splints with oc-
clusal coverage, preferring the design shown in Fig 10-21. The
splint shown is simple to construct and easy for the patient to use.
Further, it can be equilibrated quickly in the mouth. Note that its
construction requires no assumption on your part of a "correct"
jaw relationship. Wearing it simply discludes the teeth, allowing
the muscles to relax since the affe;ent avoidance signal from the
interfering tooth is lost. Muscle tension and pain often diminish
within 2 weeks, at which time the occlusal analysis can be com-
pleted more accurately. Its use facilitates occlusal equilibration
and it is especially useful in those serious cases where the casts
must be mounted on an articulator for more precise analysis. See
Chapters 8, 11, and 18 for other discussions of functional analysis,
jaw registrations, and occlusal equilibration techniques.
SUMMARY
Evaluation of the sensory and motor abilities of the orofacial
muscles; study of the specific muscle groups of the jaws, mouth,
and face; examination of critical specific neuromuscular functions;
and analysis of the temporomandibular joints are necessary parts
of the complete orthodontic diagnosis.
Sensory and motor evaluation, though difficult to quantify,
may reveal patients with neurologic disorders or neuromuscular
inabilities affecting the success of orthodontic treatment.
Muscle groups of the head, face, and mouth should be ex-
amined morphologically; but more important, they should be stud-
ied in function. Specific procedures are used for the facial and lip
muscles, tongue, muscles of mastication, and the muscles provid-
ing head and neck support.
Neuromuscular functions of concern to orthodontics include
posture (general and specific), respiration, swallowing, mastica-
tion, speech, and jaw relationships. Brief observations of posture,
respiration, mastication, and speech may be sufficient to determine
their possible roles and the need for referral. Specific and more
detailed procedures are needed for swallowing and jaw relation-
ships, since they not only are very closely related to malocclusions
but correction of abnormal swallowing and jaw relationships are
part of the actual treatment of malocclusion and thus the dentist's
responsibility.
Temporomandibular dysfunction is closely related to occlusal
dysfunction and to aberrant craniofacial morphology and growth.
Therefore, analysis of the temporomandibular joints is an important
part of orthodontic diagnosis.
REFERENCES
1. Bloomer H: Speech defects in relation to orthodontics. Am
J Orthod 1963; 49:920.
2. Bloomer H: Speech defects associated with dental maloc-
clusions, In Travis, LE: Handbook of Speech Pathology.
New York, Appleton-Century-Crofts, 1971.
3. Bosma JF: Second Symposium on Oral Sensation and Per-
ception. Springfield, Ill, Charles C Thomas, 1970, part V,
Evaluation of oral sensation and perception in children and
adults, pp 300-440.
4, Brandt, D: Temporomandibular disorders and their associa-
tion with morphologic malocclusion, in Carlson DS, Mc-
Namara JA Jr, Ribbens KA (e.ds): Developmental Aspects
of Temporomandibular Joint Disorders? monograph 16.
Craniofacial Growth Series. Ann Arbor, Mich, Cenler for
Human Growth and Development, University of Michigan,
',1985. ,~.
5. gushey RS: Adenoid obstruct~on of the nasopharynx, in
McNamara JA Jr (ed): Naso-Respiratory Function and
Craniofacial Growth, monograph 9. Ann Arbor, Mich,
Center for Human Growth and Development, University of
Michigan, 1979.
6. Cole RM, Cole JE: Myofunctional therapy in tongue thrust
swallow and related problems, in Clark JW (ed): Clinical
Dentistry, vol 2. Hagerstown, Md, Harper & Row, 1978,
vol 2, chpt 12, pp 1-20.
7. Egermark-Eriksson I, Carlsson GE, Ingervall B: Prevalence
pf mandibular dysfunction and orofacial parafunction in 7,

11, and 15-year-old Swedish school children. Eur J Orthod
1981; 3: 161-172.
8. 'Egermark-Eriksson I, Ingervall B, Carlsson GE: The de-
pendence of mandibular dysfunction in children on func-
tional and morphologic malocclusion. Am J Orthod 1983;
83:187-194.
9. Hanson ML, Barnard LW, Case JL: Tongue-thrust in pre-
school children. Am J Orthod 1969; 56:60-69.
10. Harvold EP: Neuromuscular and morphological adaptations
in experimentally induced oral respiration, in McNamara JA
Jr (ed): Naso-Respiratory Function nad Craniofacial
Growth, monograph 9. Craniofacial Growth Series. Ann
Arbor, Mich, Center for Human Growth and Development,
University of Michigan, 1979.
1,1. Harvold EP, Chierici G, Vargervik K: Experiments on the
development of dental occlusions. Am J Orthod 1972;
61:38-44.
12. Harvold EP, Vargervik K, Chierici G: Primate experiments
on oral sensation and dental malocclusion. Am J Orthod
1973; 63:494-508.
13. Linder-Aronson S: Adenoids-their effect on mode of
breathing and nasal airflow and their relationship to charac-
teristics of the facial skeleton and the dentition. Acta Oto-
laryngoI265(supp!.) 1970.
14. Linder-Aronson S: Effects of adenoidectomy on the denti-
tion and facial skeleton over a period of five years. Trans-
actions of the Third International Orthodontic Congress,
London, 1973, p 85.
15. Linder-Aronson S: Naso-respiratory function and craniofa-
cial growth, in McNamara JA (Jr (ed): Naso-Respiratory
Function and Craniofacial Growth" monograph 9. Cranio-
facial Growth Series. Ann Arbor, Mich, Center for Human
Growth and Development, University of Michigan, 1979.
16. Miller AJ, Vargervik K: Neuromuscular changes during
long-term adaptation of the Rhesus monkey to oral respira-
tion. in McNamara JA Jr (ed): Naso-Respiratory Function
and Craniofacial Growth, monograph 9. Craniofacial
Growth Series. Ann Arbor, Mich, Center for Human
Growth and Development, University of Michigan, 1979.
17. Moyers RE: The role of musculature in orthodontic diagno-
sis and treatment planning, in Kraus BS, Reidel RA (eds):
Vistas in Orthodontics. Philadelphia, Lea & Febiger, 1962.
18. Moyers RE: The infantile swallow. Trans Eur Orthodont
Soc 1964;40:180.
19. Moyers RE: Postnatal development of the orofacial muscu-
lature, in Patterns of Orofacial Growth and Development,
report 6. Washington, DC, American Speech and Hearing
Association, 1971.
20. Moyers RE: The development of occlusion and temporo-
mandibular joint disorders, in Carlson DS, McNamara JA
Jr, Ribbeps KA (eds): Developmental Aspects of Temporo-
mandibular Joint Disorders, monograph 16. Craniofacial
Growth Series. Ann Arbor, Mich, Center for Human
Growth and Development, University of Michigan, 1985.
21. Nesbitt B, Moyers RE, Ten Have T: Adult TMJ symptom-
atology and its association with childhood occlusal rela-
tions: A preliminary report, in Carlson DS, McNamara JA
Jr, Ribbens KA (eds): Developmental Aspects of Temporo-
mandibular Joint Disorders, monograph 16. Craniofacial
Growth Series. Ann Arbor, Mich, Center for Human
Growth and Development, University of Michigan, 1985.
22. Posen AL: Application of quantitative perioral assessment
to orthodontic case analysis and treatment planning. Angle
Orthod 1976; 46:69-76.
Analysis of the Orofacial and Jaw Musculature 219
23. Proffit WR: Equilibrium theory revisted. Angle Orthod
1978; 48: 175-186.
24. Proffit WR: The facial musculature in its relation to the
dental occlusion, in Carlson DS, McNamara JA Jr (eds):
Naso-Respiratory Function and Craniofacial Growth, mono-
graph 9. Craniofacial Growth Series. Ann Arbor, Mich,
Center for Human Growth and Development, University of
Michigan, 1979.
26. Solow B, Tallgren A: Head posture and craniofacial mor-
phology. Am J Phys Anthropol1976; 44:417-436.
27. Solow B, Tallgren A: Dentoalveolar morphology in relation
to craniocervical posture. Angle Orthod 1977; 47:157-163.
28. Vig PS: Respiratory mode and morphological types: Some
thoughts and preliminary conclusions, in McNamara JA Jr
(ed): Naso-Respiratory Function and Craniofacial Growth,
monograph 9. Craniofacial Growth Series. Ann Arbor,
Mich, Center for Human Growth and Development, Uni-
versity of Michigan, 1979.
29. Warren DW: Aerodynamic studies of upper airway: Impli-
cation for growth, breathing and speech, in McNamara JA
Jr (ed): Naso-Respiratory Function and Craniofacial
Growth. monograph 9. Craniofacial Growth Series. Ann
Arbor, Mich, Center for Human Growth and Development,
University of Michigan, 1979.
30. Williamson EH: Temporomandibular dysfunction in pre-
treatment adolescent patients. Am J Orthod 1977; 72:429-
433.
SUGGESTED READINGS
Bosma, JF (ed): Symposium on Oral Sensation and Perception.
Springfield, Ill, Charles C Thomas, 1967.
Bosma JF: Second Symposium on Oral Sensation and Percep-
tion. Springfield, Ill, Charles C Thomas, 1970.
Bosma JF (ed): Third Symposium on Oral Sensation and Per-
ception. Springfield, Ill, Charles C Thomas, 1972.
Bosma JF (ed): Fourth Symposium on Oral Sensation and Per-
ception, pub!. NIH 73-546. U .S. Department of Health, Ed-
ucation and Welfare, Bethesda, Md, National Institutes of
Health, 1973.
Bryant P, Gale E, Rugh J: Oral Motor Behavior: Impact on
Oral Conditions and Dental Treatment, pub!. NIH 79-1845.
US. Department of Health, Education and Welfare, Public
-..;Health Service, National Institutes of Health, 1979.
Carlson DS, McNamara JA Jr: Muscle Adaptation in the Cranio-
facial Region. monograph 8. Craniofacial Growth Series. Ann
Arbor, Mich, Center for Human Growth and Development,
University of Michigan, 1978.
Carlson DS, McNamara JA Jr and Ribbens KA (eds): Develop-
" mental Aspects of Te.mporomandibular Joints Disorders,
'monograph 16. Craniofacial Growth Series. Ann Arbor,
Mich, Center for Human Growth and Development, Univer-
sity of Michigan, 1985.
Cleall JF: Deglutition: A study of form and function, Am J Or-
thod 1965; 51:566.
Cole RM, Cole JE: Myofunctional therapy in tongue thrust
swallow and related problems. in Clark JW (ed): Clinical
Dentistry, Hagerstown, Md, Harper & Row, 1978, vol 2, ch
12, pp 1-10.
Mason R: Tongue thrust, in Bryant P, Gale E, Rugh J: Oral
Motor Behavior: Impact on Oral Conditions and Dental
Treatment, pub!. NIH 79-1845. U.S. Department of Health,
220 Diagnosis
Education and Welfare, Public Health Service, National Insti-
tutes of Health, 1979.
McNamara JA Jr (ed): Naso-Respiratory Function and Cranio-
facial Growth, monograph 9. Craniofacial Growth Series.
Ann Arbor, Mich, Center for Human Growth-and Develop-
ment, University of Michigan, 1979.
Moyers RE: 'The role of musculature in orthodontic diagnosis
and treatment planning, in Kraus BS, Reidell RA (eds): Vis-
tas in Orthodontics. Philadelphia, Lea & Febiger, 1962 .
Stelmach GE: Conceptualizing oral motor behavior: An exami-
nation of the cognitive and control aspects, in Bryant P, Gale
E, Rugh J: Oral Motor Behavior: Impact on Oral Conditions
and Dental Treatment, pub!. NIH 79-1845. US Department
of Health, Education and Welfare, Public Health Service, Na-
tional Institutes of Health, 1979.
Subtelny JD: Malocclusions, orthodontic corrections and orofa-
cial muscle adaptation. Angle Orthod 1970; 40: 170.
.'
CHAPTER 11

Analysis of the Dentition and

Occlusion
Robert E. Moyers, D.D.S., Ph.D.

If we could first know where we are and whither we are

tending, we could better judge what to do and how to do
it.-ABRAHAM LINCOLN

KEY POINTS 9. Arch dimensional changes as a result of expected

growth must be differentiated from changes which
1. In addition to direct visual observations of the the clinician can (or cannot) make as a part of
patient's dental casts, radiographs, cephalograms, treatment.
and photographs are used in analyzing dental and 10. It is possible to anticipate some of the several
occlusal development.
patterns of occlusal change during the transitional
2. Calcification is studied by reference to appropriate dentition.
standards to understand the individual's pattern of 11. Registration of jaw relationship is necessary during
tooth formation.
analysis of occlusal development status, but the
3. Eruption may be predicted by the use of tables of methods and assumptions differ somewhat from those
development or by use of crown-root ratio tables. used in reconstructive dentistry for adults.
4. Congenital absence of teeth may be discerned at the
earliest practical time by use of data on the onset of
calcification.
5. Tooth size is primarily important when related to the
space available and the clinician's ability to increase OUTLINE
that space.
6. The Bolton analysis is used.to relate ratios for A. Diagnostic data
., I. Intra-oral e~amination
maxillary versus mandibular tooth sizes, to predict 2. Dental casts
overbite and overjet.
3. Radiographs
7. The Howes' and Sanin-Savara analyses reveal teeth
a) Intra-oral periapical survey
discordant in size with others and help one b) Bite-wing radiographs
understand the clinical consequences of such c) Lateral jaw projections
disharmonies. Pont's Index is of little use for the
d) Occlusal plane projections
same purpose, though the diagnostic setup is helpful. e) Panoramic radiographs
8. A Mixed Dentition Analysis is used to predict the f) Oblique cephalograms
sizes of unerupted permanent teeth and evaluate the g) Lateral cephalograms
probabilities for their inclusion within the arch. 4. Photographs

221
222 Diagnosis

B. Analysis of tooth development tations of teeth, and other information. While one is holding the
I. Calcification casts together in the usual occlusal position, the occlusal relation-
2. Eruption ships can be observed, as well as midline coincidence, attachment
a) Predicting emergence of the frena, the occlusal curve, and axial inclinations of teeth.
I) Method 1: Use of tables of development The lingual occlusion can be studied only with dental casts (see
2) Method 2: Wainright's rule Fig 11-1).
b) Sequence of eruption
3. Number of teeth
4. Position of teeth
5. Anomalies 3. Radiographs
C. Size of teeth
a) Intra-Oral Periapical Survey
I. Individual teeth
The periapical survey is useful for any orthodontic diagnosis,
2. Size relationships of groups of teeth
for from it may be learned the eruption sequence, congenital ab-
a) Bolton tooth ratio analysis
sence of teeth, impactions, dental abnormalities, supernumerary
b) Sanin-Savara tooth size analysis
teeth, developmental progress of teeth, etc. (Fig 11-2). The intra-
3. Relationships of tooth size to size of supporting oral periapical surveyor a panoramic radiograph is an essential
structures
part of the permanent record of any case to be treated orthodont-
a) Howes' analysis
ically since it defines the exact status of each tooth before therapy.
b) Pont's Index
c) Diagnostic setup b) Bite-wing Radiographs
4. Relationships of tooth size and available space during
Bite-wing radiographs, although essential for the detection of
the mixed dentition (Mixed Dentition Analysis) interproximal caries, are of little use in the orthodontic analysis.
a) Procedure in the mandibular arch
b) Procedure in the maxillary arch c) Lateral Jaw Projections
c) Modifications
Lateral jaw projections are useful during the mixed dentition,
d) Problems
since they show the relationship of the teeth to one another and
D. Arch dimensions
to their supporting bone and are an aid in assessing the develop-
I. Changes in arch dimensions mental status and relative eruptive positions of individual teeth
2. Asymmetries of arch dimension and tooth position (Fig 11-3); however, they are inferior to both the oblique and
E. Prediction of future occlusal relationships panoramic radiographs for such purposes.
F. Registration of jaw relationships
I. Retruded contact position d) Occlusal Plane Projections
2. Ideal occlusal position Occlusal plane projections are used to locate supernumerary
3. Steps in procedure teeth at the midline and to ascertain accurately the position of
G. The temporomandibular joints unerupted maxillary cuspids (Fig 11-4).
H. Relationships of the teeth to their skeletal support
e) Panoramic Radiographs
In panoramic radiographs, one can (I) visualize the relation-
A. DIAGNOSTIC DATA ships ·of both dentitions, both jaws, and both temporomandibular
1. Intra-Oral Examination joints; (2) study the relative developmental status of the teeth and
progressive resorption of primary teeth; and (3) ascertain patho-
Most intra-oral features are noted in the cursory examination logic lesions. As ordinarily taken, the panoramic radiograph shows
(see Chapter 8). Some pertinent items in the analysis of the den- differential enlargement and therefore cannot be used for "ceph-
tition and occlusion can be seen only intra-orally, for example,
alometric measurements" (Fig 11-::5).
oral hygiene, gingival health, tongue size, shape and posture,
dental restorations, etc. j) Oblique Cephalograms
The oblique cephalometric view, a cephalometric projection
2. Dental Casts of 0f!e side of the face,' is of particular use in analysis of the
developing dentition, since it combines most of the advantages of
The record dental casts are one of the most important sources the lateral jaw view, the intra-oral periapical survey, and the pan-
of information for the dentist doing orthodontic treatment, and the oramic radiograph, plus provides a standardized cephalometric
time required for their precise construction is time well spent. registration that makes possible measurements of bone size, erup-
Technical details of impression taking, cast pouring, and trimming tive movements, etc. (Fig 11-6,A). Cephalometric procedures are
are given in Chapter 18. A good set of dental casts should show discussed in Chapter 12.
the alignment of the teeth and the alveolar processes as far as the
impression material can displace the soft tissues (Fig 11-1). From g) Lateral Cephalograms
the occlusal view, one can analyze the arch form, arch asymmetry , The lateral cephalogram is the orientation most frequently
alignment of the teeth, palate shape, tooth size, tooth shape, ro- used in evaluating the relationships of the dentition to the osseous
 Analysis of the Dentition and Occlusion 223

FIG 11-1.
A good set of diagnostic dental casts. A, right side. B, front. C, left
side. D, lingual view. E, maxillary occlusal view. F, mandibular occlusal view.

FIG 11-2.
A complete set of periapical radiographs.
224 Diagnosis

FIG 11-3.
A typical example of a well-taken lateral radiograph of the jaw.

FIG 11-4.
An occlusal plane radiograph.

FIG 11-5.
Example of one type of panoramic radiograph. In this form, the film provides excellent views in one film of most items to be considered
must be cut and spliced. The panoramic projection, as can be seen, in analyzing a case in the mixed dentition.
 Analysis of the Dentition and Occlusion 225

FIG 11-6.
Cephalograms. A, oblique view; B, typical lateral cephalogram.

FIG 11-7.
A and B are good examples of correct extra-oral photographs. (Cour-
tesy of Or. Michael Riolo.) C and D are good examples of intra-oral photographs.
 226 Diagnosis
skeleton (Fig 11-6,B). Analyses of the lateral cephalogram are
used to study morphology and growth, to diagnose malocclusion
and craniofacial dysplasia, to plan orthodontic treatment, and to
assess treatment progress and quality of result. Many orthodontists
consider it the single most important piece of -diagnostic data.
Indeed, it is easily argued that the more inexperienced the dentist
doing the orthodontics the more use that can be made of analysis
of the lateral cephalogram. The postero-anterior cephalogram is
less frequently useful in analysis of the dentition. No one treating
but the most simple of malocclusions can afford to work without
meticulous cephalometric analysis of each and every case. Ceph-
alometric procedures are discussed in detail in Chapter 12.
4. P.hotographs
Standardized intra-oral and extra-oral photographs are sup-
plemental to other diagnostic data. Parents and patients usually
can interpret conditions and changes during treatment better in
photographs than in casts or radiographs (Fig 11-7). Photographs
also serve to record changes in appliances used during treatment.
Furthermore, some developmental anomalies actually may be vis-
ualized better in the intra-oral photograph than elsewhere; for ex-
ample, mottled enamel, discoloration of enamel due to antibiotic
therapy, hypoplastic enamel, and amelogenesis imperfecta.
B. ANALYSIS OF TOOTH DEVELOPMENT
1. Calcification*
Calcification standards derived from populations of children
(see Fig 6-13) may be used in the following ways: (I) to compare
the individual patient to an appropriate population in order to
determine whether the dental development is normal, advanced,
or retarded; (2) to ascertain whether there are individual teeth
developing aberrant to the general pattern; and (3) to predict the
time of completion of root development, diminution of pulp size,
or intra-oral eruption. Ordinal stages of development, for example
those of Nolla9 described in Chapter 6, must not be assumed to
describe the same amount of development for each stage. Nor is
any stage necessarily exactly the same in one tooth as in another.
Such ordinal stages have limited use in research where quantifi-
cation is necessary but are of help in understanding the dentitional
development of an individual child.
Before planning any orthodontic treatment in the mixed den-
tition, it is essential to know the developmental status of each tooth
and the probable time each will achieve future developmental
stages. The use of group averages simply is not sophisticated
enough for a practical clinical analysis. Research is done by the
hundreds but treatments are done 9ne by one. The purpose of
dentitional evaluation is to evaluate the developmental status of
each tooth in one child; therefore, more is learned by comparing
the child to itself than to a table of values or norms of a group to
which the child does not belong.
*See also Chapter 6.
FIRST CUSPID FIRST SECOND SECOND
MOLAR BICUSPID BICUSPID MOLAR
FIG 11-8.
Approximate root development at the time of alveolar crest emer-
gence, mandibular teeth.
2. Eruption
a) Predicting Emergence
There is great clinical utility in being able to predict the time
of alveolar or gingival emergence. A few useful rules of thumb
have been developed for use in practice. All are based on a knowl-
edge of the physiology of eruption (see Chapter 6). £ruptive move-
ments begin when crown formation is completed (see Fig 6-16),
the alveolar crest is pierced when a typical stage of root devel-
opment is reached (Fig 11-8), and occlusion is achieved when
root length is almost completed but the apex is still unformed.
Yariations from population means are more apt to be due to lo-
calized conditions than is sometimes realized; for example, caries
or pulpitis in the primary predecessor or gingival and/or periodontal
inflammation all hasten resorption of the primary and eruption of
the permanent tooth independently of the root length achieved.
1) Method 1: Use of Tables of Development.- By referring
to Table 6-5, one can, in a crude way, predict the eruption of an
individual tooth in the following fashion. First, compare the stage
of calcification of the tooth to the mean stage of development for
the appropriate chronologic age. For example, if one wishes to
predict the time of alveolar emergence of a mandibular cuspid in
a 6-year-old girl, one learns by referring to Table 6-5 that, on
the average, the root formation has just begun. If the average 6-
year-old girl has just begun eruption of the mandibular cuspid, it
can be predicted that this tooth, in the average girl, will pierce the
alveolar crest at age 8, when it achieves approximately 70% of its
root length (just past Nolla's developmental stage 8). By comparing
the individual patient's deviations from the normal pattern, crude
estimates of the time of piercing the alveolar crest and reaching
occlusal contact can be made. Note that thes~ estimates are based
on alveolar crest, not gingival emergence.
i)' Method 2: Wainright's Rule.- Use of Wainright'sl4
Rule, based on data from the patient alone, is quicker, more pre-
cise, and more practical. Suppose we wish to predict the alveolar
emergence of a first mandibular premolar whose root length equals
the crown height (crown-root ratio = I: 1.00); we then locate the
appropriate row in the left column of Table II-I,A (change in
root: crown ratio per year). We note from the table that only 5%
of all first premolars are erupted with this amount of root, 28%
have emerged when the ratio is 1:1.25,56% when it is 1:1.50,
and so forth. By multiplying the factor 0.30 (found at the bottom
 TABLE 11-1.
Analysis of the Dentition and Occlusion 227
Crown Root Ratios and Eruption'

A, Mandibiular'
FIRST
. %114.
ERUPT.
43.
100.
100.
100.
246.
47.
86.
63.
98.
93.
64.
ERUPT.N
ERUPT.N
112.
33.
128.
176.
135.
72.
96.
79.45.
100.
29.
213.
221.
146.
29.
152.
102.
66.
47.
109.
43.
51.
77.
45.
56.
28.
85.
99.
91.
97.
25.
92.
89.
70.
96.
100.
27.
61.
83.
107.
18.
87.
10.
34.
85.
10.
35.
87.
86.
8.
5
3
38
12.
96.
98.
99.
61.
69.
1.
ERUPI.
O. 3N
11.
.1.
O. 33.
108.
. 1. 132.
116.
119.
52.
80.
93.
87.
77.
63.
0.26
0.30
0.25
PREMOLAR
SECOND
PREMOLAR
MOLAR
FIRST
NMOLAR
0.37 CANINE 0.32
AS OBSERVED

• Note the root portion of these ratios increases at an annual rate presented in the bottom row. To predict the percent erupted N years from that observed,
simply add N times the value in the bottom row to the denominator of the ratio and look up values at the new ratio.

S, Maxillaryt
%163. FIRST
ERUPT.
10.
194.
139.
177.
83.
172.
54.
58.40.
10.
101.
230.
147.
2.
137.
176.
121.
124.
106.52.
71.
96.
171.
67.
68.
92.
38.
ERUPT.N
186.
145.
141.
196.
30.
6.
77.
60.
17.
26.
41.
25.
74.
59.
61.
11.
86.
93.
254.
256.
129.
104.
102.
91.
97.
98.
49.
94.
96.
100.
O.
O.
O 1.
67.
39.
99.
107.
100.14.
100.
100.8.
100.
O.5.
4.
138.
87.
78.
97.
94.
60.
96.
100.
91.
49.
3
30.
99.
5 9.
6.
O.
. SECOND
74.
147.
185.
153.
155.
156.
121.
92.
28.
4. FIRST
MOLAR
NMOLAR
SECOND
PREMOLAR
PREMOLAR
6. CANINE
AS OBSERVED

tTable parts A and B show the percentage of teeth which have been found to be erupted through the alveolar crest for each radiographically observed
crown/root ratio. For example, in the normative growth data set only one mandibular canine out of 77 has penetrated the alveolar process when the
crown/root ratio was 1 to 1.25, yet 100% of 52 cases had erupted when the crown/root ratio was 1 to 3.00.

C, Wainright's Guide:j:

c
...
------- ... -- .. ) CROWN
---------
1:0.5 33.3
1: 1.0 50.0
1: 1,5 60.0
1:2,0 66.7
1,2.5 71.4
113.0 75.0
Crown: Root Percent
Ratio Total Length
That is Root
(%Root)
:j:A transparency is made of this figure and the transparency is superimposed over the radiographic image of each tooth, so that the axis of the tooth is
parallel to the vertical lines and the radiographic crown height exactly fills the stippled area. One can then quickly estimate the crown/root ratio or percent
of total tooth length that is prE)sently root length. Use this determined value to learn the percent of a population observed that shows eruption with
equivalent root development. Note that the crown/root ratio and the percent root values change in a predictable manner with age. The coefficients at
the bottom row of Table 11-1 parts A and B can be used to predict expected root development for each future year.
228 Diagnosis

of the column) by three and adding it to the denominator, the ratio
is changed to I: I. 90, the age when approximately 90% of all
mandibular first premolars are erupted. In other words, there is a
90% probability of it's being emerged in 3 years, 100% probability
of emergence in less than 4 years, 86% in 2 'I; (I. 00 + 30 x
2 '/2 = 1.75), etc.
b) Sequence of Eruption
One should always ascertain the implications to therapy of
the sequence of eruption exhibited by the patient (see Chapter 6),
for certain sequences tend to shorten the arch perimeter, whereas
others are useful in retaining arch perimeter. It should not be
assumed that any observed sequence of development will persist
and.be the exact sequence of emergence in the mouth.
3. Number of Teeth
than in the mouth or on casts but such cephalometric analysis must
use cephalometric standards appropriate for sex, age, and even
race, a procedure not always done in practice. The position of
teeth must be evaluated in the light of the normal position for that
tooth at the appropriate stage of development. For example, max-
illary lateral incisors flare slightly while crowns of the erupting
cuspids are changing their direction of movement toward the oc-
clusion. As soon as the cuspid has uprighted itself and moved off
the root of the lateral incisor, the crown of the lateral incisor moves
back into alignment in the dental arch (see Figs 6-50 and 6-59).
Thus, this slight labial position of the maxillary lateral incisors,
called by Broadbent "the ugly duckling stage," is not a malpo-
sition in the mixed dentition, but is a malposition in the completed
permanent dentition. Simply noting malpositions of teeth is of
little use; their significance to anticipated or expected tooth move-
ments must be determined as well (see Chapter 12).

Strange'as it may seem, failure to count the teeth is a common 5. Anomalies

mistake. Counting must include not only the teeth seen but those
developing-or not developing-within the jaws. Particular men-
tion should be made of the determination of the congenital absence
of teeth. Reference to tables of dental development (see Table 6-
5) provides help in determining the congenital absence of teeth.
Table 11-2 provides a very rough guide in simpler form. Variation
in development is so great, and is greatest in those teeth most apt
to be congenitally missing, that the table must be used with care.
In using it in practice remember that girls generally develop teeth
earlier than boys, blacks earlier than whites, and that there are
strong familial patterns of early and late development. If a child
does not show a particular tooth by the date shown in the table
the chances are roughly 95 out of 100 that the tooth is congenitally
missing. Careful serial study of the trabecular pattern of bone in
radiographs of the region is eventually confirmatory, of course,
but the idea is to be ready for any necessary clinical intervention
at the earliest possible time.
4. Position of Teeth
Position of teeth is far better quantified in the cephalogram
An immediate decision concerning the effects of any anom-
alies of development, size, shape, or position of teeth on the
anticipated therapy should be made. It is usually a mistake to
postpone decisions concerning anomalies.
C. SIZE OF TEETH
1. Individual Teeth
When considering the size of teeth, several measurements and
concepts seem confusing. Indeed, the word "arch" is used to
designate any or all of the dimensions shown in Figure 11-9 (we
even say "arch" when we mean archwire). Some definitions may
help clarify the important concepts involved.
The basal arch is the arch formed by the corpus mandibularis
or maxillaris. Its dimensions probably are unaltered by the loss of
all permanent teeth and resorption of the alveolar process. It is the
arcal measurement of the apical base.
The alveolar arch is the arcal measurement of the alveolar
process. The dimensions of the alveolar arch may not coincide

TABLE 11-2. Dental Arch

Estimating Probable Congenital Absence of Teeth
TOOTH MAXILLA MANDIBLE
Alveolar Arch
Central incisor 6 months 6 months
Lateral incisor 18 months' 6 months Basal Arch
Cuspid 12 months 12 months
1st premolar 3 years 3 years
FIG.1;1-9.
2nd premolar 4'/2 years' 4'/2 years'
The relationship of the three arche&. The basal arch is largely de-
1st molar 2'2 years 2'/2 years
termined by the configuration of the mandible itself. The alveolar arch
2nd molar 5 years 5 years joins the tooth to the basal arch and thus always is a compromise
3rd molar 8 years' 8 years' in size and shape between the basal arch and the dental arch. The
The figures are conservative estimates based on radio- dental arch reflects the relationship between the combined sizes of
graphic observations without respect to sex. The values the crowns of the teeth, tongue, lip, and buccal wall function, an-
represent roughly2 standard deviationsfromthe mean time gulation of the teeth, anterior component of force, etc. When the
of initiallyobservable calcificationin the radiograph.Those combined mesiodistal diameters of the teeth are harmonious with
teeth marked with an asterisk are notoriouslyvariable in
their development (see Chapter 6, part 6.E.2., number of the size of the basal arch and the relationship of the maxillary to the
teeth,fora discussionofgeneticfieldsintoothdevelopment). mandibular basal arch, the dental arch is synonymous with the com-
bined sizes of the teeth.

with those of the basal arch if, for example, the teeth are tipped
labially off the basal arch.
The dental arch usually is measured through the contact points
of the teeth and represents a series of points where the muscle
forces acting against the crowns of the teeth are balanced. When
the crowns are tipped markedly off the basal bone, the dental arch
and alveolar arch are not synonymous.
The combined mesiodistal widths of the teeth constitute still
another measurement.
One aims, by orthodontic treatment, for all of the teeth to be
so aligned that the combined widths of the teeth will be identical
with the dental arch measurement and the dental arch will be well
positioned over the basal bone. Then gross differences in the dental
arc;h, alveolar arch, and basal arch perimeters will not obscure
cosmetics or complicate occlusal function and stability.
The distribution of crown sizes for the primary dentition is
given in Table 6-3; that for the permanent teeth, in Table 6-6.
For orthodontic diagnostic purposes, size of teeth is entirely a
relative matter. Large teeth do not always result in a malocclusion,
since the available space may be sufficiently large to include them
nicely. Simple size of teeth tells little. Comparison of tooth size
and available space (see Section C-4, later in this chapter), de-
termination of the effects of the size of the teeth on overbite and
overjet (see Section C-2), and the identification of disharmonies
of tooth size within the arch are, however, of great clinical import.
The localization of intra-arch and interarch disharmonies and
their implications to treatment planning are aided by use of the
Bolton tooth ratio analysis I. 2 and the Sanin-Savara'2 analysis of
mesiodistal crown size (see next section).
2. Size Relationships of Groups of Teeth
The precise alignment of teeth and attainment of perfect pos-
terior intercuspation can be frustrating when crown size discrep-
ancies are present. For example, it is not unusual to achieve a
perfect Class I molar relationship during orthodontic treatment and
yet not be able to achieve a similar cuspid intercuspation because
of tooth-size discrepancies in the lateral segments. While left-right
symmetry of size is usually assured, the anteroposterior tooth sizes
are often not so harmonious. Not only can a single tooth's size
discrepancy be troublesome, but the accumulation of minor dif-
ferences along the arch can produce difficulties in achieving precise
occlusion. The examination of the dentition during treatment plan-
ning must include the identification of the effects of tooth size,
both local and general, upon the ultimate overbite, overjet, and
posterior occlusion. Fortunately two practical methods are avail-
able to help, the Bolton tooth ratio analysis I. 2 and the Sanin-Savara
analysisl2 of mesiodistal crown size.
a) Bolton Tooth Ratio Analysis
Boltonl. 2studied the interarch effects of discrepancies in tooth
size to devise a procedure for determining the ratio of total man-
dibular versus maxillary tooth size and anterior mandibular versus
maxillary tooth size. Study of these ratios helps in estimating the
overbite and overjet relationships that will likely obtain after treat-
ment is finished, the effects of contemplated extractions on pos-
terior occlusion and incisor relationships, and the identification of
occlusal misfit produced by interarch tooth size incompatibilities.
Analysis of the Dentition and Occlusion 229
Figure 11-10 is the suggested data form for use in recording and
computing both the overall and anterior tooth ratios.
The procedure is as follows: the sum of the widths of the
mandibular 12 teeth is divided by the sum of the maxillary 12
teeth and multiplied by 100. A mean ratio of 91.3, according to
Bolton, will result in ideal overbite-overjet relationships, as well
as posterior occlusion. If the overall ratio exceeds 91.3, the dis-
crepancy is due to excessive mandibular tooth material. In the
. chart, one locates the figure corresponding to the patient's max-
illary tooth size. Opposite is the ideal mandibular measurement.
The difference between the actual and the desired mandibular
measurement is the amount of excessive mandibular tooth material
when the ratio is greater than 91.3. If the ratio is less than 91.3,
the difference between the actual maxillary size and the desired
maxillary size is the amount of excess maxillary tooth material.
A similar ratio (anterior ratio) is computed for the six anterior
teeth (incisors and cuspids). An anterior ratio (77 .2) will provide
ideal overbite and overjet relationships if the angulation of the
incisors is correct and if the labiolingual thickness of the incisal
edges is not excessive. If the anterior ratio exceeds 77 .2, there is
excessive mandibular tooth material; if it is less than 77 .2, there
is excess maxillary tooth material. Bolton Analysis predictions do
not take into account the sexual dimorphism in maxillary cuspid
widths. Since maxillary cuspids are disproportionately larger in
men than in women, an ideal overbite and overjet, as defined by
Bolton, is less apt to be achieved in men.
When one is contemplating the extraction of four premolars,
it is useful, before selecting the teeth for extraction, to ascertain
the effects of various extraction combinations on these ratios.
b) Sanin-Savara Tooth Size Analysis
Scholars at the University of Oregon (Sanin and Savara,'2
and colleagues) devised a simple and ingenious procedure to iden-
tify individual and group tooth size disharmonies. It makes use of
precise mesiodistal measurements of the crown size of each tooth,
appropriate tables of tooth size distributions in the population, and
a chart for plotting the patient's measurements. The teeth should
be measured with a tooth-measuring gauge or a finely pointed
Boley gauge. Table 11-3, A-D displays tooth-size data for North
American whites and blacks (see Chapter 6) in percentiles and the
charts shown in Fig 11-11 show the way the method reveals the
effects of tooth size discrepancies.
3. Relationships of Tooth Size to Size of Supporting
Structures
a) Howes' Analysis
" Howes3.4 devised a-formula for determining whether the ap-
icalbases could accommodate the' patient's teeth. The procedure
is as follows. Tooth material (TM) equals the sum of the mesio-
distal widths of the teeth from the first permanent molar forward.
Premolar diameter (PMD) is the arch width measured at the top
of the buccal cusps of the first premolars. Premolar diameter to
PMD
tooth material ratio (--) is obtained by dividing the premolar
TM
diameter by the sum of the widths of the 12 teeth. Premolar basal
arch width (PMBA W) is obtained by measuring, with the bowed
end of the Boley gauge, the diameter of the apical base on the
230 20
40
30
90
80
7010
17.7
MAX
M
MIN
10.0
10.6
52.9
52.1
51.2
9.6
9.3
10.4
10.9
11.2
11.1
55.2
54.1
10.5
10.3
50.7
11.4
56.3
48.5
18.3
18.0
17.6
17.2
34.4
34.3
33.6
32.3
19.2
18.9
35.7
37.4
19.8
30.8
10.1
6.86.9
5.4
5.45.5
9.39.4
7.1
6.8
6.6
6.0
7.0
6.9
5.7
7.5
5.3
9.9
33.2
32.9
31.2
35.1
34.1
11.3
11.0
8.7
5.1
29.9
.10.010.1
6.76.9
21.8
22.8
5.35.4
31.5
8.4
8.2
9.1
9.0
5.8
7.7
9.8
58.0
56.2
55.8
10.7
8.6
54.5
54.4
53.1
51.1
22.4
22.1
23.6
24.5
5.2
5.0
5.6
30.5
29.4
33.3
23.9
10.0
8.78.8
56.7
6.7
6.5
6.3
6.1
7.3
7.2
9.2
9.7
8.5
8.3
8.1
59.9
58.5
56.0
55.0
53.7
61.0
10.4
7.9
7.8
7.6
7.4
6.4
6.2
23.3
23.2
22.7
21.9
25.1
24.4
25.4
20.5
10.110.3
.10.8
9.5
36.2
9.4
8.8
53.5
50.4
49.6
48.7
31.3
18.6
17.3
19.0
17.0
42.3
5.9EDIAN
59.6
11.8
12.2
8.0
53.2
10.1
9.9
10.7
16.6 6109.0
8.9
53.6
11.0
20.7
7
918.4
34.6
18.6
35.2068.0
38.0107.0
11.0
6.6
12.1
7.1
5.2
6.4
6.0
7.0
7.3
5.5
33.4
.8
.2
.1
27.8
47.3
19.44.8
7.1
7.3
10.7
5.6
33.7
9.6
11.6
59.1
34.7
8.9
4.7
6.8
5.0
6.6
4.6
8.6
7.5
6.5
8.7
55.1
23.2
31.6
52.4
8 6.7
6.6
65.0
6.9
57.3
.5
5.6
3.74.6
7.8
7.1
27.8
6.9
5.5
5.7
6.7
23.6
.9
.4
11.1
7.7
15.7
21.1
56.0
10.9
7.9
9.5
51.4
17.9
39.4
6
32.6 .6
8.4
8.6
26.3
>:34.5
52.8
33.3,
37.4 107.0
55.7
8.8
7.6
10.3
9.1
23.3
5.5
32.3
7.0
9.0
57.8
6.9
7.2
8.1
6.8102.0
106.0
24.0
10.4
52.2
18.1
9.7N 61.0
58.0
59.0
64.0
83.0
67.0
55.0
80.0
69.0
. 33.634.0
108.0
86.0
62.0
87.0
65.0
63.0
53.0
97.00
37.0
38.0
95.0
89.0
98.0
74.0
79.0
97.0
42.0
47.0
35.3
2p.69,0
Diagnosis
PERCENTILES FOR TOOTH SIZE
Tooth Sizes Arrayed as Oeciles'
A, North American
TABLE 11-3. White Men
 MIN
20
40
30
70
MAX
90
M
8010
10.8
10.1
22.5
5.2
6.0
5.9
7.8
7.7
6.9
6.7
11.5
11.3
11.1
7.17.3
6.8
6.5
9.9
9.7
10.2
23.6
23.3
22.8
24.5
8.5
9.2
9.8
25.9
5.65.7
7.77.8
10.5
5.5
5.8
10.8
10.6
20.1
19.5
19.3
7.9
12.5
5.1
6.2
8.2
25.6
25.1
27.0
8.3
10.7
6.1
12.0
11.6
8.8
8.6
9.5
10.2
9.0
9.6EDIAN
10.9
9
21.2
1
12.8146.0
8
13.5
7
27.3
27.8
12.5
9.2
6.1
7.5
10.3
7.7
5.6
7.0
10.3
10.9
8.9
8.7
7.37.5
12.0
18.7
18.5
17.9
7.3
7.1
7.0
8.1
18.1
17.8
17.0
8.0
7.2
7.6
7.523.1
15.2
8.2
24.3
7.07.0
6.6
12.2
20.2
19.8
18.9
23.9
23.2
1004
804
904
504
604
7049.3
9.0
20.6
16.2
6.5
24.6
1804
604 TOOTH
6
6.7
11.1
18.6
7.1
24.0
11.6
.0
2.0303.0
.2
.7
.5
.1
4.3
8.8
9.9
6.5
4.7
11.8
5.8
7.6
19.0
7.5
5.3
24.3
9.5
11.3
7.2
7.8
10.6
9.1
.9
.3
5.9
10.7
9.2
6.0
6.1
5.7
9.6
19.5
8.3
7.9
7.1
25.2
5.5
19.1
21.3 6.2
24.8
1904
704
2504
8 04
704N088.0
498.0
344.0
432.0
529.0
351.0
260.0
114.0
158.0
323.0
125.0
171.0
104.0
1004
904 74.0
106.0
84.0
98.0
82.0
492.0
302.0
162.0
109.0
124.0 231 Analysis of the Dentition and Occlusion
11
JAnn
Phys
Ann Anthrop
Communicative
Arbor,
Arbor, 1979; Tables
Michigan. 5:665-677.)
Disorders
The andCStress.
data and
were (See Garn
0 courtesy
extracted SM, Osborne
of from
Professor S.M.RH, McCabe
the Collaborative
Garn, Center KO:
Perinatal
PERCENTILES
The
forFOR
Humaneffect
Project ofof the
Growth
TOOTH SIZE
prenatal
and factors
National
Development,on crown
Institute dimensions.
University
of Neurological Am
of Michigan,
and
, University of Michigan,

"

,.
 232 Diagnosis

A
HO
103
105
12
104
106
107
108
109
84.0
80.3
81.3
82.1
83.1
79.4
77.6
85.8
78.5
86.7
87.6
88.6
89.5
90.4
100
101
12
95.0
94.0
95.9
96.8
97.8
98.6
91.3
99.5
92.2
94
95
96
97
98
99
84.9
102
93.1
100.4 Over-all Ratio 638.2
42.1
41.7
41.3
40.9
42.5
39.0
37.4
35.5
38.6
37.8
37.1
34.4
34.0
33.6
33.2
31.3
648.0
49.5
49.0
48.5
46.0
6
40.5
40.1
39.854.0
53.0
55.0
54.5·
53.5
51.0
SO. 5
36.7
35.1
36.3
35.9
30.9
32.0
32.4
31.7
47.0
45.5
47.5
46.5
52.0
51.5
52.5
34.7
39.4
32.8
SO.O AnteriorMandibular
Maxillary Ratio
12_mm. -- Over-all S. D. (0") 1.91 = -- x 100 = Anterior '!o Mean
S. D. (,,)
77.21.65
= 0.22
12 43.5
43.0
45.0
40.5
42.5
41.5
42.0
41.0
44.5
44.0 6 Sum maxillary 6_mm. ratio Range 74.5 - 80.4
40.0 ratio .Range 87.5 - 94.8 If anterior
Sum mandibularratio 6_mm.
exceeds 77.2: Patient Analysis
Mandibu
12_mm. lar Maxi Ilary
x 100Mandibular • '!o Maxillary
Mean 91.3 = 0.26 Mandibular
=
Sum maxillary
=

Patient Analysis

If the over-all ratio exceeds 91.3 the discrepancy is in excessive

mandibular arch length. In above chart locate the patient's maxillary
12 measurement and opposite it is the correct mandibular measurement.
The difference between the actual and correct mandibular measurement
Actual mandibular 6 Correct mandibular 6 Excess mandibular 6
is the amount of excessive mandibular arch length.
If anterior ratio is less than 77.2:
Actual mandibular 12 Correct mandibular 12 Excess mandibular 12
Actual maxillary 6 Correct maxi Ilary 6 Excess maxillary 6
If over-all ratio is less than 91.3:

Actual maxi Ilary 12 Correct maxi Ilary 12 Excess maxillary 12

B Bolton Tooth Ratio Analysis

(Means are in percent units; standard
deviations are in parentheses)

Female
University
73.5
91.012.8)
73.4
90.6
77.2 (1.9) of Michigan
91.3(3.5)
(3.6)
(2.0)
(1.7)
Male teethSchool Sample Bolton Sample
Total
Anterior

FIG 11-10.
Bolton Analysis.'·2 A, the Bolton Analysis of tooth size discrepancies. (University of Michigan Growth Study) for comparison with the Bolton
The sizes of the individual teeth are measured and recorded on the values. The differences noted are those between a normal standard

form. The anterior ratio and the overall ratio are computed separately. and a contrived ideal. The sexual differences noted are sometimes

B, the figures in the Bolton Analysis are based on selected samples important in setting treatment goalS for overbite and overjet.
of ideal cases. The ratios shown here are from a normative sample

A Small AveroQe
~ I
Min 10 20
, ,
30 40 50 60 70 80 90 Molt
, ~
.
-
1- ~ I
~
Inc. 1
0
~
.. ,
InC.2
c.•. 2
;)m.t
-
I
;:lm.2
"
<l:
C.
Pm.2
Inc.2
M.2
M. I
FIG 11-11.
Sanin-Savara analysis. A, blank form. 8, an illustrative case. Note
the relative. smallness of the maxillary lateral incisor and the man-
dental casts at the apices of the first premolars. The ratio of the
. PMBAW
premolar basal arch width to tooth material (----) is obtained
TM
by dividing the premolar basal arch width by the sum of the width
of the 12 teeth. Basal arch length (BAL) is measured at the midline
(Fig 11-12) from the estimated anterior limits of the apical base
to a perpendicular that is tangent to the distal surfaces of the two
first molars. The ratio of basal arch length to tooth material
BAL
(--)
TM ' is obtained by dividing the arch length by the sum of the
widths of the 12 teeth. Figure 11-12,B shows the mean values
and the range of values found for both arches from a study of
normal occlusion. Howes3.4 believed that the premolar basal arch
width (he called it the canine fossa diameter) should equal ap-
proximately 44% of the mesiodistal widths of the 12 teeth in the
maxilla if it is to be sufficiently large to accommodate all the teeth.
When the ratio between basal arch width and tooth material is less
than 37%, Howes considered this to be a basal arch deficiency
necessitating extraction of premolars. If the premolar basal width
is greater than the premolar coronal arch width, expansion of the
premolars may be undertaken safely.
Since this method was introduced, rapid palatal expansion
has come into more common use (see Chapter 15), and clinicians
have much more opportunity to alter the apical base itself than
once was thought. Nevertheless, Howes' analysis is useful in plan-
ning treatment of problems with suspected apical base deficiencies
and deciding whether to (I) extract teeth, (2) widen the dental
arch, or (3) expand rapidly the galate. Mandibular apical base
restrictions are more critical than maxillary. In the author's opin-
ion, the Howes' analysis is more logical and superior to the Pont's
IndexlO (see below) because the Howes' analysis is applicable to
eacQ.arch and has been represented as an aid to thoughtful diagnosis
and planning while the Pont's Index is often used as a rigid rule
and an illogical excuse for not extracting.
b) Pont's Index
In 1909, Pont 10 devised a method of predetermining an "ideal"
arch width based on the mesiodistal widths of the crowns of the
Analysis of the Dentition and Occlusion 233
Large
~
8
<0
Small Average Large
r-"--, I r-"--,
Min IQ 20 30 40 50 60 70 80 90 Mall.
~
.
InC.t
~
••
"~
~
~
~
Pm.1
dibular second premolar (see Chapter 6, section E.2.).
maxillary incisors. Pont suggested that the ratio of combined in-
cisor to transverse arch width (as measured from the center of the
occlusal surface of the teeth) was ideally 0.8 in the bicuspid area
and 0.64 in the first molar area. He also suggested that the max-
illary arch be expanded 1 to 2 mm more during treatment than his
ideal to allow for relapse. In recent years there has been an un-
fortunate revival of the use of the Pont's Index in a most sloppy
and indiscriminate manner; some practitioners depend on it almost
entirely for determining the "proper" arch width. Used alone in
such an unsophisticated way, it is useless; at best, it is only a very
crude guide.
Researchers at The University of Washington applied the
Pont's Index to patients who had undergone complete orthodontic
treatment and were out of retention for at least 10 years7 No
permanent teeth had been extracted in any of the patients. They
found very poor correlations between the combined maxillary in-
cisor widths and the ultimate arch width in the bicuspid and molar
areas, and concluded that measuring the mesiodistal widths of
incisors to predetermine maxillary bimolar and interbicuspid widths
is of no value. Mandibular arch form and mandibular intercanine
diameter have been repeatedly found to be more reasonable treat-
ment guides for both mandibular and maxillary ultimate arch widths
than the Pont's Index. The Pont's Index is naive in concept and,
in my opinion, of little use in rational treatment planning.
c) Diagnostic Setup
It is useful in difficult space management problems to ascer-
tain,;. before orthodontic'tleatment is begun, precisely the amount
and direction each tooth must be moved. Useful as the Mixed
Dentition Analysis is (see Section C-4), it is at best a mathematical
representation of the problem during the mixed dentition. A pop-
ular practical technique for visualizing space problems in three
dimensions in the permanent dentition is that of cutting off the
teeth from a set of casts and resetting them in more desirable
positions (Fig 11-13). This procedure is called a diagnostic or
prognastic setup. The record casts are not used for this technique,
since they must be saved for comparison with the diagnostic setup
and with progressive record casts.
234 Diagnosis

B Relationship of Tooth
Material to Supporting Bone
98 85
Material (TM)
_ Tooth 8~_(.84r:l\ 78.5
Diameter (PMD)

Premolar .... ~7..~..\.~31:9

PT': .% 43.'.,.39.5 .

..... 4~./ 4r ..405.. p;::o~

::::;::."" ~3.5.. r 3.7.5

51.514r455 P';":W.% 51.5.4r4'5

..... 3.6;5..I.3~1<l· .. ?~..5 Le~~~~I(~~t) :3<7:5.. ~11:4\.~~ .

.. 39'5l'"Jg5 .. ":'~'% 3~We55 ..

FIG 11-12.
A, Howes' analysis measurements. 8, see text for details of use.

Steps in the technique are as follows:
a) Obtain an accurate wax bite (see Section F). Trim the
posterior portion of the bases of the casts with the wax bite in-
terposed so the bases are flush (see Fig ll-13,A).
b) Drill a hole through the alveolar portion of the cast well
below the gingival margin of the teeth.
e) Insert a fine saw blade through the hole and cut up to the
crest of the gingival margin between two of the teeth. Cut along
the line of the arch, well beneath the gingival margin of the teeth,
and come up again at the point of the gingival crest below the
contact point on the opposite side of the tooth. Repeat this for all
the teeth to be cut off the cast. Do not cut through the contact
points. Cutting up to the gingival crest will permit gentle breaking
of the plaster without damage.

FIG 11-13.
The diagnostic setup. A, before, and 8, after the teeth have been cut off and set in a corrected
d) Align the teeth and wax them into the desired positions
(see Fig ll-13,B). It is best not to cut off all of the teeth so that
the bite relationship can be kept. One may combine the cepha-
lometric analysis and prediction of incisal positioning and angu-
lation with the prognastic setup as a means of visualizing incisor-
profile relations and as an aid in the selection of teeth for extraction.
A more accurate method involves taking a wax bite in the
retruded contact position, mounting the casts on an adjustable
articulator, and finishing the diagnostic setup within the limits of
the jaw relationships thus imposed (see Section F).
When extractions are contemplated as part of the orthodontic
treatment, the diagnostic setup will demonstrate vividly the amount
of space created by the extractions and the tooth movements nec-
essary to close the space. It will also aid in choosing which teeth
to extract.
4. Relationships of Tooth Size and Available Space During
the Mixed Dentition (Mixed Dentition Analysis)
The purpose of a Mixed Dentition Analysis is to evaluate the
amount of space available in the arch for succeeding permanent
teeth and necessary occlusal adjustments. To complete an analysis
of the mixed dentition, three factors must be noted: (1) the sizes
of all the permanent teeth anterior to the first permanent molar;
(2) the arch perimeter; and (3) expected changes in the arch pe-
rimeter which may occur with growth and development (see Chap-
ter 6). The Mixed Dentition Analysis helps one estimate the amount
of spacing or crowding which would exist for the patient if all the
primary teeth were replaced by theIr successors the very day the
analysis is done, not 2 or 3 years later. It does not predict the
amount of natural decrease in perimeter which may occur during
the transitional period without the loss of teeth.
Many methods of Mixed Dentition Analysis have been sug-
gested; however, all fall into two strategic categories: (1) those in
which the sizes of the unerupted cuspids and premolars are esti-
mated from measurements of the radiographic image, and (2) those
in which the sizes of the cuspids and premolars are derived from
knowledge of the sizes of permanent teeth already erupted in the
Analysis of the Dentition and Occlusion 235
position.
mouth. The method presented here is of the latter type and is
advocated for the following reasons: (1) it has minimal systematic
error and the range of such errors is. known; (2) it can be done
with equal reliability by the beginner and the expert, as it does
not presume sophisticated clinical judgment; (3) it is not time-
consuming; (4) it requires no special equipment or radiographic
projections; (5) although best done on dental casts, it can be done
with reasonable accuracy in the mouth; and (6) it may be used for
both dental arches.
The genetic fields within which permanent tooth size is con-
trolled extend to involve a number of teeth (see Chapter 6); there-
fore, people with large teeth in one part of the mouth tend to have
large teeth elsewhere. A number of researchers have studied the
correlative relationships between groups of teeth in the permanent
dentition, no one more exhaustively than Garn (see Chapter 6).
Very high correlations exist between left-right groups of teeth in
the same arch and there is a decreasing correlation gradient, gen-
erally from front to back within an arch. Important as these findings
are to our understanding of the genetics of tooth development (see
Chapter 6) few are of practical use in treatment planning or pre-
diction; exceptions to this statement are the left-right relationships
and the correlation between the sizes of the mandibular incisors
and the combined sizes of the cusp}ds and bicuspids in either arch,
which is high enough to predict the amount of space required for
the unerupted teeth during space manageme,nt procedures.
Mixed Dentition Analyses have been misused in several ways.
First, they have been applied mechanically without proper regard
for)~e biologic dynamics~of a critical stage in dentitional devel-
opme·nt (see Chapter 6). Second"naive assumptions have been
made (e.g., a universal 1.7-mm late mesial shift). Third, many
have presumed them to have an accuracy that is not present in any
of the methods yet developed. None of the Mixed Dentition Anal-
yses are as precise as one might like, and all must be used with
judgment and knowledge of development. See Suggested Readings
for articles on errors in these methods and comparisons of different
Mixed Dentition Analyses.
The mandibular incisors have been chosen for measuring,
since they are erupted into the mouth early in the mixed dentition,
 236 Diagnosis

FIG 11-14.
A tooth-measuring gauge.

are easily measured accurately, and are directly in the midst of
most space management problems. The maxillary incisors are not
used in any of the predictive procedures, since they show too mu<;h
variability in size, and their correlations with other groups of teeth
are,of lower predictive value. Therefore, the lower incisors are
measured to predict the size of upper as well as lower posterior
teeth.
a) Procedure in the Mandibular Arch
I. Measure with the tooth-measuring gauge (Fig 11-14) or
a pointed Boley gauge, the greatest mesiodistal width of each of
the four mandibular incisors. Record these values on the Mixed
Dentition Analysis form (Fig 11-15).
2. Determine the amount of space needed for alignment of
the incisors. Set the Boley gauge to a value equal to the sum of
the widths of the left central incisor and left lateral incisor. Place
one point of the gauge at the midline of the alveolar crest between
TOTAL SPACE AVAILABLE
Maxilla: Mandible:
Right
the central incisors and let the other point lie along the line of the
dental arch on the left side (Fig 11-16). Mark on the tooth or the
cast the precise point where the distal surface of the lateral incisor
will be when it has been aligned. Repeat this process for the right
side of the arch. If the cephalometric evaluation shows the man-
dibular incisor to be too far labially (see Chapter 12), the Boley
gauge tip is placed at the midline, but moved lingually a sufficient
amount to simulate the expected uprighting of the incisors as dic-
tated by the cephalometric evaluation.
3. Compute the amount of space available after incisor align-
ment. To do this, measure the distance from the point marked in
the line of the arch (step 2, above) to the mesial surface of the
first permanent molar (see Fig 11-16). This distance is the space
available for the cuspid and two bicuspids and for any necessary
molar adjustment after the incisors have been aligned. Record the
data for both sides on the Mixed Dentition Analysis form (see Fig
11-15).
4. Predict the size of the combined widths of the mandibular
cuspid and biscuspids.
Left
Long method.-Experienced clinicians may choose to use the
50% prediction since it is a more precise estimate. Those who are
inexperienced or without the use of cephalometrics and a precision

fj ~
e~h
Right

Arch Segments
Lengths
Left Vd b c
Arch Segments
Lengths
appliance method would do well to proceed more conservatively
(i.e., use the 75% level of prediction).
Prediction of the combined widths of cuspid, first bicuspid,
and second bicuspid is done by use of probability charts (Table
e: mm
mm
mm a: mm
11-4). Locate in the left column of the mandibular chart the value
t:
h: b: mm
g:
Total:
c: mm
that most nearly corresponds to the sum of the widths of the four
d: mm
mandibular incisors. To the right is a row of figures indicating the
Total: _
range of values for all the cuspid and bicuspids sizes that will be
TOTAL SPACE REQUIRED found for incisors of the indicated size. For example, note that for
mall incisors of 22.0 mm combined width the summated mandib-
- mm.
,
mm.1 mm.1
mm.+ MAXILLA mm.1
MANDIBLE ular cuspid and bicuspid widths range from 22.6 mm at the 95%
e Class I occlusion
of molars
(measured)
and
(predicted) (estimated)
bicuspids level of confidence to 18.7 mm at the 5% level. This means that
of all the people in the universe"whose lower incisors measure
22.0 film, 95% will have cuspid and bicuspid widths totaling 22.6
mm or less. No one figure can represent the precise cuspid-bicuspid
surp for all people, since. th.ere is a range of-posterior tooth widths
seen"even when the incisors are ipentical. The value at the 75%
level is chosen as the estimate, since it has been found to be the
most practical from a clinical standpoint. In this instance, it is
21 .4 mm, which means that three times out of four the cuspid and
bicuspids will total 21.4 mm or less. Note also that only five times
right left
in a hundred will these teeth be more than I mm greater than the
Estimated possibilities of maxilla: mm mm
mandible mm.
estimate chosen (21 .4 mm). Theoretically, one should use the 50%
increasing space available mml
level of probability, since any errors would then distribute equally
FIG 11-15. both ways; clinically, however, we need more protection on the
Mixed Dentition Analysis form. down side (crowding) than we do on the up side (spacing).
 20.0
24.0
23.5
23.0
22.5
22.0
21.0
20.5
25.5
25.0
24.5
21.5
17.8
18.8
18.6
19.2
20.1
21.3
22.2
22.0
21.1
21.7
21.4
22.1
21.8
22.5
21.6
23.0
23.1
22.8
22.6
22.4
23.7
23.5
22.7
23.2
24.2
24.1
20.3
20.8
18.5
19.5
19.3
20.1
20.5
20.3
21.2
21.0
18.9
18.7
19.4
21.5
19.9
20.7
23.3
23.9
22.9
18.2
21.4
20.1
18.7
19.6
18.9
22.1
16.7
18.3
19.7
18.5
17.5
18.1
18.4
2.9
17.4
17.9
20.0
19.1
20.2
20.9
21.9
22.3
20.4
23.6
23.4
20.0
20.4
20.6
21.6
21.2
19.7
17.5
20.0
19.8
19.6
19.3
18.2
18.0
17.7
20.2
19.119.5-20.2
19.0
20.8
19.5
17.2
17.0
18.8
19.2
18.2
20.6
19.0
18.8
17.8 230.1
20.2
20.4 20.67
128.9
19.7 21.1
19.1
19.3 20.9 237
19.4-
2.~.3 :.19.6 Analysis of the Dentition and Occlusion
obtain
wish
for
75%
distribute
95thethehorizontal
to
predictive
the
prediction
choose.
normally
valuesrow
values
Ordinarily
of
forof
toward
both
expected
the
thus
the
appropriate
Icrowding
protects
use
mandibular
width
the 75%
the
of
and
male
the
clinician
and
of
spacing,
or
cuspids
probability
female
maxillary
oncrowding
and
the
table.
rather
cuspid
premolars
MALES
safe
Reading
isthan
side.
and
a much
corresponding
the
bicuspid
Note
downward
mean
more
thatwidths.
of
the
serious
in50%
the
mandibular
to the
appropriate
since
clinical
level
although
incisors
of
problem
probability
vertical
the
are
and
values
column
used
you
the
Probability
anent mandibular incisors and find that value in Tables for Predicting the Sizes of Unerupted Cuspids and Bicuspids'
A, Mandibular Bicuspids and Cuspids
238 Diagnosis
Method for Localization of
Space Needs In the Mixed Dentition
FIG 11-16.
Mixed Dentition Analysis measurements. A, method for localizing
space needs. e, marking the distance in the line of arch that is needed
for the alignment of central and lateral incisors. This distance shows
how much of the arch perimeter will be taken up during alignment
of the mandibular incisors. It is repeated for both sides. C, measuring
the space left in the arch after incisor alignment. After it has been
ascertained how much space is needed for the incisors, it·is nec-
essary to measure the space left for cuspids and premolars and
molar adjustment.
Short method.-A shorter, but less precise method has been
developed which is of merit,13 but does not allow for sexual
dimorphisms with equal accuracy.
a) Add the widths of the mandibular incisors and divide by
two.
b) To the value obtained add 10.5 mm to predict the combined
widths of the mandibular cuspid and bicuspids and 11.0 mm to
predict the combined widths of the maxillary cuspid and bicuspids.
Whether using the long or short method, record the estimated
values for the combined cuspid and bicuspid widths in the Mixed
Dentition Analysis form for both sides and each arch (see Fig Il-
lS).
5. Compute the amount of space left in the arch for molar
adjustment by subtracting the estimated cuspid and bicuspid size
from the measured space availablt; i~ the arch after alignment of
the incisors. Record these values for each side.
From all the values now recorded, a complete assessment of
. the space situation in the mandible is possible.
b) Procedure in the Maxillary Arch
The procedure is similar to that for the lower arch, with two
exceptions: (J) a different probability chart is used for predicting
the upper cuspid and bicuspid sum (see Table 11-4) and (2)
allowance must be made for overjet correction when measuring
the space to be occupied by the aligned incisors. Remember that
the width of the lower incisors are used to predict upper cuspid
and bicuspid widths.
Figure 11-17 illustrates an application of the Mixed Dentition
Analysis to a specific problem. note that the localization of any
space shortages helps greatly in selection of the space-management
appliance. Discussion of the treatment of space problems is found
in Chapter 15.
It is good practice to study the radiographs when the Mixed
Dentition Analysis is done in order to note absence of permanent
teeth, unusual malpositions of development, or abnormalities of
crown form. For example, mandibular second bicuspids sometimes
have two lingual cusps. When they are s~ formed, the crown is
larger than might be expected from the probability chart; therefore,
a higher predictive value is used. One may, of course, measure
the ,size of the crowns of the unerupted cuspid and premolars in
periapical radiographs for supplemental information or corroboration
of the Mixed Dentition Analysis estimate.
c) Modifications
A technique for Mixed Dentition Analysis that compensates
nicely for radiographic enlargement of tooth images in periapical
films is available6 It is based on the assumption that the degree
of magnification for a primary tooth will be the same as that for
its underlying permanent successor on the same film. (I,) Measure
the width of the primary tooth on the x-ray film (Y') and the width
 Analysis of the Dentition and Occlusion 239

B
TOTAL SPACE AVAILABLE
Mandible:

Right Left

Arch Segments Arch Segments FIG 11-17.

Lengths Lengths
mm Illustrative case to show the application of the Mixed Dentition Anal-
L ,.3 mm Iq,S
IjJ: [ mm
mm
.,
f,
':'i' 0 mm (,.7 mm ysis. A, the patient's casts. S, completed mixed dentition analysis
h9' J.:: I· 'l1
'1 mm ~J., er mm
measurements, predictions for probability tables, and estimations
·£;.7· 'f Total. n.T_ from study of casts (molar and overjet correction) are entered into
TOTA{ SPACE REQUIRED ;'1. 'I the form. T!1e total arch perimeter needed is entered above MAXILLA
~1l.S and MANDIBLE. In this instance distal movement of the maxillary
~/.
;'/.$
S'
~:J'7 ~:'I.LL
MAXILLA molars could provide sufficient space to correct the molar relationship
~ MANDIBLE ~~._ ~
:.JLL:L- and the overjet and overbite (67.4 mm vs 71.5). In the mandible,
-I( ./ :11.5 mm. ~mm. however, a more serious problem obtains (55.7 mm vs 64.5-64.5
= 21.7 + 21.4 + 21.4) and there is little chance to gain the estimated
width of cuspids
needed 6.8 mm by increasing the perimeter, even when the molar
and bicuspids
(predicted) "/.5' mm. :/,1.{ mm. correction is obtained by maxillary tooth movements alone.

needed to achieve "

Class I occlusion ,.
of molars (estimated) + :J. S I mm. ~mm.

right left
Estimated possibilities of maxilla: ) J. S mm.:L..l:~ mm
increasing space available mandible ----0..Q mm 0.0 mm
240 Diagnosis

of its underlying permanent successor (X') on the x-ray film. (2)
Measure the primary tooth (Y) directly in the mouth or on the
dental cast. The width of the unerupted permanent tooth (X) can
then be calculated by simple mathematical proportion: X:X'
X'Y
Y'Y' or w= -
~·Y'·
For example, if the image of the second primary molar on
the x-ray film (Y') is 1O.S mm, the image of the underlying second
premolar (X') is 7.4 mm, and the width of the second primary
molar as measured on the cast (Y) is 10.0 mm, then X =
7.4 x 10
--IO-.-S- or X = 7.0 mm. This procedure is particularly u~eful
when planning treatment for space supervision problems (see
Chapter IS) in which every fraction of a millimeter must be
accounted for. Inaccuracy in radiographic tooth size measurements
is not the dentist's fault. It occurs because the developing teeth
are not always placed exactly at right angles to the central ray;
therefore, the radiographic image of the tooth, when slightly rotated
or tipped, is significantly larger than the actual size of the tooth.
The tables used herein are based on size variations and re-
lationships in teeth of North American whites and mayor may not
be valid for other ethnic groups.
d) Problems
A problem arises when considering the space left for molar
adjustment. If this value in the chart is negative, that is, the pre-.
dicted sizes of 3, 4, and S are greater than the space left after the
alignment of the incisors, then crowding will occur in the arch
even without any forward molar adjustment. When the first per-
manent molars are in an end-to-end relationship (i.e., a flush
Class I relationship (see Fig II-IS). The treatment plan is then
devised to accomplish the precise amount of correction needed in
each arch.
Perhaps the most severe limitation of Mixed Dentition Anal-
yses is their inability to reflect the position of the incisors with
respect to the skeletal profile. There are a number of crude rules
of thumb for determining how much arch perimeter reduction
occurs for each degree or millimeter the incisor edge is changed
in the cephalometric visualization of treatment. For example, one
degree of tipping or I mm of lingual displacement of the man-
dibular incisal edge is said to be equal to I mm of arch shortening
on each side. Useful as such estimates are the simple truth remains:
We must use some clinical judgment to fit the Mixed Dentition
Analysis into the facial skeleton both at the profile and over the
apical bases.
A problem is imposed when the occlusal curve is assumed to
be a flat plane. Mixed Dentition Analyses assume, by projection
to a flat plane, no vertical occlusal curve. Often in the mixed
dentition there is indeed a flat occlusal plane, but many times the
Curve of Spee is exagerrated or complicated. Enhanced and elab-
orated occlusal curves are, unfortunately, seen frequently with
some of the most severe malocclusions. The arch perimeter is
usually longer than it is measured when the Curve of Spee is
exaggerated or shows complicated vertical curves. As a result the
clinician may assume there is sufficient space for all the teeth until
the arch is made level during treatment. Then it becomes obvious
that the Mixed Dentition Analysis is a two-dimensional visualiz-
ation of a complex three-dimensional problem.
D. ARCH DIMENSIONS

,
terminal plane of the second primary molars), approximately 3.S
mm of space (one-half a cusp width) is required to convert to a 1. Changes in Arch Dimensions
Class I molar relationship. This needed 3.S mm might be acquired,
A discussion of the expected changes in arch dimensions
without orthodontic intervention, in any of three ways: (1) 3.S mm
during growth and development and methods of measuring arch
more late mesial shift of the mandibular first permanent molar
than the maxillary; (2) at least 3.S mm more forward growth of
the mandible than the maxilla; or (3) some combination of dental
~SIO I')
'J >
0--
+++0--
?+
,.Growth
Growth
10
-TxTxTransitional
0??++
0Growth
?0
Tx 0+Primary
0Skeletal
No Growth
Permanent Plus
Skeleta I Growth
adjustment and differential skeletal
Ol.?;, 'J/I/ growth. Since we cannot yet Width
• (El

Growth
Perimeter
p'erimeter
Maxilla Width
Mandible
predict accurately the amount of differential skeletal growth that
will occur, treatment planning must be based on dental adjustment
factors. If differential skeletal growth occurs during this period,
alterations in the molar relationship will result and the Mixed
Dentition Analysis predictions must be altered accordingly. When
there is a Class I molar relationship in the mixed dentition (mesial
step of the second primary molars), no part of the arch perimeter
need be preempted for molar adjustment and all the space can be
made available for incisors, cuspids, and bicuspids.
It has become the fashion in-many Mixed Dentition Analysis
procedures to assume that every child will require precisely 1.7
o Some + Mild increase occurs or con be obtained
mm of late mesial shift. Such fallacious reasoning is unfortunate, -- Decreases greatly ++ Significant increase occurs or con be obtained
since it leads to errors in treatment planning. One cannot assume ? Some change possible in particular instances
average mesial shift or leeway space values any more than one
can assume average tooth sizes. As was stated earlier, though some FIG 11-18.
children will require no mesial shift of the first permanent molars Expected arch dimensional changes.
(Class I molar relationship), the greatest number of children will
require approximately 3.S mm late mesial shift or differential skel-
etal growth (end-to-end molar relationship). It is best to quantify
the amount of mesial shift necessary to bring the molars into a
 Analysis of the Dentition and Occlusion 241

FIG 11-19.
Method of using dividers to measure from the median raphe to estimate asymmetries of the dental arches.

dimensions is found in Chapter 6. Clinically, the problem of arch
dimensions is how to analyze what space is needed and which
dimensions can be increased therapeutically to acquire the needed
space. Figure 11-18 summarizes in a simplistic way dimensional
changes in the primary and mixed dentitions that occur during
growth and those that might be induced with treatment. What
nature does and what we are able to do clinically often are different;
for example, the mandibular arch perimeter, one of the most critical
of all dimensions, usually decreases markedly at the time of ex-
foliation of the primary teeth and is not easily increased signifi-
cantly by simple therapy in the mixed dentition. Since maxillary
dimensions can be altered much more easily by treatment, it is
natural for Mixed Dentition Analyses to emphasize mandibular
measurements. Experienced clinicians are able, in some instances,
to produce changes in the mandibular arch perimeter which one
could never predict from the Mixed Dentition Analysis alone. They
can do so because they can discern those cases in which the pos-
sibility for incisal or molar repositioning is present and they have
the skill and the use of an appliance which makes possible the
improvement (see Chapter 15). Figure 11-18 is a conservative
guide for use in passive space-management treatment.
E. PREDICTION OF FUTURE OCCLUSAL
RELA TIONSHIPS
It has been known for some time that predictions of future
skeletal relationships are not good predictors of the eventual oc-
clusal relationships. Studies have also shown that the traditional
ways of noting the occlusion in the primary and early mixed den-
tition provide few good clues for the permanent dentition. In Chap-
ter 6 it was noted that while an end-to-end molar relationship (flush
terminal plane) was "normal" at the start of the mixed dentition,
it offers no proof that either ideal or "normal" development will
obtain as the permanent dentition is completed. Moyers and
Wainright8 have demonstrated at least five different patterns of
occlusal development during the mixed dentition (see Chapter 6).
Of these five, three are of particular importance when predicting
future occlusal relationships in the early mixed dentition since these

2. Asymmetries of Arch Dimension and Tooth Position

Figure 11-19 shows a simple method by which to estimate
asymmetries of tooth position in the arch. Figure 11-20 illustrates
the use of a symmetrograph to determine asymmetry within the
max.illary arch. The symmetrograph, a transparent plastic device
with an inscribed grid, may be purchased or made. Place the
maxillary cast on its base and carefully mark the median raphe
with a series of tiny dots. The medilin raphe is a proper represen-
tation of the skeletal midline. Orient the symmetrograph so that
its midline is directly superimposed over the median raphe and
parallel to the occlusal surface. Total and partial arch asymmetry
are quickly visualized and localized, as are drifting, tipping, and
rotations of individual teeth. This simple step is most useful in
planning individual tooth movements and determining appliance
design. A similar analysis of the mandibular dentition is likely to
be less precise, since mandibular landmarks are not as reliable as FIG 11-20.
the median raphe. Use of a symmetrograph to determine asymmetry in the dental arch.
"
A
,
242

'"
"
",
Diagnosis
I

~',,,
,&) ~~1&f'"~~~
~ Wj~~)
~'''' '" ~
C B

"9&
"
D

"
'"
I; (

;
C

,8& ~ &
~~
(11121

,~~f"
,"',

8~']&~
"'B
,',

'~8~,,,
I

'"

FIG 11-21,
Variations in occlusal relationship with each molar relationship in the
"
mixed dentition. A, mesial step. e, flush terminal plane. C, distal
step. D, Class III (super mesial step).

three start the same (end-to-end) but finish quite differently. Be-
cause normality is seen at one age is no proof it will continue.
Many children display an end-to-end relationship in the early
mixed dentition and later develop a Class I molar relationship of
the permanent dentition. This favorable change is most apt to occur
in children who show the following characteristics:"
a) Skeletal Morphology
The cranial base is shorter than normal.
The mandibular plane angle is less than normal.
The occlusal plane is flatter than normal.
The maxillary length is slightly shorter than normal.
b) Skeletal Growth Changes
The occlusal plane flatness is maintained.
The mandibular plane maintains its flatness.
Mandibular length increases are greater than normal.
c) Dental Features
Maxillary mesial drift is much less than normal.
Maxillary first molars are more distally placed than normal.
The dental arches are wider than normal.
The mandibular first molar is more mesially placed prior to
the loss of the primary molars.
Some children begin with a normal end-to-end molar rela-
tionship and steadily worsen into Class II; we call these "retru-
sives." They show the following characteristics:
,.
a) Skeletal Morphology
Occlusal and mandibular planes are steeper than normal.
The midface and anterior cranial base are longer than
normal,
The posterior maxillary height is greater.
b) Skeletal Growth Changes
Maxillary length increases are greater than normal.
Anterior face height increases are greater than normal.
Children who maintain their end-to-end molar relationship
through time have been difficult to characterize and identify early
except by eliminating the possibility of classifying them as "re-
trusives" or the more favorable "protrusives." It is most important
to note that the amounts of leeway space available in no way
discriminates which group a child is apt to join during development.
Figures 11-21 and 11-22 are designed to help the clinician
estimate what sort of occlusion may result when various combi-
nations of occlusal, arch space, muscular, and skeletal features
are seen. Note that this is an aid for use only in the early mixed
dentition and is not a substitute for serial observations of change.
Deleterious changes should be heeded, particularly when they in-
dicate a "retrusive" Class II occlusal type or a hitherto unsuspected
Class III malocclusion. To use Figure 11-22 begin by noting the
present occlusal features and assign a tentative occlusal pattern.
The columns headed "Leeway Space Difference" and "Lips"
itemize aggravating factors which may alter the occlusal change
pattern. The columns headed "Skeleton" are those cephalometric
measures which are known to influence the occlusal change pattern
the most. Pay particular attention to those noted (--) for they in
combination dominate. There is no magic formula, no substitute
for careful, clinical notation and judgment. It is, however, reas-
suring to know that careful study and analysis provide a practical
clinical payoff. I cannot emphasize too much the need for early
study of the cephalogram.
"
F.'REGISTRATION OF JAW
RELATIONSHIPS
The primary purpose of registering jaw relationships for or-
thodontic analysis is to determine any clinically significant dif-
ferences in these three jaw positions: the intercuspal position, the
ideal occlusal position, and the retruded contact position. It is
important to ask at the start which jaw position is to be registered
and for what purpose. The ideal occlusal position and the retruded
contact position are used for different purposes and should not be
 Analysis of the Dentition and Occlusion 243

- --
-ill ---
--
---
---
i--Ill-I?-I~~
-- -x+ -----
-- ---
-I I-I??- ?-?-----
-?+I7EE. -IMax.~
I ??I ill.,.,
?+
-Plane -
Cl.
.~ -0
'§ .~ 1*
::!; o-
LL-
(5
g~S
~I::l K-0.,
., <n CIT
x+
x7IT?
Flat 7+
Leeway
17+
x7IT?
xn?
+
0c'
ill7IT
nIT
n*
17
IT?
ill?
Steep
I?
Mand>
?x
nm*
Steep
EE
+Flat
IMand.
IT
IT nII
IJSPids
+7? 77tsors
Excessive
Difference
IT
E.E.
IT3mm
?7Mandibular
7? ??77x+
Space +Occlusal
Heiaht
Post.
m* 1*m*>1*
nIIT*
n* -
I Face
n* Lips +
A-B reI.
CraniofacialPlaneSkeleton

+ Favorable Factor; ? Questionable Factor; - Unfavorable Factor; - - More Unfavorable Factor;

o No Likely Effect; x Unlikely Observation

FIG 11-22.
Summary chart to aid in the prediction of expected occlusal changes. sible effects of various other factors; leeway space, lips, skeletal
Locate the present molar relationship in the extreme left column then relationship, etc., on the anticipated changes in the original occlusal
find the patient's cuspid and incisal relationship (see Fig 11-21). relationship.
Now reading across in the appropriate selected row ponder the pos-

confused (see Chapter 5). Neither the ideal occlusal position nor contact position (centric reJationship) can and do occur frequently
the retruded contact position is necessarily synonymous with the during and after orthodontic therapy-a point often confusing to
patient's intercuspal position. dentists working primarily with adult patients. Since most patients
Many dentists who are particular about registration of jaw are reflexly prehensile when biting, I
prefer the wax bite method
relationships on casts are rather casual about the cephalometric illustrated in Figure 11-23 to the usual method for it minimizes
occlusal orientation. One should know which jaw relationship was sensory input from the incisors. Since no wax touches the incisors,
obtained when the cephalogram was exposed. This is especially the· tendency of most people to bite protrusively is diminished.
important for mal occlusions in which there is a strong functional The use of a solid sheet of wax is definitely contraindicated, since
element, patients with a temporomandibular disturbance, and young the tongue is displaced, and accurate recording of the retruded
children whose temporomandibular joints are not fully matured. contact position becomes much more difficult.
For such cases it is advised to have a wax bite in place in the
mouth when the x-ray exposure is made and to note on the film
2. Ideal Occlusal Position
which jaw registration was used.
The ideal occlusal pOSItIOn is a pOSItIOn of muscle bal-
1. Retruded Contact Position ance-on the undeviated path of reflex jaw closure and the position
of the jaws during the ,unconscious swallow. Unfortunately, it is
Every dentist has a favorite technique for recording retruded rather awkward to say to the pat(ent, "Won't you please swallow
contact position (centric relation, terminal axis, etc.). It is used in I
unconsciously in order that may record your jaw relationship?"
restorative and prosthetic dentistry when it is necessary to mount The ideal occlusal position cannot be recorded as reliably as the
casts reliably on an articulator. It is used in restorative dentistry, retruded occlusal position; hence, it does not have practical use
periodontics, and orthodontics as a starting position for occlusal for precise restorative and prosthetic construction techniques. The
equilibration (see Chapter 18). It is not so precisely useful in ideal occlusal position is not dependent on teeth as is the intercuspal
children with malocclusion, since mobility or the immaturity of (usual occlusal) position, nor is it a bony relationship as is the
their temporomandibular joint structures often permits a more pos- retruded contact position; rather, it is ajaw relationship determined
terior retruded contact position than will be noted when the patient by a primitive reflex (Chapter 5). When there is a Class II mal-
is older or the malocclusion corrected. Changes in the retruded occlusion or a functional crossbite, the retruded contact position
244 Diagnosis
FIG 11-23.
Procedure for registering the ideal occlusal relationship in the primary
or mixed dentition. A, the original eccentric relationship. e, bite reg-
istration wax is rolle.d to form a scroll and adapted to the maxillary
cast in the midpalatal region. C, the fit in the maxillary arch. Note
the vertical size of the occlusal wax pads. Ordinarily, the wax bite
willstay in position by itself, but sometimes it is necessary to reinforce
may be of less clinical usefulness than the ideal occlusal position.
The ideal occlusal position is used for equilibration procedures in
the primary and mixed dentitions (see Chapter 18). It also is used
for diagnosis of all functional malocclusions.
3. Steps in Procedure
A length of beeswax or special jaw registration wax, 1 cm
wide and approximately 13 to 15 cm in length, is rolled from each
end a~d adapted across the palate and occlusal surfaces of the
posterior teeth on the maxillary cast (Fig 11-23,8). The rolled
portion of the wax becomes an occlusal pad into which the man-
dibular teeth will bite; therefore, the' rolled portion should be flat-
tened and made parallel to the occlusal plane. The wax is removed
and the portion directed toward the lower teeth on either side is
softened. With the patient sitting upright in the chair and the
Frankfurt Plane parallel to the floor, the wax is reinserted into the
mouth and the patient instructed to dose the jaws gently until the
teeth just feel the wax. The dentist must not guide, direct, or touch
the patient's jaws or give directions concerning biting or retruding.
The patient is simply told to close the teeth gently until wax is
first felt. The wax is then removed and a hot spatula is plunged
it with hard base plate wax. Do not use the base plate wax over the
occlusal pads. D, softening the occlusal pads. The patient is seated
upright with the Frankfurt Plane parallel to the floor. The bite regis-
tration wax is introduced into the mouth and the patient is told to
close the jaws gently until he or she just feels the wax. (Continued.)
into the impression made in the wax by the lower teeth (Fig 11-
23,D). The wax bite is reinserted and the procedure repeated,
usually two or three times, until the jaw has been closed far enough
to record the relationship but not so far as to perforate the wax
(Fig 11-23,E).
The wax insulates the teeth from those of the opposite arch,
enabling one to record a late stage in the balanced path of closure
(Fig 11-23 ,G). The final wax bite record thus obtained should be
kept with the casts as a part of the patien(s permanent records
(Fig 11-23 ,F). It also may serve to show the direction and extent
of functional malocclusions and those interfering teeth that need
grinpi.ng during equilibration procedures in the primary and mixed
dentition (see Chapter 18).
G. THE TEMPOROMANDIBULAR JOINTS
The analysis of temporomandibular function and relationships
is essential to orthodontic treatment planning. The arbitrary di-
vision of a book into chapters written around discrete topics is a
necessary but artificial interference to the thoughtful integration
of all aspects of the diagnosis. The patient reader will find a cursory

FIG 11-23 (cont.).
E, the bite wax placed on the maxillary cast after first jaw closure.
Usually it is necessary to soften the wax about two or three times
and to reintroduce it into the mouth in order to obtain the final reg-
istration. Do not let the patient bite through the wax. F, the final wax
bite registration. G, the wax bite record in place on the casts. Com-
procedure for analysis of temporomandibular function and dys-
function in Chapter 8, The Orthodontic Examination, and more
detailed procedures in Chapter 10, Analysis of the Orofacial Mus-
culature. The impatient reader may also argue that analysis of the
temporomandibular joint belongs in the chapter on occlusion, but
I placed it arbitrarily in Chapter IQ for reasons of logic and avoid-
ance of redundancy.
H. RE LA TIONSHIPS OF THE TEETH TO
THEIR SKELETAL SUPPORT
The appraisal of the buccolingual relationships of the teeth
to alveolar processes and skeletal support usually is best determined
from the dental casts, though the posteroanterior cephalogram is
very useful (Chapter 12). The relationship of the dentition to the
skeletal profile is done in the cephalometric analysis (see Chapter
12). It is important when using casts for analysis (e.g., the Mixed
Dentition Analysis or the diagnostic setup) to keep in mind the
relationships of the teeth to their supporting bases and the skeletal
profile. Sophisticated diagnosticians try to relate tooth positions
on diagnostic casts to their positions in the cephalogram after
treatment and growth, a very difficult task indeed given the present
state of the art of growth prediction.
Analysis of the Dentition and Occlusion 245
pare with A. Note that the midlines now coincide. This registration
is much more critical anteroposteriorly and mediolaterally than it is
vertically. Therefore, it does not matter that the teeth are not in
occlusion. Indeed, they must not be or the old, eccentric occlusion-
ship will be recorded instead of the ideal occlusal relationship.
SUMMARY
The dentition and occlusion are analyzed directly by studying
the patient and indirectly by studying data such as casts, radio-
graphs, and photographs. Calcification, eruption, congenital ab-
sence, tooth size disharmonies, the relationships between teeth and
osseous bases, occlusal changes, and other features are quantified
and integrated during analysis to plan orthodontic treatment.
REFERENCES
I. Bolton W A: Disharmony in tooth size and its relation to the
analysis and treatment of malocclusion. Angle Orthod 1958;
28:113.
2. Bolton W A: The clinical application of a tooth-size analy-
. sis. Am J Orthod 1962; 48:504.
3.' R~:.ves AE: A polygon portrayal of coronal and basal arch
dimensions in the horizontal plane. Am J Orthod 1954;
40:811.
4. Howes AE: Expansion as a treatment procedure-Where
does it stand today? Am J Orthod 1960; 46:515.
5. Huckaba GW: Arch size analysis and tooth size prediction.
Dent Clin North Am July 1964, p 431.
6. Hunter WS: Application of analysis of crowding and spac-
ing of the teeth. Dent Clin North Am 1978; 22:563.
7. Joondeph OR, Riedel RA, Moore AW: Pont's Index: Clini-
cal evaluation. Angle Orthod 1970; 40:112.
246 Diagnosis
s development, in McNamara lA (ed): The Biology of Oc-
8. iM\yers RE, Wainrightmonograph
RL: Skeletal contributions Growth
to occlu-
lusal Development, 7. Craniofacial
Series. Ann Arbor, Mich, Center for Human Growth and
Development, University of Michigan, 1977.
9. Nolla CM: The development of the permanent teeth. J Dent
Child 1960; 27:254.
10. Pont A: Der Zahn Index in der Orthodontie. Z Zahn Orthod
1909; 3:306.
11. Richardson E, Malhotra SK: Mesiodistal crown dimensions
of the permanent dentition of American Negroes. Am J Or-
thod 1975; 68:157.
12. Sanin C, Savara BS: Analysis of permanent mesiodistal
crown size. Am J Orthod 1971; 59:488.
13. Tanaka MM, lohnston LE: The prediction of the size of the
unerupted canines and premolars in a contemporary ortho-
dontic population. J Am Dent Assoc 1974; 88:798.
14. Wainright RL: Prediction of alveolar penetrance by mandib-
ular buccal teeth (submitted for publication).
SUGGESTED 'READINGS
McNamara lA lr (ed): The Biology of Occlusal Development,
monograph 7. Craniofacial Growth Series. Ann Arbor, Mich,
Center for Human Growth and Development, University of
Michigan, 1977.
van der Linden FPGM (ed): Transition of the Human Dentition,
monograph 13. Craniofacial Growth Series. Ann Arbor,
Mich, Center for Human Growth and Development, Univer-
sity of Michigan, 1982.
Moyers RE, van der Linden FPGM, Riolo ML, et al: Standards
- of Human Occlusal Development, monograph 5. Craniofacial
Growth Series. Ann Arbor, Mich, Center for Human Growth
and Development, University of Michigan, 1976.
Nanda SK: The Developmental Basis of Occlusion and Maloc-
clusion. Chicago, Quintessence, 1982.
CHAPTER 12

Analysis of the Craniofacial

Skeleton: Cephalometries
Robert E. Moyers, D.D.S., Ph.D.
Fred L. Bookstein, Ph.D.
W. Stuart Hunter, D.D.S., Ph.D.

You who wish to represent by words the form of man and

all aspects of the ways his parts are put together, drop that
idea. For the more minutely you describe, the more you will
confuse the mind of the reader and the more you will prevent
him from knowtedge of that which you describe. So it is
necessary to draw and describe.-LEoNARDO DA VINCI,
Notebooks (translation by R.E.M.)

KEY POINTS 10. Cephalometric limitations and problems include

conventions or assumptions, fallacies, and blatant
misuses of the method.
1. Cephalometries is a radiographic technique for
abstracting the human head into a geometric scheme. 11. Future cephalometric improvements can be expected
2. Cephalometries is used to describe morphology and to include technical advancements, new concepts,
growth, to diagnose anomalies, to predict future and innovative applications.
relationships, to plan treatment, and to evaluate
treatment results.
OUTLINE
3. Cephalometric comparisons are made to standards, to
ideals, or to the subjects themselves.
A. Purposes of cephalometries
4. Conventional and standardized methods are used in
I. Description
exposing and tracing cephalograms. a) Comparison with standards
S. The basic elements used in geometric analysis of b) Comparison with ideals
cephalograms are curves, landmark points, and lines. c) Comparison with self
6. A cephalometric analysis is. a collection of numbers . 2. Diagnosis' ~.
3. Prediction
to compress information from the cephalogram for
clinical use. 4. Planning treatment
5. Evaluation of treatment results
7. Measurements are made of size and growth, pattern,
B. History
morphology, deformation, and displacement.
C. Obtaining the cephalogram
8. Both the measures which comprise an analysis and I. Cephalometric equipment
the cephalometric analysis itself have important 2. Conventions in taking cephalograms
characteristics which determine their clinical worth. a) The lateral projection
9. Different analyses are necessary for different b) The posteroanterior projection
purposes. c) Oblique projections

247
248 Diagnosis

D. Anatomic structures in the cephalogram a) Purpose

E. Techniques of tracing cephalograms b) Basis
F. c) Method
d) Remarks
Geomet?i\
1. BasilO\elements
a) methods
Curves 6. Analysis of growth
11) Edges of surfaces a) Purpose
2) Curves in space b) Basis
3) Transversals of surfaces c) Method
b) Points and landmarks, classified 7. A method for discriminating Class 11 types
I) True anatomic points a) Purpose
2) Implants b) Basis
3) Extremal points I) Horizontal types
4) Intersection of edges of regression as 2) Vertical types
"points" 3) Combining horizontal and vertical types
5) Intersection of constructed lines a) Method
c) Points and landmarks, described I) Identifying horizontal types
1) In the lateral projection 2) Identifying vertical types
(a) Unilateral landmarks 8. A method of discriminating Class III types
(b) Bilateral landmarks a) Purpose
2) In the PA projection b) Basis
(a) Landmarks on midline structures c) Method
(b) Landmarks on bilateral structures I) Variations in form
d) Lines ("planes") 2) Profile analysis
2. Numerical methods 3) Vertical analysis
a) Why use numbers? . 4) Analysis of incisal adaptation
b) How do we measure? 5) Class Ill, summarized
c) What do we measure? 9. Visualizing treatment objectives
I) Size and growth 10. A method for evaluating the effects of orthodontic
2) Pattern treatment
3) Morphology a) Purpose
4) Deformation b) Basis
5) Displacement c) . Methods
d) What do we do with measures? I) General effects
G. Understanding and using the cephalogram- 2) Regional effects
cephalometric analyses (a) Maxilla
I. Definition (b) Mandible
2. Requisites of individual measures in an analysis 11. A general assessment of deformation in triangles
3. Requisites of a cephalometric analysis a) Purpose
4. Evaluating morphology (variations in form) b) Basis
a) Basic morphologic analysis c) Method
I) Purposes H. Some problems and limitations of cephalometries
2) Basis I. Assumptions =-
3) Method a) Symmetry
b) Vertical analysis b) Occlusal position
I) Purpose c) Orientation on the transmeatal axis
2) Basis d) Adequacy of one or two planar projections
3) Method, pattern analysis 2. Fallacies
4) Method, growth analysis a) The f~llacy of false precision
5) Method,'functional analysis b) The fallacy of ignoring the patient
c) Profile analysis c) The fallacy of superpositioning
I) Purpose d) The fallacy of using chronologic age
2) Basis e) The fallacy of the "ideal"
3) Method 3. Misuses of cephalometric analyses
d) Analysis of symmetry I. The future of cephalometrics
I) Purpose Appendix: A Brief Cephalometric Atlas
2) Basis A. Overall facial dimensions
3) Method I. Vertical distances (facial height)
5. An analysis for prediction of morphology 2. AP distances (facial depth)

3. Bilateral distances (facial breadth or width)
B. Regional anatomic dimensions
I. Mandible
3. Anterior cranial bas (cranial floor)
c. Craniofacial
2. Maxilla constants
~ facial forms for use in clinical comparisons. The difference be-
Clinicians are faced with the problem of developing systems of
knowledge that are more powerful than common sense, more prac-
tical than intuition. Because skeletal dysplasia is associated with
a high percentage of severe malocclusions, craniofacial morphol-
ogy must be analyzed carefully before treatment begins. The anal-
ysis is carried out routinely in orthodontics by means of a
standardized radiographic procedure called cephalometries. This
chapter introduces the reader to the methods, applications, and
limitations of radiographic cephalometries in clinical practice.
Cephalometries is a technique for abstracting the complexities
of the live human head into a geometric scheme. Current practice
utilizes a two-dimensional radiographic image on film, the ce-
phalogram. From the cephalogram is derived a cephalometric
analysis in which anatomic structures are reduced to landmark
points supposed to indicate shapes and relative locations of curves.
The input to cephalometries is biology; the output, geometry. The
purpose of cephalometries is to interpret this geometric expression
of cranial anatomy. Conventionally, it proceeds in two stages.
First, the geometric abstraction is "measured" using dis-
tances and angles; then, these measures are compared with pop-
ulation standards, ideals, or their own earlier values. From the
comparisons emerge "analyses," "predictions" or "forecasts,"
"facial types," and assessments of "growth" and "the effects of
treatment. " In this chapter we explain these current cephalometric
conventions, including our reasons for placing so much of the
preceding sentence in quotation marks, and introduce certain sim-
pler and more direct methods of arriving at the same goals.
A. PURPOSES OF CEPHALOMETRICS
Cephalometries is a tool for dealing with variations in cra-
niofacial morphology. Its purpose is always comparison. In prac-
tice these comparisons are made for one of five reasons: (I) to
describe morphology or growth; (2) to diagnose anomalies; (3) to
predict future relationships; (4) to plan treatment; or (5) to evaluate
the results of treatment.
1. Description
Cephalometric description aids ·in the specification, locali-
zation, and understanding of abnormalities. (Cephalometries is a
description, not a prescription.) The cephalometric description of
a patient comprises three kinds of comparisons: (a) comparison
with a standard; (b) comparison with an ideal; or (c) comparison
with self.
a) Comparison With Standards
Research populations provide extensive statistics for details
of craniofacial morphology and growth. Measures of central ten-
dency-mean, median, mode-are often used as norms with which
Analysis of the Craniofacial Skeleton: Cephalometries 249
an individual patient is compared; in this sense, they present "nor-
mal" form*
b) Comparison With Ideals
Certain clinicians have also contrived subjective ideals of
tween standards and ideals is important. Standards are objective
measures statistically derived from populations. Ideals are arbi-
trary, subjective concepts of facial esthetics represented with num-
bers. They cannot be used interchangeably. Note that the patient
is not a member of the population from which the norm or ideal
was derived.
c) Comparison With Self
The patient may also be described by cephalometric com-
parisons with his or her earlier cephalogram. Comparisons with
self involve no notion of "norm" in the sense of an ideal. The
findings may be compared· with norms, for "amount" or "direc-
tion" of growth.
2. Diagnosis
In orthodontics, diagnosis is the determination of significant
deviations from the normal. The diagnostic purpose of cephalo-
metries is to analyze the nature of the problem and to classify it
precisely. For instance, cephalometric diagnosis leads to assign-
ment to facial types and classes. Since some aspects of facial
morphology are relatively stable under treatment, cephalometric
diagnosis contains a strong component of prediction.
3. Prediction
Description, diagnosis, and prediction are conceptually and
practically quite different. To make a cephalometric prediction is
to observe certain quantities, assume they will behave in deter-
minate ways, and extrapolate the consequences. The clinician would
like to be able to predict future form in the absence of treatment,
then estimate the effects of particular treatments on that prediction.
We are not yet able to predict well several important aspects of
craniofacial growth, for example, changes in principal directions
of growth, the precise onset of periods of accelerated growth, or
the cessation of such periods. Therefore, the most practical pre-
diction currently involves the exploitation of "craniofacial con-
stants" to supply predictions of shape approximately independent
of net amount of growth remaining.
4..Planning Treatment, ~.
"If the clinician can describe"diagnose, and predict craniofa-
cial morphology, a clearer plan of orthodontic treatment can be
derived. All treatment occurs after the initial cephalogram in a
face which is constantly changing (and being changed). Clinicians
use the cephalogram to define expected changes resulting from
growth and treatment and to plan appropriate biomechanics. Plan-
ning orthodontic treatment is applied prediction.
*These populations usually include cases which would be charac-
terized clinically as malocclusions.
250 Diagnosis

5. Evaluation of Treatment Results
Successive cephalograms are used to discern the progress of
treatment and to plan any changes in treatment which may seem
necessary. Evaluation of treatment results is re.current description
and diagnosis.
B. HISTORY
By the sixteenth century the artists Diirer and da Vinci had
sketched series of human faces with straight lines joining homol-
ogous anatomic structures; variations in the lines highlighted struc-
tural differences among the faces (Fig 12-1). Much later,
anthropologists invented an instrument, the craniostat, for orient-
ing dry skulls, which improved the art of comparisons. But several
professions, ours among them, needed a method for studying serial
changes; the successive forms of the living head. This required a
modification of the craniostat for use with the live patient, that is,
a standardized radiographic procedure.
The first paper on on what we today would call "cephalo-
metrics" was probably that by Pacini in 1922." Credit for stan-
dardizing and popularizing the procedure goes to Broadbent,IO
whose classic paper of 1931 was received with great interest
throughout orthodontics. Hofrath IXpublished in German during
the same period. Also at that time Simon's31 system of gnathos-
tatics, a method for orienting orthodontic casts, was in use. These
ideas from anthropometrics and gnathostatics naturally evolved
and fused into a new technology: radiographic cephalometries.
Other workers experimented with cephalostats during this period;
from Higley'sl7 instrument, for instance, has evolved the design
of most modern cephalometers (Fig 12-2).
C. OBTAINING THE CEPHALOGRAM
1. Cephalometric Equipment
A cephalometric apparatus consists of a cephalostat or head
holder, an x-ray source, and a cassette holder (see Fig 12-2).

A B

FIG 12-1.
Anatomic drawings from Diirer, On Measurement (circa 1570).

FIG 12-2.
Patient in a cephalometer. Note use of the lead apron.
Cephalostats are of two types. The Broadbent-Bolton 10 method
utilizes two x-ray sources and two film holders so that the subject
need not be moved between the lateral and posteroanterior (PA)
exposures. Although this method makes more precise three-
dimensional studies possible, it requires two x-ray heads and more
space and it precludes oblique projections.
The Higley'7 method, used in most modern cephalostats, uses
one x-ray source and film holder with a cephalostat capable of
being rotated. The patient is repositioned in the course of the
various projections. This method is more versatile, but care must
be taken so that the horizontal relationship of the head does not
alter during repositioning.
The x-ray source must produce sufficiently high voltage (usu-
ally above 90 kYp) to penetrate the hard tissues well and to provide
good delineation of both hard and soft structures. A small focal
spot (frequently obtained by a rotating anode) results in sharper
radiographic images.
The x-ray film is held within a cassette that usually also
contains intensifying screens to reduce the exposure from that
otherwise required. In conjunction with the cassette film holder,
a fixed or moving grid may be used to produce sharper images.
A grid resembles a venetian blind in the open position. It absorbs
the secondary (scattered) radiation produced by deflections from
the bones and permits only those tays coming directly from the
source to proceed to the film. Scattered radiation tends to obscure
images, making bony shadows appear fuzzy and landmarks more
difficult to locate.
2. Conventions in Taking CephaIograms
a) The Lateral Projection
The midsagittal plane of the subject's head is conventionally
placed 60 inches (152.4 cm) from the target of the x-ray tube with
Analysis of the Craniofacial Skeleton: Cephalometries 251
the left* side of the subject toward the film. The central beam of
the x-rays coincides with the transmeatal axis, that is, with the ear
rods of the cephalostat. Under most circumstances, the distance
from the midsagittal plane to the film is held constant, usually at
7.0 inches (18 cm). (In the Broadbent-Bolton cephalometer, this
distance is varied according to the subject.) Constancy of distance
from midsagittal plane to film makes compensation for enlarge-
ment easier. The patient's head is placed with the Frankfurt Plane
parallel to the floor and the subject's teeth together in their usual
occlusal position (Fig 12-3). The lateral cephalogram also may
be taken with the mandible in its postural position, which may be
achieved by exposing the film after the patient has swallowed or
has repeated several times the words "Michigan" or "me." If
the ear rods are too large or too firmly placed in the external
auditory meati or if there is inflammation within the ear, a false
mandibular position may obtain.
b) The Posteroanterior Projection
The head is rotated by 90 degrees so that the central ray
perpendicularly bisects the transmeatal axis (Fig 12-4). In the PA
cephalogram it is crucial that Frankfurt Plane be accurately hori-
zontal, beca.use when the head is tilted, all vertical displacements
measured are altered. Maintaining the identical horizontal orien-
tation from lateral to posteroanterior projections is critical when
comparative measures are made from one to the other.
e) Oblique Projections
The right and left oblique cephalograms are taken at 45 and
135 degrees to the lateral projection, the central ray entering behind
one ramus to obviate superimposition of the halves of the mandible
(Fig 12-5). As in the posteroanterior projection, the Frankfurt
Plane must stay horizontal; any tipping will alter most measure-
ments. The oblique cephalogram is particularly useful for patients
in the mixed dentition.
D. ANATOMIC STRUCTURES IN THE
CEPHALOGRAM
Figure 12-6 is a lateral cephalogram of a skull of a 9-year-
old child on which markers have been placed along the sagittal
plane of the cranial base and at the suture sites. In addition, the
accessible surfaces of the zygomatic bones were covered with thin
lead foil. Figure 12-7 is a tracing of the skull shown in Figure
12-6. The major bony structures in the tracings are as follows:
a) Sphenoid bone. Figure 12-8 shows in heavy outline those
structu'res of the sphenoid bone seen most readily in the lateral
and PA cephalograms. ~.
'b) Zygomatie bones. Figure I~-9 depicts the structures of the
zygomatic bones ordinarily visualized in the lateral and postero-
anterior cephalograms.
e) Maxillae. Figure 12-10 shows the maxillary structures as
visualized in the lateral and PA cephalograms.
d) Mandible. Figure 12-11 illustrates mandibular structures
seen 'in the lateral and posteroanterior cephalograms.
*European convention is the subject's right side to the film.
 FIG 12-3.
Typical lateral cephalogram.

FIG 12-4.
Posteroanterior cephalogram of the patient shown in
Figure 12-3.

,.

252 Diagnosis
 FIG 12-5.
Oblique cephalograms of the patient shown in Figures
12-3 and 12-4.

FIG 12-6.
Cephalogram of a child's skull with lead mark-
ersirl"place (see text). (From Enlow OH: The
Human Face.,New York, Hoeber Medical Di-
vision, Harper & Row, 1968. Reproduced by
permission.)

Analysis of the Craniofacial Skeleton: Cephalometries 253

254 Diagnosis

FIG 12-7.
Tracing the cephalogram shown in Figure 12-6. A = spheno-
occipital synchondrosis; B = sphenoethmoidal synchondrosis; C =
cribriform plate; C = foramen cecum. The structures traced with
dotted lines sometimes are not seen in the radiographs.

FIG 12-8.
The sphenoid bone. Left, lateral projection: A = lesser wings; B = cesses; 0 = dorsum sella; E = floor of the hypophyseal fossa; F
greater wings; C = pterygoid processes. Right, posteroanterior pro- = spheno-occipital synchondrosis. The greater wing at G is the floor
jection: A = lesser wings; B = greater wings; C = pterygoid pro- of the middle cranial fossa and coincides with the orbital outline.

'"

FIG 12-9.
The zygomatic bones. Left, lateral projection:A = zygomatic frontal jection; C inferior surface of the occipital bone; 0 occipital
suture; B = zygomatic temporal suture. Right, posteroanterior pro- condyles.
 Analysis of the Craniofacial Skeleton: Cephalometries 255

RIG 12-10.
The maxillary bones. Left, lateral projection: A = frontomaxillary jection: A = frontomaxillary sutures; B palatal surface; C al-
sutures; B = pterygomaxillary fissure. Right, posteroanterior pro- veolar process.

O/~\O ."

FIG 12-11.
The mandible. Left, lateral projection. Right, posteroanterior projection showing the coronoid process, marked A.

E. TECHNIQUES OF TRACING ing improves accuracy. Ahhough bilateral landmarks may be av-
CEPHALOGRAMS eraged, it is better to draw both right and left shadows.

Most cephalometric analyses are made from tracings rather

than directly from the cephalogram. (Otherwise, the superposition F.· GEOMETRIC METHODS
of successive images is impossible.) For tracing, the cephalogram
1. Basic Elements
is taped to a tracing box or x-ray illuminator that has an even,
well-diffused light source. Frosted acetate film 0.003 inch thick A tracing has some actual biological information, namely,
is taped to the top margin of the film, allowing the tracer to lift locations of curves and landmarks. It also contains some non-
the tracing from time to time to inspect the cephalogram. Tracing biological information-artifacts-such as noncurves (edges of
is easier when done in a darkened room with all of the light box regression, * such as the symphysis or cragial base) and nonpoints
covered by black paper except that portion occupied by the ceph- (like Articularet).
alogram. To maintain fineness of line one should use a pencil with
a lead 0.3 to 0.5 mm in diameter. The initial (pre-treatment) a) Curves
cephalogram is conventionally traced in black; subsequent films . The curved images in the ct;:phalogram are of three different
may be traced in a series of colors. biologic types: (I) edges of regression; (2) curves in space; and
Tracing should be systematic. One should begin with a general (3) transversals of surfaces.
inspection of the cephalogram, then locate and identify standard
landmarks, trace anatomic structures in a logical sequence, and,
finally, construct derived landmarks and lines. One cannot obtain 'Edge of regression, the points on a surface that also lie on the
silhouette of the surface as seen from a particular vantage point, e.g., a
accurate cephalometric tracings without a thorough knowledge of skyline or the earth's horizon.
the underlying anatomy. Although not every anatomic structure is
traced, one must recognize them all in order to locate the important tSpecific landmarks are described in Section F-l-c later in this
chapter. .
elements. Reference to preceding or succeeding films during trac-
I
256 Diagnosis
FIG 12-12.
Alveolar crest and col. Right, image of an upper molar as seen in
a periapical view. Left, the true nature of the "crest" of the alveolar
process is seen when viewed at 90 degrees to the central ray. The
col is the dip between the buccal and lingual alveolar crests.
1) Edges of RegressionSurfaces.- The edges of surfaces are
sometimes properly shown. The anterior border of the coronoid
process, for instance, really is a fairly sharp edge (see Fig 12-3).
But .sometimes that which we perceive as an edge of a surface is
neither an edge nor a horizon. For example, the line we call the
"alveolar crest" line represents a col, a saddle-shaped depression
in the crest of a mountain ridge (Fig 12-12).
2) Curves in Space.- In a cephalogram curves are seen but are
foreshortened and simplified by flattening: for instance, the image
of the mandibular canal in Figure 12-3. The resulting image in
not realistic.
3) Transversals of Surfaces.- Transversals of surfaces are nei-
ther edges nor true anatomic loci but places where a bone of
irregular shape is viewed most parallel to the central ray. Some
surfaces are nearly parallel to the central ray and hence appear as
a line, a problem inherent in reducing three dimensions to two.
Examine, for example, the radiographic shadow of the bony orbit
in Figure 12-4 and compare it with a real bony orbit on a dry
skull.
b) Points and Landmarks, Classified
A landmark is a point serving as a guide for measurement.
An ideal landmark is located reliably on the skull and behaves
consistently during growth. It should not be assumed that all land-
marks are equally reliable and valid. The reliability (reproduci-
bility, dependability) of a landmark is affected by the quality of
the cephalogram, the experience of the tracer, and confusion with
other anatomic shadows. The validity (correctness or use as proof)
of the landmark is determined largely by th~ way the landmark is
used.
Cephalometric points and landmarks are of the following kinds:
(I) true anatomic points; (2) implants; (3) extremal points; (4)
intersections of edges of regression; and (5) intersections of con-
structed lines.
1) True AnatomicPoints.- An'atomic "points" are really
small regions which might be located on the solid skull even better
than in the cephalogram. Each point has its own scale and its own
uncertainty in one or two dimensions (Fig 12-13). Examples in-
clude the anterior nasal spine (ANS), infradentale (Id), cusp tips
or incisal edges (Is), or nasion (Na) (Fig l2-l3,A). The sella (S)
is a special case: the single point summarizes an extended curve
by its center (Fig 12-13,B).
2) Implants.- Implants are artificially inserted radiopaque
markers, usually made of an inert metal. They are not landmarks
in the usual sense of having a name which identifies their location.
They are "private points"; their position from subject to subject
is not homologous, making cross-sectional studies of implants very
difficult. They may be located more precisely than traditional
points and provide precise superpositioning, but they cannot be
used to measure accurately any aspect of the single form.
3) Extremal Points.- Extremal points are points charac-
terized by their properties relative to the entire outline:
a) Points which are extrema of curvature, for example, in-
cision superius (Is).
b) Points whose coordinates are largest or smallest of all points
on a specific outline, for example, "A point", "B point," gnathion
(Gn), or condylion (Co). These points have less precision of lo-
cation than true anatomic points. For example, gnathion ("the
most anterior inferior point on the chin") moves as the mandible
opens and changes its position during development.
c) Points defined in pairs, for example, the two Gonions (Go)
used to m.easure mandibular width in the PA projection.
4) Intersection of Edges of Regression as "Points."-
"Points" defined as the intersection of images are really lines
looked at down their length. For instance, articulare (Ar) and
pterygomaxillary fissure (PTM) are not points at all and are in no
way part of the solid skull. Such "points" exist only in projections
and are dependent on subject positioning.
5) Intersection of Constructed Lines.- Intersections of
constructed lines are used as "points," example, "gonion" some-
times is defined as the intersection of the ramal and mandibular
lines.
c) Points and Landmarks, Described
1) In the Lateral Projection (Refer to Figs 12-13,A and
B).- Precise definitions of the points and measures used in current
cephalometrics lead to improved use in practice. All definitions
are from Riolo et al.'o
(a) Unilateral Landmarks.-
Nasion (Na): The frontonasal suture at its most superior point
on the curve at the bridge of the nose.
Anterior nasal spine (ANS): The most anterior point on the
maxilla at the level of the palate. The ANS is of limited use for
analyses in the posteroanterior projection, as the actual spine often
cannot be seen and its location varies considerably according to
radipgraphic exposure, but~1t is useful for vertical measurements.
Subspinale (' 'A" point): The lTJostposterior point on the curve
between ANS and PR (SPr; see following item). "A" point usually
is found approximately 2 mm anterior to the apices of the maxillary
central incisor roots. "A" is not an anatomic point, of course. Its
vertical coordinate is unreliable and therefore this point is largely
used for posteroanterior measures. "A" point is routinely obscured
and/or rapidly moving during the eruption of the upper central
InCisors.
Superior prosthion (SPr or PR) (also termed supradentaLe):
 Analysis of the Craniofacial Skeleton: Cephalometries 257

c 0 z<wI0
::lE< ::-
..J
a::
..J
X
aa::
tt
>-
<t

FIG 12-13.
Cephalometric landmarks and lines (for definitions, see text). A and posteroanterior cephalogram (see Fig 12-53). 0, some cepha!o-
B, some landmarks in the lateral cephalogram. C, landmarks in the m~tTic lines used in the lateral cep'halogram.
258 Diagnosis
The most anterior inferior point on the maxillary alveolar process,
usually found near the cemento-enamel junction of the maxillary
central. incisors.
Incision superius (Is): The incisal tip of the most anterior
maxillary central incisor. • surfaces of the tuberosities of the maxilla. The landmark is taken
Incision inferius (li): The incisal tip of the most labial man-
dibular central incisor. .•
Infradentale (Id) (also termed inferior prosthion): The most
anterior superior point on the mandibular alveolar process, usually
found near the cemento-enamel junction of the mandibular central
InCISorS.
Supramentale ("B" point): The most posterior point of the
bony curvature of the mandible below Infradentale and above
Pog..onion. "B" point usually is found near the apical third of the
roots of the mandibular incisors and may be obscured during erup-
tion of these teeth. When the profile of the chin is not concave,
"B" point cannot be determined.
Pogonion (Pog): The most anterior point on the contour of
the chin. Pogonion usually is located by a tangent perpendicular
to the mandibular line or a tangent dropped to the chin from nasion.
The astute reader will notice that these three definitions do not
quite agree.
Gnathion (Gn): The most anterior inferior point on the lateral
shadow of the chin. Gnathion may be approximated by the mid-
point between pogonion and menton on the contour of the chin.
Menton (Me): The lowest point on the symphyseal outline of
the chin.
Basion (Ba): The most inferior posterior point in the sagittal
plane on the anterior rim of the foramen magnum-the tip of the
posterior cranial base.
Posterior nasal spine (PNS): The most posterior point 0'1 the
bony hard palate in the sagittal plane; usually the meeting point
of inferior and superior surfaces of the hard palate. Vertical mea-
sures using PNS are more reliable than horizontal ones.
Sella (S): The center of the hypophyseal fossa (sella turcica).
It is selected by eye, since that procedure has been shown to be
as reliable as a constructed center.
(b) Bilateral Landmarks.- The following are bilateral land-
marks. Both left and right points are located and used, though
some clinicians use the midpoint between the two, an unfortunate
convention of less precision.
Orbitale (Or): The lowest point of the bony orbit. In the PA
cephalogram, each may be identified; in the lateral cephalogram,
the outlines of the orbital rims overlap. Usually, the lowest point
on the averaged outline is used for the construction of Frankfurt
Plane.
Gonion (Go): The most posterior inferior point at the angle
of the mandible. It may be determined by inspection (see Fig 12-
13,A). Bisecting the angle formed by the junction of the ramal
and mandibular lines, and extending this bisector through the man-
dibular border, is a method of constructing gonion, but the result
is different (see Fig 12-13,B) .
Condylion (Co): The most posterior superior point on the
condyle of the mandible.
Articulare (Ar): The intersection of three radiographic shad-
ows: the inferior surface of the cranial base and the posterior
surfaces of the necks of the condyles of the mandible. Articulare
is systematically used for condylion when the latter is not reliably
discernible. Note that displacement of the condyle moves articulare.
Pterygomaxillary fissure (PTM): A bilateral teardrop-shaped
area of radiol ucency, the anterior shadow of which is the posterior
where the two edges, front and back, appear to merge inferiorly.
Porion (Po): The "top" of the external auditory meatus.
Sometimes, because porion is quite unreliable, the "top" of the
shadow of the ear rods is called "machine porion," but it is a
quite different point. Porion is taken as the point of contact of the
tangent to the meatus from orbitale used in constructing the Frank-
furt Plane.
Sphenoethmoidal point (SE): The intersection of the shadows
of the great wing of the sphenoid and the cranial floor as seen in
the lateral cephalogram.
Frontomaxillary nasal suture (FMN): The most superior point
of the suture where the maxilla articulates with the frontal and
nasal bones. FMN is on the anterior cranial base, unlike nasion;
therefore, FMN may be preferred when measuring or defining the
cranial base.
2) In the PA Projection (Refer to Fig 12-13,C).-
(a) Midline Structures.-Crista galli: A vertically elongated
diamond shape whose location helps establish the Midsagittal Line
(A, in Fig 12-13,C).
The floor of the hypophyseal fossa (B).
The septal structures of the nose (C).
(b)Bilnteral Structures.-Frontozygomatic sutures: These are
seen as dark lines on a gray background (D).
Zygomatic processes: The lateral surfaces can usually be seen
(E).
Mastoid processes (F).
Gonial areas of the mandible (G).
Foramina rotunda (singular. foramen rotundum): In the me-
dial inferior portion of the orbital outlines (H).
d) Lines ("Planes") (Refer to Fig 12-13,D)
Because cephalometric geometry appertains to the cephalo-
gram we will use the term lines, in order to emphasize their abstract
character, though "planes" is in common usage. In reality many
of the so-called cephalometric planes are not flat. For instance,
the occlusal "plane," drawn in the cephalogram as a straight line,
represents a very complicated three-dimensional
• relationship of
cusp contacts.
Most analyses invoke one or more cephalometric lines, usu-
ally of the following typ'e,s:
;'1) Lines joining true anatomic points. For instances, the pal-
atal line joins the anterior nasal ;pine (ANS) and posterior nasal
spine (PNS).
2) Anatomic tangent lines.
• Lines through an anatomic point and tangent to an outline
elsewhere. For example, the facial line is defined as join-
ing nasion to pogonion; but pogonion is (usually) just the
point of tangency of this line at the chin.
• Lines formed by double tangents, that is, lines tangent to a
structure, or structures, at two points. For example, the ra-

mal line usually touches the mandible both at th~ posterior
border of the ramus and along the condyle; the mandibular
line touches both near menton and near gonion, and the
Frankfurt "Plane" touches orbitale and porion.
Conventionally, cephalometric lines are used to form the rays
of angles and to provide orientations for measuring distances. Of.
the many cephalometric lines in use, those utilized in'the analyses
described later are shown in Fig 12-130 and characterized as
follows.
Posterior maxillary line (PM vertical): A line drawn inferiorly
from SE along the posterior shadow of the maxillary tuberosity,
passing through PTM.
Anterior maxillary line (facial line): A line drawn parallel to
PN! vertical through nasion (F).
. Upper Maxillary Line (UM): The line through SE and FMN.
Palatal line: A line joining PNS and ANS.
Functional occlusal line (FOL): A line averaging the points
of posterior occlusal contact from the first permanent molars to
the primary molars or bicuspids. It makes no reference to incisor
and cuspid landmarks.
Mandibular line: Several mandibular lines are in use. The
usual mandibular line, which cannot always be drawn, is simply
a double tangent to the lower border of the mandible. Another
mandibular line is doubly tangent to the height of the contour of
the lower border of the mandible at the mandibular notch and to
the symphyseal curve (near menton). Yet another version is the
line joining gonion and menton (E). Although all mandibular lines
may provide essentially the same information, the practitioner
should choose one and use it.
Midsagittal line: A line representing the midline of the head
in the PA projection. It is constructed as the bisector of crista galli
and the upper nasal septal structures (see Fig 12-13,C).
Frankfurt "Plane" (or Frankfurt "horizontal"): The com-
mon tangent to the upper external auditory meatus (at porion) and
the inferior border of the orbit (at orbitale). Frankfurt "Plane" is
traditional and is easy to locate on the actual patient. It is unfor-
tunate that the cephalometric landmarks on which it depends are
so unreliable.
Sella-nasion: A line joining sella and nasion.
2) Numeric Methods
During childhood and adolescence many important changes
occur simultaneously in the head and face. Careful cephalometric
procedures offer an opportunity to segregate and analyze clinically
significant developmental events. The measures must be chosen
to exclude, as much as possible, whatever confounds or is of little
interest. There are four basic questions: (a) Why use numbers? (b)
How do we measure? (c) What do we measure? (d) What do we
do with the measurements?
a) Why Use Numbers?
Nothing in the head, including the mandible itself, looks like
the tracing of the mandible. The tracing is a simplification of
selected portions of the cephalogram, but the tracing is not a
quantification. Basically, numbers are used to make fine distinc-
tions. It is not enough to say, "This child has a big mandible."
We must be able objectively to relate one person's mandible to
Analysis of the Craniofacial Skeleton: Cephalometries 259
S.O.
3+T
2
3 2
S.O. + +
-,+
FIG 12-14.
Two cephalometric variables that are normal separately but abnormal
when taken together. Note that the variable X is within 1 SO on both
the ordinate and abscissa but is outside the ellipse of normality when
the two measures are taken together.
others of the same age, sex, and ethnic group and even to other
parts of the child's own face. A "big" mandible in one 9-year-
old North American white boy is "small" in another. We work
with quantities, not words.
Values are distributed statistically to establish a "normal"
range, to identify outlying values, and to detect abnormality
objectively.
I) The normal range is far more useful clinically than the
norm (mean) alone. In analyzing a mandible, for instance, the
patient's measures must be compared with the appropriate popu-
lation range to learn both just how "big" the mandible is and
whether other measures are appropriately "big". Some measures
show more variance than others, an important clinical point that
is concealed if one uses the mean alone. All of the cephalometric
procedures presented later in this chapter readily permit compar-
ison of the patient's measures to the normal range as well as to
the normal mean.
2) The detection of outlying values likewise serves important
clinical functions. Determining the facial measures that contribute
most importantly to a skeletal dysplasia to identify an abnormal
facial type focuses the mind on sites of primary clinical attention.
Extremeness of any variable is a substantive finding with which
treatment planning must cope.
3) Abnormality must be detected objectively or it cannot be
dealt with practically. Let us consider, for instance, values for a
particular patient on two variables, X ana Y (Fig 12-14). Our
patient is normal on each variable taken separately, but the com-
bination is abnormal. Cli9.ically, we call this "imbalance," which
thee;xperienced clinician intuitively senses from studying the face
and cephalogram. When variables' don't go well with one another,
they reflect important clinical problems, and a third variable must
be devised to measure the imbalance directly. In the analysis of
Class 11malocclusions, for instance, if the position of the maxilla
is partly characterized by the angle SNA and that of the mandible
by SNB, their "difference" is the angle ANB. The angle SNA may
be slightly larger than normal and SNB slightly less than normal,
yet their difference may be clinically rather large (Fig 12-13, see
also Fig 12-15).
 260 Diagnosis

FIG 12-15.
The angle ANB is shown in several different faces of varying mor-
phology. The angle is precisely the same in each, showing its limited
discriminatory capabilities.

b) How Do We Measure?
Reduction of the living head to usable numbers requires a
series of simplifications each of which necessarily loses information.
1) Tissue ~ absorption. As the x rays traverse the head with
its many tissues, all information is reduced to a single number,
the x-ray absorptivity. Variations between tissues having the same FIG 12-17.
absorptivity are ignored. Triples of points. A, used to form the angle S-N-ANS and to register
2) Three dimensions ~ two dimensions. All absorptivities changes in that angle during growth or treatment. B, used to define
are summed along the paths ofthe x-ray beams, producing densities a triangle for the measurement of deformation.
in a two-dimensional cephalogram: a quantitative picture of areas
• Quadruples of points may be used to study displacements,
of varying darkness. Variations along the beam are ignored.
that is, translations and rotations. The four points must
3) Cephalogram ~ tracing. All information about darkness
comprise two pairs, each pair at fixed distance (Fig 12-
is discarded and replaced by a tracing of edges.
18).
4) Forms ~ landmarks. Much of this information is then cast
aside when forms are reduced to landmarks. Information about
1) Size and Growth (Distance Between Points and Change
curving form is discarded as the data are reduced to a configuration
in Distance Between Points).- The rearrangements associated
of points alone.
with development are many and varied, and include cellular ac-
tivities, translations of cells and tissues, and increases in size. Of
c) What Do We Measure?
these, increase in size measures-linear distances between
A configuration of landmarks and outlines as our ultimate
points-is the only one which can fairly be discerned as growth
representation of the living head and face can be used to understand
from the cephalogram. There are great variations in the amount
natural and clinically planned alterations in form, growth, dis-
of growth in different directions, at different ages, in different
placement, remodeling, etc. We do this by measuring in three
parts, etc. Some growth appears as accelerations ("spurts") which
different ways:
are endocrinally mediated such as the increase in mandibular length
• Pairs of points define lengths of line segments- at pubescence (Fig 12-19). More even increments may reflect
distances-the primary use of which is to measure growth remodeling in specific regions as they adapt gradually to primary
(Fig 12-16).
growth or to translation elsewhere. Irregular, localized growth
• Triples of points define angles and triangles for measuring
occurs in response to a change in the immediate environment, as
, pattern (constants), form change, and deformation. (See
in the area of muscle attachment (when muscle function is altered)
Figs 12-17 and 12-19.)
or in the alveolar process (during ~ruption of a tooth). Change in
Some measures involving triples of landmarks may mislead.
distance between two landmarks on the same/structure mayor may
For instance, an angle which changes (e.g., angle ANB) is difficult not be a measure of growth; change in distance between points on
to use in analysis unless we can discern whether it is A, N, or B
different structures is prob~bly not a measure of growth at all but
(or some combination) which is changing.
,. a complex mixture of developmental activities.
Measurement of growth is not as simple as it seems. Deducing
A •B' •BB •
B'
•
e
AA'.
•
A'
A B
o •
oD,

C'O)
C2·~.D2
FIG 12-16.
Pairs of points defining lengths of line segments. When A' is su- FIG 12-18.
perposed over A, it is assumed that "growth" is the distance between Displacement. When registration is made onA-B, C and 0 are seen
B andB'. to displace.
 Analysis of the Craniofacial Skeleton: Cephalometries 261

B
mm
I11

Mo-N

97

126

CO-GN 114

102

'Regions of Greatest Constancy

c 98 PTM-A

46
60.0 90.4 120.8 151.2 181.6 212.0
AGE IN MONTHS

Three growth measures in the same individual (2026)

75

N_S_GN65~

60
60.0 90.4 120.8 151.2 181.6 212.0
AGE IN MONTHS

Three constants in the same Individual (2026)

FIG 12-19.
Growth measures and "constants." A, anatomic regions of greatest
constancy. B, three growth measures in the same individual (subject
2026). (Anatomic abbreviations are shown in Fig 12-13 and defined
in the text.) C, three "constants" in the same individual (2026). Note
that there are minor fluctuations around 0 change. 0, ratios of dis-
tances. These measures from the Counterpart Analysis (discussed
later in this chapter) are used not only to measure effective growth
but also to compare relative growth in different parts of the face as
both the maxilla and mandible grow. Certain ratios thus show pro-
p~~ionate growth of theypper and lower jaws (Table 12-1).
262 Diagnosis

3) Morphology' (Difference in Form).- Form is bounded

FIG 12-20.
Two mandibular registrations of the same growth change. In the
upper figure, the registration is on the symphysis and the inferior
border. In the lower, the registration is on the condylar region. In the
upper figure the mandible appears to grow upward and backward.
In the lower it appears to grow downward and forward. Yet each is
depicting exactly the same growth.
mandibular growth from cranial-base registrations far removed is
intrinsically confusing though often attempted. Such distant reg-
istrations summate translations, growth, and shape changes for all
intervening structures, making it difficult for one to know how
much of the total "growth change" is mandibular (Figs 12-20
and 12-21).
Aspects of growth may be measured by size comparisons in
areas of the face which do not show confounding effects such as
displacements between structures. For instance, "total mandibular
length," variously measured, is of great interest when studying
the effects of Class II treatment. Keep in mind that the vertical
displacement of menton from the cranial base is of interest sep-
arately, as are ramal height, corpus length, and the angle between
them, for they help reveal how total mandibular growth changes
may have taken place. Lower face height (lip commissures to chin)
is directly perceived by the layman and is thus worth measuring
if only for its convenience in discussions with the patient and his
or her family. But other aspects of facial form, just as directly
perceived, cannot be measured as "sizes" in this way: they are
determined as proportions, by points in threes or fours.
biologically; cephalometric configurations are collections of
landmarks to represent biologic form: But form is easier to name
or describe than it is to measure. One may name and measure
simple geometric shapes-circles, squares, rectangles-with ease,
but there are no circles or squares in the head. It is important to
keep clearly in mind the difference between form (shape) and
changes in form. Confusion arises in cephalometries by attempting
to measure form and form change (deformation) in the same
units-degrees or millimeters (see topic 4, Deformation, which
follows).
In craniofacial diagnosis it is necessary to compare the
morphology of a single case with some population standard. This
comparison is made to understand how a patient differs from the
norm, not to measure the complicated forms which comprise the
craniofacial complex. In Section G we suggest referring selected
"constants" to their ranges as appropriate for sex, ethnic group,
etc., in the diagnosis of the form variations. Study of the relation
of the patient to a population in this way will help localize those
parts of the face most deviant from appropriate population norms,
making differences in form more obvious. Several of the analyses
presented later in this chapter make use of pattern measures
(constants) to diagnose form differences between the patient and
an appropriate population distribution.
A more sophisticated tensor method has been devised which
makes use of form differences of triangles (see Fig 12-45)2-9
4) Deformation.- Much of the skeletal change we observe,

2) Pattern (Persistence of Form Through Time).- Even

during periods of the most active growth, certain aspects of facial
form remain relatively unchanged (see Fig 12_19)25.27 We know
this intuitively-the facial pattern peJ;I11itsrecognition of a person
unseen for many years. We have difficulty in locating important
differences among faces from measurement of separation of land-
marks only because distances grow over time more or less. Pattern
measures, which show relative stability through time, permit cer-
tain discriminations not possible with growth measures. The three
main kinds of measures which may be unchanging over time are:
a) angles (see Figs12-17,A and 12-19), FIG 12-21.
b) proportional divisions (see Fig 12-19), and Superpositioning in the cranial base to assess crudely the overall
c) ratios of distances (see Fig 12-19 and Table 12-1) effects of growth and treatment on the craniofacial pattern.'
 263

MALE
TABLE MEAN 12-1.
12
60
67
42
71NA
N
1NA
67
73
15
58
64NA
N
1.01
53
50
0.04
.04
0.99
1.04
1.06
1.02
1.05
1.08
1.09
1.10
1.07
36
1.03
1.04
23
6028
45
47
0.06
52
61
10
12
0.07
0.09
0.08
.07
0.07
0.10
0.97
0.99 so
so
0.06
62
29
0.05
.02
1.03
30
0.95
1.000.08
0.04
48
.10
0.06
0.05
67 FEMALE
cephalometric analysis, displacement, movement of parts irre-
Ratio (B-2 + B-3)/(B-5 + B-6)
ular Skeletal Unit (yr) .
Counterpart
Maxillary MALE
Analysis Ratios (see Fig 12-28)
to Mandibular spective of size or shape change, must be separated from all other
A. AGE
Skeletal, Horizontal Dental Unit Ratio (B-1 )/(B-4)
changes. In Fig 12-2], registered on the cranial base, the mandible
may appear to have grown, and have been tipped and carried
downward and forward, but we cannot read growth, in the man-
dible or elsewhere, from this diagram. Registration on the sym-
physis, or on the mandibular canals, may provide a better
appreciation of mandibular size change (see Fig 12-20).

d) What Do We Do With Measures?

The obvious answer to the question of what we do with these
data is that we use them to achieve the five purposes discussed in
Section A of this chapter. The use of cephalometric measures is
the subject of Section G.

G. UNDERSTANDING AND USING THE

NA = no data available.
during both growth and treatment, is deformation of form, but the
study of such deformations is difficult with most current
cephalometric analyses. It is easier to describe deformation of a
mandible than to describe its form: shape change is easier to describe
than shape itself (see Fig 12-46).
Deformation is measured as a pair of size changes in two
perpendicular directions. For instance, for all Class II malocclu-
sions grouped, the average change in the triangle S-M-N over
normal growth is an extension of 1.14% per year horizontally
(along SoN) and 2.14% per year vertically (menton moving straight
downward, as in Fig 12-23).5 Changes of all distances, angles,_
and proportions relating S, N, and M can be derived from this
single summary.
5) Displacement.- (translation, "rotation"; rigid motion
relating two pairs of points at fixed separation) (see Fig 12-18).-In
CEPHALOGRAM-CEPHALOMETRIC
ANALYSES
1. Definition
A cephalometric analysis is a collection of numbers intended
to compress much of the information from the cephalogram into
a usable form for diagnosis, treatment planning, and/or assessment
of treatment effects. An analysis provides information about sizes
and shapes of craniofacial components and their relative positions
and orientations.
]n practice, the unit of analysis really is the single patient
over time, for all cephalometric analyses are intrinsically longi-
tudinal. A cephalometric analysis helps the clinician perceive better
four important aspects of craniofacial morphology:
a) what the face is now (current morphology),
b) what is was (past growth),
c) what it will be (expected growth), or
d) what the clinician wishes it to be (idealized or corrected
morphology).
Cephalometric analysis should begin with identification of a
problem to be solved, not with selection of an "analysis." Dif-
ferent problems require different solutions, and no one cephalo-
metric analysis is appropriate for all clinical needs. What follows
in this section is a list of analyses, like a menu, from which may
be selected that most appropriate for a particular clinical need.
2. Requisites of Individual Measures in an Analysis
All cephalometric analyses are collections of measures, norms,
and/or ideals which in combination provide information needed
for treatment planning, and assessment. The total analysis is de-
pindent on the worth of the individual measures which comprise
it and on the adequacy of their combination.
a) One should know whether the value to which the measure
is compared is a sample mean or an esthetic objective. "]deals"
are not "norms."
b) One should know how the value, whether mean or ideal,
changes with age, how it varies by sex or ethnic group, and how
it co-varies with other measures in the analysis. Is the measure a
typical measure of growth with "s" -shaped configuration due to
periods of acceleration; is it a growth measure showing steady,
264 Diagnosis

even increments; or is it a "constant" which is relatively invariant? A Mean 80° S.D. 4°

Measures of growth behave differently from measures of pattern, +1
I S.D I I I I I I I I I I I I I
I .•.\ I I I
and many traditional cephalometric measures are not good depic- . I 72 I_ -1 76
74 S.D. 78 80 82 84 86 88
tors of either pattern or growth.
c) Measures which are esthetic objectives shollld be explained
as to their origin and clinical application. Ideals are contrived
configurations; a value which is "ideal" for one face may be Mean 80° S.D. 1°
inappropriate for another. Clinicians who prepare and advocate
72 74 76 78 80 82 84 86 88
cephalometric ideals are trying to give us images of faces they
like, facial shapes to be achieved during treatment. Potential users
I I I I I I I I I I I I I I I
should ask how the values were determined, how they relate to
- 2 S.D. + 2 S.D.
normal means, and how they vary according to sex, ethnic groups,
facial type, and age .
.d) When measures are derived from research populations one
-3 -'5$'5.0
S.D.\'" -1+ 3 S.D.
FIG 12-22.
should know the nature of that population and the variability of Identical means with different variances. Note that measures A and
the measure. Many measures commonly used show marked changes e have a mean of 80 degrees, but mean A has a SD of 4 degrees
in value during growth and significant differences between the and mean B has a SD of 1 degree. Suppose that a patient has the
sexes and among various ethnic groups. As no patient is a member measure A and e, each showing 80 degrees. For measure A, 83
of the sample from which a mean was obtained, the mean is useful degrees is within the range of normal; for measure e, this is such
only if the sample which it summarizes is appropriate to the clinical an extreme measure that it would be seen only about twice per
comparison. All norms should be described statistically and iden- hundred in a normal distribution. Therefore, the same numeric value
tified as to the population they sample: the method of sampling has clinical significance for e, but not for A.
must be specified. Furthermore, the norm is properly construed should be able to reconstruct the major features of the craniofacial
as a range, not a single value (see Fig 12-22). In clinical use,
form. If this is impossible with a particular analysis, then signif-
the extent of the range and its changes with facial type and age
icant parts of the facial form are unrepresented in it.
often are of more practical interest than the simple mean itself.
e) Ideally, faces having the same analytic values would grow
e) For any particular measure one should know the circum-
in the same way and respond to a particular treatment in a similar
stances under which it is systematically misleading. 11 (For in-
fashion. Unfortunately, cephalometric analyses have not yet be-
stance, anteroposterior [AP] measures of HA" point are consistently
come that specific in their classifications ..
misleading during the eruption of maxillary permanent incisors,
f) Simple combinations of the variables in an analysis ought
because "A" point is obscured by the incisors' crowns).
to segregate similar cases with similar prognoses.
fJ For any value of a measure, ideal or not, one must under-
g) Treatment which purposefully alters one measure should
stand the full range of configurations which have that measure
have predictable effects on other measures.
(see Fig 12-22).
h) Specific measures of the analysis applied to a patient should
g) Each measure should have a clearly understood subject
correspond to particular aspects of of the treatment intervention
matter: size, shape, relative position, or relative orientation. Some
planned. For example, an XYZ angle of 7 degrees should prescribe
current measures are mixed in nature, embodying both size and
one aspect of a consistent, specific therapeutic procedure. But if
position. A large angle SNA may be due to a long maxilla, a
an angle of 7 degrees means one treatment in one face, and another,
maxilla more ventrally positioned than normal, a short anterior
totally unrelated treatment in another face, then this measure by
cranial base, or any combination of these factors. As the measure
itself probably is useless to the clinician. To state that a particular
is not specific, the clinician cannot use it for effective discrimination.
angle "therefore must be reduced 3 degrees" is not a treatment
prescription, as it does not tell how to reduce the angle in that
3. Requisites of a Cephalometric Analysis particular face.

Our literature offers many so-called "cephalometric anal-

When a patient's measures are close to the mean, the analysis
yses." These have several purposes and are of widely varying
is of lesser importance. Modern orthodontic biomechanics is quite
utility. Here are some criteria to aid in evaluating them.
sophisticated, so that the \;linician can camouflage mild skeletal
a) An analysis should comprise "a set of measures each of
dysplasia by clever treatment involving only tooth repositioning
which meets the requirements of individual measures listed earlier
and remodeling of the alveolar process. The most critical test of
(see Section G2).
any cephalometric analysis is the detail it reveals and the clinical
b) The purpose(s) for which the analysis is (or are) intended
insight it provides for patients having several measures far from
must be clearly stated-diagnosis, prediction, assessment of treat-
their expected values. For such patients, routine treatment is in-
ment effects, etc.
adequate. Should only the mean value be known and no idea of
c) Each measure in the analysis should have a specific func-
variance given, the clinician cannot know how far from the norm
tion, and there should be minimal redundancy. A parsimonious
the patient's measures are (see Fig 12-22). One might even regard
set of proper measures is more practical than a large set of poorly the means as reasonable treatment goals, but would not do so if
selected measures whose purposes are obscure.
important measures were known to be far from their normal values.
d) Given the quantities of the analysis for an individual, one
 Analysis of the Craniofacial Skeleton: Cephalometries 265

4. Evaluating Morphology (Variations in Form)

This is a textbook; therefore, we must recommend some (sI TIER

cephalometric procedures for clinical use. There is no published

advice about designing a best cephalometric analysis (but see
Bookstein, 1983, for a not particularly constructive critique of
""7
2"d TIER

some bad ones). What follows, in this section, is th,e senior author's
(REM) personal preference, found suitable in his practice, but not
claimed to be optimal. The analyses presented in this section arose
from ransacking a large collection of conventional cephalometric SYMMETj
ANALYSI~l
3rd TIER
variables, including many with other eponymous proponents (e.g.,
Down's analysis, Tweed's analysis, McNamara's analysis, etc.).
We selected those variables that had the smallest mean square for
time trend and highest autocorrelation in our data base of Michigan
school children aged 5 to 18. Other lists of variables no doubt ""7
41h TIER
TYPING
could be constructed that serve this same purpose as adequately
or better; these are Moyers'. I
INTEGRATION
a TREATMENT
The variables utilized display relatively weak time trends and PLANNING

thus will be called "constants" in what follows: "constants" in

the sense that the average time trend is small. We do not mean
to imply that they do not, in fact, vary, nor that they show no
trends in individuals, only that the mean trend of each variable is
nearly flat.
If we are persuasive in sections A through F, then this Section
G should soon be superseded by other analyses more in keeping
with the design criteria we set forth earlier.
a) Basic Morphologic Analysis
1) Purposes.- This analysis has two purposes:
a) Diagnosis. To identify any skeletal basis for the maloc-
clusion by comparison of the patient's skeletal morphology with
appropriate standards.
b) Screening. To identify the need for more specific cephalo-
metric analysis (Figs 12-23 and 12-24).
2) Basis.- A small set of selected "constants" -measures
which are relatively unchanging through time-are used for the
comparison. ]8.20 They were developed for this specific purpose
from the University of Michigan Growth Study, an extensive col-
FIG 12-24.
Elaborated cephalometric flow chart (see text).
lection of serial growth data on North American white children,
largely of North European ancestry. The measures may be constant
for other ethnic groups-that has not yet been tested-but they
would in any case undoubtedly have different means.
3) Method.-
a) Trace the patient's lateral cephalogram and measure each
of the angles included in the analysis (Fig 12-25,A). An alternative
set of measures is provided (Fig 12-25,B) if any landmarks in the
preferred set cannot be used.
b) Compare the patient's values for each angle with the ap-
propriate Z-score chart* (Fig 12-25 ,C).
e) Try to discern the implications of any measure more than
I standard deviation (SO) from the mean. In particular, try to
understand the effects of combinations of atypical measures. By
the end of Chapter 18 you may be able to tell whether they ag-
gravate, compensate, obscure the principal symptoms, which de-
viant measures can be changed by orthodontic treatment, and which
cannot be changed, but can be masked by treatment.
cl) Any measure or combination of measures deviating sig-
nificantly from the mean signals the need for another more specific
analysis.

b) Vertical Analysis

1) Purpose.- The purpose of vertical analysis is to localize

j and quantify any vertical skeletal contributions to the malocclusion.
"

2) Basis.- A selected set of, "constants' , (except those using

1
x-x
*The Z score for a variable X is the new variable --- . It has a
Sd (X)
mean 0 and a standard deviation ] (see Chapter I) and so purports to
allow deviations from "normal" on diverse variables to be compared on
FIG 12-23. a common (dimensional) scale. Any variable that is a score of 1.96 is
Basic flow chart for cephalometric analyses. The Basic Morphologic thus "equally abnormal" (in this sense) regardless of the original varia-
ble irrespective of the units of the original measure. Therefore, meas-
Analysis is used first to discern which other analyses may be nec- ures, even if in different units (e.g., degrees and millimeters), can be
essary for a specific patient. compared.
266 Diagnosis

c -3 -2
MALES
-tS.D X 15.0. 2 3 -3 -2
FEMALES
-15.0.X ISD. 2 3
Crania/ Bos~ I
Ba-SE-FMN
.u. ': .• ", J. .... I•... ,I., ,I... ,I. ..•. ~.
1'25 130 135 140.0
I, ..145h, I~ 155,
155,

Ba-S-Na
1
'I' , ,11 . , , ,I. , , , .• J I . , . ,. ,
II~ I 120 125 130.2 135 140 1'45
1
Crania/Base-Maxilla I I i
S-N-A 751
I ~ ~ ~ W1
SE-FMNA 85 90 95 105 110
Crania/Bas8-Mandiblt1(H) I
Ba-SEeMe 55 60
Ba-SE-Pag 60 I 65 80
Crania/ Base-Mandible(Vj
Ba-SE/Mand. Line 55 1 60
PM Vert /Mand. Une
Maxilla-Mandible
Mend. Line/A - B

Fl.flCl.Occl.Ln./A-B
(not 0 cooslont)

Skelelal Profile
FMN-A'B
1145
,

FIG 12-25.
Basic Morphologic Analysis. A, preferred measures. B, alternate in the center of the scale and range out ±3 SO on either side. In
me~sures. C, Z-score chart for use in practice. The patient's exact this fashion, one can quickly discern those basic skeletal measures
measures taken from the cephalogram are recorded on the appro- of clinical significance.
priate scales according to sex. Note that the mean values are arrayed

the functional occlusal line) and measures of relative stability from Occlusal Line is not a constant, but it is clinically important to
the same data as the Basic Motphologic Analysis (Michigan Growth note, bow the occlusal and~'alveolar regions have adapted to the
Study). ,. unfolding skeletal pattern of growth. Note too that the more stable
lines are in constant relationships, but the rate or duration of growth
3) Method, Pattern Analysis.- along those directions varies, hence the need to do a vertical growth
a) Trace the lateral cephalogram and construct the PM ver- analysis when the pattern is shown to be abnormal and during
tical, upper maxillary, palatal, functional occlusal, facial, and pubescence (see Tables 12-3,A to 12-3,J in the Appendix.
mandibular lines (see Figs 12-13,D and 12-26).
b) Measure the anterior-superior angles where the PM vertical 4) Method, Growth Analysis.- Rigid proportionate rela-
line intersects the other lines. tionships of face height are often presumed or presented as treat-
c) Refer to Figure 12-26,B to identify those measures which ment ideals. Natural age changes and important sex differences
deviate from the standards. Note that the angle to the Functional (especially during and after pubescence) in facial proportions are
 Analysis of the Craniofacial Skeleton: Cephalometries 267

FIG 12-27.
The effects of mandibular position on the profile. The dotted line
shows the mandibular postural position; the solid line, the occlusal
position. Note the improvement in the skeletal profile when the man-
dible is "at rest."

12-3 which presents mean values and standard deviations of all

usual facial height measures (see Fig 12-48) for both sexes from
age 4 to 18 years as well as several similar statistics for the most
frequently used facial proportions. Such comparisons help define
desired treatment changes.

5) Method, Functional Analysis.- Vertical analysis should

..
3'
-2
- -- -
2X .. - MALES include the skeletal relationships when the teeth are occluded and
-3
B90 -\5.0.
15.0.
PM Vert/FMN-SE
'~85
VERTICAL ANALYSIS
apart in the mandibular postural position (Fig 12-27), particularly
if a large interocclusal distance was noted during the cursory ex-
amination. Differences in these two mandibular positions affect
diagnosis and treatment planning, particularly in young children
Maxilla with Class II malocclusion, Class. III malocclusion, and/or exces-
PM Vert/Pal. line MAlES sive vertical overlap (see Chapter 15).
90 95
I

FEMALES
85 90 c) Profile Analysis
Occlusion
PM Vert 10eel. Line MAlES
(not a constant in Class D) ~5
100 105 1110 115 1) Purpose.- The purpose of the Profile Analysis is to
I
FEMALES .j..... evaluate the craniofacial skeletal and dentoalveolar profiles and to
175 100 1051 110
I localize the regions contributing to any "imbalance," that is,
Mandibl.
PM Vert/Mond. Line MAlES obvious retrognathism or prognathism of either jaw. Several stud-
ies, notably those of Graber's and Lucker,22 found that a straight
FEMALES
profile is considered more pleasing at all ages.

FIG 12-26.
'Vertical Analysis. A, lines and measures of Vertical Analysis I(pattern
analysis.). B, Vertical Analysis I (pattern) Z-score chart.
ignored in such narrowly defined "ideals." Study of the graphs
of height changes presented in the Appendix to this chapter is a
useful supplement to sensible ~~e of any vertical cephalometric
analysis. Growth in face height is much more varied and compli-
cated than may be realized. For example, Figures 12-49 and 12-
50 and Table 12-3 show distinct sexual dimorphisms in growth
of some facial height measures (particularly in adolescence), changes
in facial proportions with time, and significant differential timing
of decelerations in facial height increments. If the vertical pattern
analysis reveals abnormality in any angle of at least one standard
deviation, use the vertical growth analysis to aid in localizing any
disproportions. Compare each of the patient's measures to Table
2) Basis.- The analysis presented here is derived from the
Counterpart Analysis devised by Enlow et al. (Fig 12-28).13 They
found the ratio of maxillary to mandibular skeletal and dental unit
distances to be relatively invariant, with a mean value quite close
to 1.0 for both sexes (Table 12-1).
":. 3)Method.-"
" a) At lines parallel to the functional occlusal line measure the
distance to PM vertical from "A" point, superior prosthion, in-
ferior prosthion, and "B" point (see Fig 12-28).
b) Compare maxillary unit distance, skeletal, with mandibular
unit distance, skeletal. In Fig 12-28 this becomes (B2 + B3)/(B4
+ B6).
e) Compare the maxillary and mandibular unit distances, den-
toalveolar; in Fig 12-30, this is (Bl + B3) = (B4 + B6).
cl) Study the soft-tissue profile and occlusal relations at the
268 Diagnosis
FIG 12-28.
The Profile Analysis (modified Counterpart Analysis). The complete
array of counterpart measures are shown in Fig 12-19,0. (From
Enlow OH, Moyers RE, Hunter WS, et al: A procedure for the analysis
of intrinsic facial form and growth. Am J Orthod 1969; 56:6-23.
Reproduced by permission.)
postural and occlusal positions to identify mandibular translations
on closure and opportunities for clinical utilization of the inter-
occlusal distance (see Fig 12-27). This is especially important in
some Class 11treatments. (See Chapters 15 and 16 and also Section
G-9 later in this chapter.)
e) Try to estimate the effects on the unit distance ratios and
the profile of altering any of these distances or angles (see Section
G-5).
A further simplified version is sometimes used for analysis
of the profile of "nongrowing" adult patients (see Fig 12-40).
See Chapter 17 for its application in orthodontic treatment of older
patients with malocclusions complicated by periodontal disease
and/or loss of teeth.
d) Analysis of Symmetry
1. Purpose.- Analysis of symmetry is done to identify any
mediolateral skeletal asymmetry which might be related to the
malocclusion. Asymmetry may be either dysplastic (i.e., part of
the fundamental morphology) or compensatory or adaptive to ac-
cidents, trauma, or alterations in the functional environment.
2. Basis.- Left-right symmetry is generally presumed. Since
we do not yet know the amount considered clinically significant
for particular malocclusions (e.g. crossbite), the basis for this
analysis is somewhat different than most, and these comparisons
are within the patient, not to standards. It must be remembered
that this procedure detects only two-thirds of the asymmetries for
it ignores those in the AP direction.
3. Method.-
a) Trace the PA cephalogram, locating all structures shown
in Fig 12-13,C, and construct the midsagittal line.
b) Measure distances at right angles to the midsagittal line
for the skeletal landmarks shown in Fig 12-13,C, noting left-right
differences vertically and mediolaterally (see Table 5).
c) Measure the distances to dental landmarks of particular
interest, for example, the dental midlines, the positions of indi-
vidual teeth, etc. (Fig 12-29).
5. An Analysis for Prediction of Morphology
Some introductory comments are necessary on the prediction
of craniofacial growth, a popular topic these past few years.'9
Properly defined (see Section F-2-c), craniofacial skeletal growth
measures are very difficult to predict precisely enough for practical
use. Clinically we would like to be able to predict accurately for
one specific individual (I) the amount of remaining growth of
critical anatomic parts, (2) the timing of important growth events,
such as the onset and cessation of the pubescent growth" spurt,"
(3) "growth vectors" and their changes in any conventional reg-
istration, and (4) the specific effects of orthodontic treatment on
craniofacial growth. But at this time these characteristics of growth
are not predictable-some are not even defined or definable, e.g.,
growth vectors and changes in growth vectors during treatment.
Most current "growth predictions" or "forecasts" based on one
cephalogram are too crude to be clinically useful." Practical pre-
diction of craniofacial skeletal growth is not yet available. In the
meantime, prediction of skeletal morphology is u~eful and simple.
a) Purpose
The method described here has as its purpose the estimation
of the future relationships of the most stable and least adaptive
parts of the face. It does not predict how the alveolar and other
adaptive areas will behave, when growth in a particular direction
will change its rate or stop, nor does it predict the effects of
treatment on growth or morphology. It simply displays how the
most important stable regions will likely relate to one another in
the future. That display makes possible a better visualization of
treatment objectives (see Section G-9, Visualizing Treatment Ob-
jectives, later in this chap~er).
A B
\\J
'J
" I
I
\
: DK
I". 12-6
L
--.-
3
FIG 12-29.
Analysis of symmetry. A, registering on the shadows of crista galli
and its immediate region, an arbitrary midsaggital plane is drawn.
The structures on the left side of the head are traced as shown, then
the cephalogram is turned over and the structures on the right side
are traced, thus permitting the superpositional observation of local-
ized asymmetry. e, measurement of asymmetry both horizontally
and vertically in the posteroanterior cephalogram.

A c
E F
Ba
FIG 12-30.
Prediction of future morphology. A, summary sketch of procedure.
S, method for estimating the position of the mandible after growth.
C, method for estimating cranial base change anteroposteriorally. D,
b) Basis
This analysis approximates average growth changes as ex-
tensions at the average rates along directions which do not, on
average, rotate with respect to cranial base. Other ways of carrying
out this same purpose are more precise but more complex5. 7
c) Method
a) Complete the Basic Morphologic Analysis of the lateral
cephalogram (see Section G-4-a.). ,.
b) Holding the angle Ba-SE-Me "constant," extend the line
from SE to Me by the distance indicated in Table 12-6 (see Ap-
pendix) as the average amount for the patient's age and sex for
the time period to be predicted, and trace the outline of the man-
dible and the mandibular first molar (Fig 12-30,8).
c) Extend the line SE-FMN the distance indicated in Table
12-6 the average amount for the correct age and sex for the time
period to be predicted, and trace the nasal bone and forehead region
(Fig 12-30,C).
Analysis of the Craniofacial Skeleton: Cephalometries 269
composite to show effects of cranial base prediction on maxillary
prediction. E, method for estimating maxillary position after growth.
F, composite prediction of growth.
d) Holding the angle SE-FMN-A constant, register on the just
estimated predicted position of FMN and extend the line FMN-A
the distance indicated in Table 12-6 for the correct age and sex
and the time period to be predicted. Then trace the outline of the
palate and central incisor (Fig 12-30,0 and E).
e) Figure 12-30,F displays the complet~ traced prediction.
'.
6. Analysis of Growth
a) Purpose
The purpose of growth analysis is to assess the patient's
growth by comparison with appropriate standards.
b) Basis
The tendency for children to maintain the same relationship
to normative values during growth is called canalization or chan-
nelization. This relative stability is better for constants, of course,
270 Diagnosis
but it is far less certain for growth measures; hence, the need for
regularly monitoring them.
The standards of The Univers}ty of Michigan Growth Study2)
are the source of the tables of selected growth measures presented
in the Appendix to this chapter. These standards were derived from
an extensive collection of serial growth data on North American
white children largely of North European ancestry. The values
cannot be assumed to be pertinent for children of other ethnic
origins and circumstances. Reference to Riolo et al. 23 is recom-
mended for readers seeking information about normative age means
and variances of measures not listed in the Appendix to this chapter.
c) Method
a) Measure the distance as defined.
b) Compare the patient's value with those in the appropriate
table in the "mini-atlas" at the end of this chapter (Tables 12-
3,A to 12-3,1, Tables l2-4,A to l2-4,F, Tables 12-5,A to 12-
5,G, and Figures 12-55 to 12-62). A good generalization to keep
in mind is that ± I SD includes about 67% of the total population,
± 2 SD includes approximately 95%, and ± 3 SD more than
99% of all normal cases.
7. A Method for Discriminating Class 11 Types
The analysis described here is a simple noncomputerized
method of discriminating several of the quite different morphol-
ogies which comprise the large designation "Class 1I malocclu-.
sion. " 19 Its place in the overall scheme of cephalometric analysis
is shown in Figures 12-23, 12-24, and 12-31.
a) Purpose
a) To localize and quantify any possible skeletal contributions
to Class II malocclusion.
BASIC
MORPHOLOGIC
ANALYSIS
CLASS IT
ANALYSIS
VERTICAL
CLASS IT
ANALYSIS
FIG 12-31.
Flow chart for discrimination of Class 11malocclusion.
b) To identify dental displacements associated with the Class
II malocclusion.
c) To assign the patient to one of the Class II types.
b) Basis
"Class II" is a loose, subjective designation including an
assortment of problems ranging from simple to the most difficult. 19
It is useful for the clinician to group together cases whose features
are sufficiently similar to permit a common treatment. Such group-
ings, to be useful, must be natural and determined by the mea-
surable morphologic features of the patients to be treated. Sub-
jective groupings are less reliable than those which result from
statistical clustering of cephalometric measures. 26
Six horizontal types of Class n malocclusions have been
identified as well as five vertical types.
1) Horizontal Types.- There is a continuum from cases
with normal skeletal characteristics but Class II dental features
(type A) through those with mild skeletal features (type F) to four
distinctly different skeletal types (types B, C, D, and E). The
diagrams in Figure 12-32 provide ways of mentally depicting the
six horizontal groups. Four (Types B, C, D, and E) might be
termed syndromal types of Class n, for they have distinctively
combined skeletal and dental features. Type F, the largest group
of all, has less well defined, less characteristic features of skeletal
Class n, yet is clearly not Class I. In type F each individual has
some Class n characteristics, although not sufficiently severe to
be termed either type B, C, D, or E. Each type F case looks like.
a milder version of type B, C, D, or E and may be so designated
(FB). Type A has scarcely any Class n skeletal features. See Table
12-2 for data on the distribution of one pool of clinical samples.
Other forms of Class n undoubtedly exist but are not seen in North
American whites often enough to be characterized as a "type."
Type A is characterized by a normal skeletal profile and normal
AP position of the jaws. The mandibular dentition is placed normally
on its base but the maxillary dentition is protracted, resulting in
a Class n molar relationship and greater incisal overjet and overbite
than normal (see Figs 12-32 and 12-36,A). Type A is sometimes
referred to as a "dental Class n."
Type F is a large, heterogeneous group with mild skeletal
Class II tendencies. It is useful to think of each type F as a milder,
nonsyndromal form of types B, C, D, or E (see Fig 12-32, Fig
l2-36,B, and Table 12-2).
Type B displays midface prominence associated with a man-
dible of normal length. Measures of maxillary prognathism are
greater than normal, but the mandible is in a normal relationship
anteroposteriorly (see Figs 12-32 and 12-36,C and G).
Type C cases display a Class n profile, though the maxilla
arid~\Tlandible are furthe~ back beneath the anterior cranial base
than normal. Type C cases have smaller facial dimensions than
other Class n types on average. The lower incisors are tipped
labially, and the upper incisors are either upright or tipped off the
base labially according to the vertical category (see Figs 12-32
and 12-36,D). Significantly more women than men are seen in
type C.
Type D displays a skeletal profile which is retrognathic be-
cause there is a smaller than normal mandible. The midface is
normal or slightly diminished. The mandibular incisors are either
 271

A 8
~

Lj
NORMAL

A (Maxi Ilary Dental D (Mandibular Retrognathism

Pratractian) ond Maxi lIary Retrognathism

B (Mid- Face
Prognathisml
o
+Maontal

Protraction
Protraction)

E (Maxillary Prognathism and Dental

and Mandibular

q
Dental Procu,:"bency)

Ljl
C (Maxillary F (Combination of Slightly
Retrognathism + Abnormal Variables)
Dental Protraction and
Mandibular Retrognathism
+ Dental Procumbency)

FIG 12-32.
Horizontal Class 11types. A, schematic comparisons of the horizontal types as the fingers of a hand where the bones are distinctly sep-
types. In this arbitrary depiction, normal is perfect anteroposterior arated from one another, yet in the palm (type F) their distinctness
alignment (see top drawing). B, one may fancy the Class 11syndromal is obscured.

upright or lingually inclined, whereas the maxillary incisors are
typically labially positioned (see Figs 12-32 and 12-36,E).
Type E shows a "Class 11" profile even though there is a
prominent midface and a normal or even prominent mandible.
Bimaxillary protrusion Class 11 malocclusions are more apt to be
horizontal type E. Both dentitions have a tendency to be forward
on their bases, and the incisors are often in strong labioversion
(see Figs 12-32 and 12-36,F).
2) Vertical Types.- The five vertical types are not as clearly
differentiable as the four syndromal horizontal types. Certain ver-
tical types are characteristically identified with certain horizontal
groups (see Table 12-2). It is not necessary for a case of a hor-
izontal type (especially types A or F) to be associated with any of
the described vertical Class 11 types, for the subject could have
normal vertical measures. The vertical types are depicted in Figure
12-33.
Type 1: The dominant feature of vertical type I is an anterior
face height disproportionately greater than that of the posterior
face (Fig 12-33,A). The mandibular and functional occlusal lines
are steeper than normal, and the palate may be tipped somewhat
downward while the anterior cranial base tends to be upward. Type
I is often called a "steep mandibular plane" case or a "high
angle" case and probably corresponds to the surgeon's so-called
"long face" syndrome (see Figs 12-33,A and 12-36,E).
Type 2: Vertical type 2 is essentially a "square face". The
mandibular line, functional occlusal line, and palatal line are more
horizontal than normal and often seem nearly parallel. The gonial
angle is smaller than normal, and the anterior cranial base appears
horizontal. Under these ~onditions the incisors adapt to more ver-
tical positions than normal and a skeletally imposed deep. bite
results (see Figs 12-33,B and 12-36,A, C, and D).
Type 3: The characteristic feature of vertical type 3 is a palatal
line tipped upward anteriorly associated with a decreased anterior
upper face height and resultant predisposition to an open bite.
When the mandibular line in vertical type 3 is steeper than normal,
a severe skeletal anterior open bite is inevitable. The features of
type 3 are shown in Figures 12-33,C and 12-36,B.
. Type 4: In vertical type 4, the mandibular, functional occlusal,
and palatal lines are all tipped downward though the mandibular
line is near normal, leaving the lip line unusually high on the
maxillary alveolar process. The gonial angle is relatively obtuse.
Because of the length of the midface in horizontal type B, with
which all vertical type 4 malocclusions are associated (see Table
12-4 in the Appendix), the upper incisor~ are usually tipped la-
bially, and the lower incisors are tipped lingually. (Upper incisors
are usually normal or labial in all other type B Class 11malocclu-
siQn.s.) (See Figs 12-33,D and 12-36,G). Fortunately, type 4 is
rare ...
Type 5: In type 5, the mandibular and functional occlusal
lines are placed normally, but the palatal line is tipped downward,
and the gonial angle is smaller than normal. The result is a skeletal
deep bite similar to but different than that seen in vertical type 2
(Figs 12-33,E and 12-36,F). In type 5 the lower incisors are
found in extreme labioversion whereas the upper incisors are nearly
vertical.
3) Combining Horizontal and Vertical Types.- In Table
 272 TYPEIncomplete
11.4
45 %
100.0
37.4
25.4
5.3
3.6
1.9
27.3
1.7
60.0
18.9
33.4
21
Diagnosis data 132
233
80
37
13
190
418 25
NO.
NO.
177
52
25
12 Normal
D. Vertical Types
697 Distribution
TABLE A. Horizontalof Class 11Types
12-2.

12
%%
27.3
100.0
12.0
3.6
11.4
7.4
38.6
1.7
3.6
26.5
27.3
21.4
1.7
NO.
190
52
269
9.9
149
B. Horizontal:
-
F E 190
7.4 Maxillary Prognathism and C,D
TYPE
B,
A 69
185
84
80
5225
Mandibular12NO.
25
Dental Class 11
----- -
697 TYPERetrognathism
DESCRIPTION E. Matrix of Horizontal and Vertical Types
10
40
39
410
23 -15
18
547825 84 I1
0IT
OP
TL
A
ZY
8013
185
69
52
190 03BAF24
46
45
54
233
aV)C
Data
(H
E 45
54
0 68
16
18
24
11
32
132
697
15
14
165 1
Normal 4'4
VERTICAL
Unclassified 12 Total
NE
R TYPE
Incomplete
H ~L ~

12-2,E the joint distribution of horizontal and vertical types in a
sample of 697 Class II malocclusions are displayed. Note that
since type A is not truly a skeletal Class II malocclusion, a normal
vertical is usually displayed. However, milder versions of the two
most common Class II vertical types, types I and 2, are found in
association with type A. There is a similarity between horizontal
and vertical distributions of types Band E (high percentages of
them are vertical types 2 or 5), but they differ in their dental
features. Only type B manifests the anomalous, difficult vertical
type 4. There are similarities in the distribution of vertical types
in horizontal types C and D.
c) Method
1) Identifying Horizontal Types.- The procedure for iden-
tifying horizontal types utilizes an arborization which segregates
these types. On the left side of Figure 12-34 are arrayed five
questions to aid in the differential typing of Class II malocclusions.
These questions are answered after comparing the patient's values
of specific measures to normative standards (Fig 12-35). The
measures used in this procedure are mostly constants found useful
in differentiating the horizontal and vertical types described earlier.
For example the first question, "Is the subject a skeletal Class
I1?" is answered by particular measures of A-B relationship whose
means and range are displayed above the first dotted line in Fig
12-.35. Skeletal Class il cases show values above the mean. In
this instance the arbitrary cutoff value is 0.5 SD above the mean.
If the patient falls above of this value, he or she is assumed to be
in skeletal Class 11, and type A has been eliminated as a possibility,
as have some of the milder forms of type F (Fig 12-34). When
analyzing a patient exhibiting skeletal Class 1I, it is useful to
determine which anatomic regiClns are the principal contributors
to the dysplasia. The second question, "Is the midface prog-
nathic?" and the third question, "Is the mandible retrognathic?"
help us. Values above the cutoff (0.5 SD) for mid face prognathism
i~dicate maxillary cont;fbutions to the Class 11; those below the
cutoff value (0.5 SD) for mandibular retrognathism indicate man-
dibular involvement. Types Band E show midface prognathism;
types C and D have mandibular inadequacy. Type F is a combi-
nation of mild maxillary and mandibular skeletal f~atures by these
conventions and definitions. The remaining two questions pertain
to dental features of Class 11 whose measures are less constant
than the skeletal measures but are characteristicalJ~ typical of the
clinical types; therefore the cutoff value is largef, namely, 0.75
SD. Assigning choices to each of the five questions leads one
through the arborization to the bottom of the chart, where a hor-
 Analysis of the Craniofacial Skeleton: Cephalometries 273

izontal type is named. Those position,s of the arborization which' A

have no letters indicate rare or ambiguous outcomes of this clas-

sification procedure. A heavy vertical line within the arborization
indicates a point on a path only rarely followed.

2) Identifying Vertical Types.- In Figure 12-33 the five

vertical types are depicted. The measures used for their discrim-
ination are angles cut upon the posterior maxillary vertical line.
Figure 12-26,B is a Z-score chart for comparing the patient's
values with those of the population at large. Remember that many
patients with horizontal Class Il malocclusions, especially of types
A and F, have vertical features within normal ranges. Vertical
c
type I shows typically large values for angles of PM vertical with
the lIlandibular, occlusal, and palatal lines. Vertical type 2 man-
ifests small values for the same angles. Vertical type 3 usually
shows a relatively small palatal line angle alone. Vertical type 4,
found only in association with horizontal type B, shows high angles
for palatal, occlusal, and mandibular lines and a relatively obtuse
gonial angle. Vertical type 5 shows a relative large angle of PM
vertical with the palatal line, nearly normal angles with the occlusal
and mandibular lines, and a small (nearly orthogonal) gonial angle.
Figures 12-32, 12-33, and 12-36 may be studied to understand
better the various types.
The assumption of this procedure is that the identification of
E
the clinical type leads to more logical treatment planning (Chapter
14) and treatment for Class Il types (Chapters 15 and 16).

8. A Method of Discriminating Class III Types

Although a variety of mal occlusions are grouped together

under the general category called "Class Ill," few quantitative
discriminative studies of types within Class III have been done.12
The literature speaks generally about mandibular prognathism (Class
III resulting from mandibular hyperplasia), midface deficiency
(Class III resulting from relative AP shortening of the maxillary
region), and "pseudo" or "functional" Ciass III (Class III molar
FIG 12-33.
relationship resulting in part from a functional forward shift of the
A, vertical type 1. e, vertical type 2. C, vertical type 3. D, vertical
mandible on closure to occlusion). Anterior crossbites whose in-
type 4. E, vertical type 5.
cisal relations simulate some Class III dental features are not truly
Class III malocclusions. CLASS n PLOT, HORIZONTAL

Analysis of possible Class III morphology must include (I)

the general facial morphology, (2) identification of disharmonious Skeletol Class II?
+,-
regions, (3) the vertical position of the mandible in posture and
Mid-face Prognathic?
occlusion, and (4) the position and angulation of the incisors.
Proper cephalometric analysis as early as possible is essential since Mandible
RelrOf}lIo!llic .?
the skeletal aspects of Class III are often overlooked in young
Mandibular leeHl +I-
children (Fig 12-37). Figure 12-38 is a simplified version for use Procumbtlnl

with adults.

5014294026542757661197191947"100558\21133222761128
a) Purpose E (El 8+ 8 C+ C D+ D F F F F FE FE Fa Fe Fe Fe Fo Fo A A A A

The purpose of the analysis is to localize the primary mor-

N~697
phologic sites contributing to the Class III malocclusions. Unclassified:: 12
Incomplele Dolo ~ 25
b) Basis
FIG 12-34.
The basis for discriminating Class III types is a self-com-
Arborization (decision tree) for diagnosis of Class 11 horizontal types.
pariso'n of the patient's maxillary skeletal and dento-alveolar unit
(From Moyers RE, Guire KE, Riolo M: Differential diagnosis of Class
distances to the patient's own mandibular skeletal and dento- 11 malocclusion. Am J Orthod 1980; 78:47'7-494. Reproduced by
permission.)
 1

rl , 90
274 I~5
-3
I110
341.8 3I.J
Horizontal
-2 50 X
Xtl~
-3
III
Ll..u
I ..
MALE 85 1
1.1
I I90
, .•
FEMALE ) ,,~
process. 350,
-SE-FMN-A
--______
_____ 65
--------1
________
-------1 1
,80
"60 2
70 B?7j
80 60
Bo-Se-B
-ISO
-ISD
-2 29
17570
155
301 125
ISO
lS0
Diagnosis
.185
.!...L
ISO
lS0
70
95
,~~,
1
I. 2I
, '1'~5"
I '7b 72d5' 85 I' "siJl '
arborization
the steep mandibular
,
Z score
line. _. form for the Vertical Analysis. Note
I/Md
SNB PI Ba-Se-B
I/MdPI
Class
lIFOP
Pal SNA
I/F.OP
PI./A-B11Z-score
~o chart
85 and arborization. A, the blank Z score form. OJ
pe by the
IIA-Po 11 FOP
______ 1

A f
 Analysis of the Craniofacial Skeleton: Cephalometries 275

c CLASS IT PLOT, HORIZONTAL

A
Skeletol Closs n,?

Mid-foce Proqnotllic?

MondJ/)le
Retroqnotllic ,?
Mondib/llor teetll
Proc/lmbent

Moxillory teeM +,-

Proc/lmbent

5014294026542757661197191947'1100558121133222761128
E (El B+ B C+ C D+ D F F F F FE FE Fe Fe FC FC Fe Fe A A A A

N=697
Unclassified = 12
Incomplete Data = 25

o VERTICAL ANALYSIS

-3 -2 -IS.o. X IS.O. 2 3
Cranial Base
PM Vert/FMN-SE MALES

Maxilla
PM Vert/Pal. Line MALES

FEMALES

Occlusion
PM Vert /Oee!. Line MALES
(not a constant in Class III
FEMALES

Mandible
PM Vert/Mand. Line

FEMALES

"
 276 Diagnosis

A 8 C

o E F

FIG 12-36.
Cephalometric tracings of typical Class 11 types. A, Class 11 type Class 11type 8-2. D, Class I1 type C-2. E, Class 11 type 0-1. F, Class
A-2 (horizontal type A and vertical type 2). e, Class I1type F-3. C, 11type E-5. G, Class 11type 8-4.
 Analysis of the Craniofacial Skeleton: Cephalometries 277

ASSUMED CLASS ill

OCCLUSAL SYMPTOMS

Mid - Face Mid-Face Deficiency Mondi buler

De ficJency Plus Mandibular Prognathism
Only ProQnathism On Iy

Growth +~rowth Growth + 1- No Growth Gro~- No Growth

81 r C D 1 r E

FIG 12-37.
Class III cephalometric analysis flow chart.

alveolar unit distances by means of the Counterpart Analysis (Fig
12-28). Further comparisons are made of the individual distance
of each horizontal Counterpart Analysis measure to appropriate
norms for age and sex (see Table 12-4).
c) Method
1) Variations in Form.- First use the Basic Morphologic
Analysis as a screening mechanism to identify any evident Class
III skeletal features (see Fig 12-25). If the Z-score chart shows
all values within I SO of the means, the malocclusion likely is
dominated by dental or functional features (see Fig 12-25,C).
2) Profile Analysis (See Also Section G-4-c).-
12-28 a useful simplification of the Counterpart or Enlow Analysis7
is shown. This method is one of the best for understanding the
basis for a skeletal Class III malocclusion since it emphasizes the
relative relationships of parts in one face (see Table 12-1). The
norms of reference are of these relations, not of explicit sizes. A
skeletal Class III malocclusion is presumed when the Skeletal Unit
Distance Ratio is 0.9 or less (at least 2 SOs from the mean of
1.0). When the midface measures (B-1, B-2, and B-3 in Fig 12-
28) are in harmony, that is, are nearly equal to the measures
contributing to mandibular prognathism (B-4, B-5, and B-6 in Fig
12-28), real size is of less consequence. When they are not, the
analysis helps localize the probable primary site of the problem
(Fig 12-39).
Though the Profile Analysis identifies a Class III and helps
localize it, it is still necessary to compare the patient's dimensions
with appropriate tables displaying means and ranges for sex and
In Figure age (see Table 12-4, which shows real distances as means for sex
and age). Dentoalveolar Class III problems are discriminated in a
similar way by use of the dentoalveolar unit distance ratio.
3) Vertical Analysis.- The Vertical Analysis (see Fig 12-
26), applied to cephalograms of both the postural and occlusal
positions (see Fig 12-27), helps identify any functional contri-
bution, often an important complicating factor in Class III mal-
occlusion. Reference to Table 12-3 is helpful in discriminating
and localizing, even at an early age, vertical contributions to and
complications of Class Ill.

4) Analysis of Incisal Adaptation.- An important feature

FIG 12-38.
Simplified profile analysis
pected during treatment.
used for adults when little growth is ex-
in Class III malocclus}<:ms is the way the incisors cope with the
dy:sgnathia. Determining factors. are the jaw(s) primarily involved
and the cant of the occlusal and mandibular lines. It is an unfor-
tunate convention to relate incisal angulation to distant structures
in the cranial base (e.g., Frankfurt Plane or S-N line). Sometimes
it is more revealing to note how the incisors and occlusal line have
adapted (Fig 12-40). The mean incisal angles (see Figs 12-35
and 12-40) may not be realistic goals to be achieved in treatment
of skeletal Class III malocclusion, but the means provide a way
of testing how the incisors have adapted. The comparisons may
 278 Diagnosis

/ 57 (54.5)
(51)
(51) (477) . (52.5)
(58)
(51) 056/(536)
~

5.5. 11-2 G.M. 11-8

FIG 12-39.
Examples of the Class III analysis. A, midface deficiency. B, man- dibular prognathism. Numbers in parentheses are the mean lengths
dibular prognathism. C, combination of midface deficiency and man- (mm) for age and sex of patient (Modified Counterpart Analysis).

give clues about how to place the incisors when the severity of
skeletal relationships makes it impossible to impose normal or 9
ideal incisal angulations (see Section G-9).

5) Class Ill, Summarized.- The methods outlined are use-

NORMAL
ful for identifying and understanding a particular Class III case
(see Figs 12-38 and 12-39). They will also help in discriminating
severe skeletal Class III from the simpler problems with only dental
and functional symptoms. Some basic principles for orthodontic
treatment of Class III patients are given in Chapters 15 and 16. A
brief discussion of the combined orthodontic-surgical correction
of severe Class III mal occlusion is found in Chapter 17.
TYPICAL
CLASS II
9. Visualizing Treatment Objectives

Depiction of expected future relationships was first developed

by Ricketts22 and has come to be termed Visual Treatment Objec-
tives. Any diagnostic cephalometric analysis is outdated at once TYPICAL
CLASS ill
for it reveals only the relationships at the start of treatment. Treat-
ment planning therefore must cope with expected changes due to
growth, displacement, and pattern persistence as well as the effects
of treatment itself-a very complicated problem indeed! In ad-
dition the clinician would like to have in mind some image of how
the face is intended to look after treatment is over. Such images FIG·1?-40.
are expressed as cephalometric value~' in sets which we may clas- Incisal adaptation to the profile. Due'to variations in the steepness
sify as (1) ideals, (2) norms, or (3) "archetypes." Ideals are of the mandibular line and the occlusal line, it may be unrealistic to
assumed esthetic values; norms are statistically derived population use normal incisal angulations as a goal in treatment. Note in par-
means; while "archetypes" 21 are ideal values for all individuals ticular that, as the mandible becomes more prognathic (Class Ill),
of the same type. All are used to visualize treatment objectives, not only does the inter-incisal angle increase, but the proportions of
and each has problems associated with it in practice. the inter-incisal angle contributed by the upper incisor and lower
incisor change greatly.
The use of the method of morphology prediction described
 Analysis of the Craniofacial Skeleton: Cephalometries 279

in Section G-5 above is useful as a Visual Treatment Objective in this context. However, only a gross, not particular, interpretation
(see Fig 12-30). can be expected (see Fig 12-41).

10. A Method for Evaluating the Effects of Orthodontic
Treatment
It is difficult to separate growth changes from treatment ef-
fects, important events taking place simultaneously, but there are
simple procedures to help one visualize and comprehend better the
effects of treatment during growth. The method is not sensitive to
some treatment effects on growth, for example, deformation (see
Bookstein5) nor does it clearly separate tooth movements from
orthopedic effects (see Baumrind et al.'). It is, however, a useful
introduction to the study of treatment effects. Innovative and re-
vealing new techniques have been developed recently of interest
to those intent on pursuing this topic. Bookstein's5 method of
deformation of triangles (described briefly in Section G-II) has
been successfully used to report the mean effects of different ap-
pliances, and Baumrind et aI.' have reported a method using more
conventional techniques to separate orthodontic from orthopedic
effects of therapy.
a) Purpose
1) To improve one's understanding of what happens during
treatment.
2) To separate growth changes from dentoalveolar alterations
resulting from orthodontic therapy.
3) To localize and specify the effects of treatment. For ex-
ample, has the wearing of a headgear in a Class II case (I) re-
strained expected maxillary growth forward?, (2) held the maxillary
dentition from being carried forward by maxillary growth?, (3)
moved the maxillary dentition dorsally?, (4) extruded the maxillary
molars?, and similar questions.
b) Basis
1) Prediction of morphology using pattern measures (see Sec-
2) Regional Effects.-
(a) Maxilla.- Changes within the maxilla may be assessed
by superpositioning on the superior and internal aspects of the
palatal bone (Fig 12-42). One should avoid the palatal curvature
directly behind the incisors since it is altered during the retraction
and repositioning of maxillary anterior teeth. Translation of the
entire maxilla occurs during growth alone and may also be an
important goal of treatment in some Class 11 and Class III cases.
Such changes can be observed by the cranial base registrations
noted above (Fig 12-41). This method does not quantify nor does
it separate the displacements of growth from those produced by
treatment, which can only be conjectured.
(b) Mandible.-Disceming changes within the mandible
may be visualized by registration on the mandibular canals and
the lingual aspect of the symphysis (Fig 12-43). Use of the medial
axis technique (Fig 12-44), currently only a research method, has
promise in this application as well. Neither quantitatively separates
growth from treatment effects, and both depend on knowledge of
normal growth and adaptation, eruption of the teeth, natural drift-
ing of the teeth, etc.; but they are superior to studying mandibular
change with distant registrations. Tensor methods (see Section G-
11) are efficient in revealing mean mandibular shape changes re-
sulting from treatment (see Fig 12-46).
\
\
\
\
\
I
I
I
I

tion G-5). t\
'~\ \
'-..,
2) Techniques for localizing areas for better visualization and \\
measurement. \
\ \
/
c) Methods /" /"
(
\
1) General effects.- Growth takes place unevenly but gen- AK "'j
erally while orthodontic treatment is planned to be localized se- -12-0 /\
--13-1 //
lectively. The cranial base displays small amounts of well-
understood normal change, and orthodontic treatment forces are
thought to have but minor effects on the area. Cranial base land-
marks are therefore not useful registrations even for visualizing .,
the general effects of craniofaciargrowth and attendant treatment.
The frontomaxillarynasal suture (FMN), sphenoethmoid registra- FIG 12-41.
tion (SE), and basion (Ba) (see Fig 12-13), are favored landmarks. Evaluating the general effects of treatment. Here registration is on
Registration at SE minimizes the effects of the minor changes in the sphenoethmoidal registration point and orientation is on the
cranial base length and angle which occur (Fig 12-41). FMN is sphenoethmoidal-PTM line (posterior maxillary line.) The case shown
chosen rather than nasion since the latter is not of the cranial base is a Class III malocclusion with midface deficiency treated by face
mask and full banded therapy.
and displays more varied behavior which obfuscates interpretation
 280

FIG 12-42.
Evaluating maxillary treatment changes. Registration is on the palatal
curvature (same case as in Fig 12-41).
f;;,J
~
c
11. A General Assessment of Deformation in Triangles
a) Purpose
The tensor method of Bookstein2. 4.7.8 constructs the distance
measures and shape variables that are most sensitive to particular
comparisons of clinical interest. By dealing directly with digitized
landmark locations, it avoids the need for any a priori choice of
variables, "constants" or otherwise, and is nevertheless a com-
plete cephalometric analysis.

b) Basis
Tensor biometrics is the expression of a rigorous new ap-
proach to the statistics of landmark points. It has close ties with
the techniques of "finite" element analysis familiar in engineering,
but is not equivalent (see Bookstein8•9).
c) Method
An explanation of the tensor computations requires more space
than is available in an introductory text such as this. Rules for
hand computation are found in Bookstein,' for automatic com-
putation in Bookstein,s or Bookstein!
G
. FIG 12-44.
Medial axis method. The axis is defined bya line joining a series of
points, each of which is equidistant to the external outline. In practice,
registration is always over one of the trifurcations. The examples
shown reveal essentially the same information as is gained from
metallic implants experimentally placed in the mandible of monkeys.
Note the growth adaptation in the condyle and regions of muscle
attachment. Shown are superposed oblique tracings of serial data
from seven Class mandibles.
11

d) Examples
Here we precis some research findings from the literature that
have exploited this method to organize reports of systematic shape
changes throughout the head. The method defines "form" as the
geometric configuration of a set of landmarks, and "change" as
the simultaneous change in all possible size and shape measures
of form. The underlying mathematical model is of deformation,
not rotation or translation.

1) Normal Growth.- The most precise characterization of

FIG 12-43.
Evaluating mandibular treatment changes. Registration is on the dor-
sal shadow of the symphyseal region on the shadow of the mandib-
ular canal. (Same case as in Figs 12-41 and 12-42.)
the" growth axis" from age 6 to 14 years is in terms of the relation
of Menton to the Sella-Nasion line (Fig 12-45).
In the lateral view, the most autocorrelated (i.e., predictable)
measure of splanchnocraniaUorm for males from 8 to 14 years is
very 'fl()arly the angle between Sella-Nasion and Mandibular lines.
The least predictable aspect of form i's associated with size change
"along" the growth axis.
2) Treatment Changes.- The principal skeletal effect of
intraoral treatment of Class 11 by Activator or Function Regulator

"v'"'
2~ ~ V
~IG 12-45.
v ..'"v
mO'" MEN
:h
The use of tensors to show form difference. This set of figures shows
the mean biorthogonal analyses, by sex, for sella-nasion-menton, a
typical cephalometric triangle. The subjects for this analysis were all
normal children followed between the ages of 11 ± 1 and 15 ± 1 years
from the University of Michigan Elementary and Secondary School
Study. The dilatations are annualized and printed in units of percent
per year.
The panel at upper left displays the mean annual change for
the 42 males of this sample, that at the upper right the mean annual
change for the 29 females. The lower right diagram represents the
relative tensor analysis comparing the sex-specific changes.
Either subgroup mean clearly corroborates the growth axis noted
by previous investigators. With respect to the cranial base, menton
appears to be displaced by growth along a line roughly perpendicular
to basion-nasion. In this analysis the baseline becomes the connec-
tion of nasion to a point 10% of the way from sella to menton, as
drawn. It is this triangle, not basion-nasion-menton or any triangle
on PtM, which locates the growth axis with greatest precision. Form
differences in two groups at the start of orthodontic may be compared
in a similar way.
11 is the relative displacement of Menton downward away from
the anterior cranial base (Fig 12-46). These treatments have no
net effect on the Maxilla, whereas extraoral treatment (cervical)
alters maxillary form in a manner best measured by the angle ANS-
S-N.
This method reveals the deformations of form (I) accom-
panying growth (see Fig 12-17) and (2) occurring in a patient
under treatment. Figure 12-46 shows how the method has been
applied to study the effects of treatment with different appliances.
Computer programs and data bases of normative growth and suc-
cessfully treated cases expedite and extend greatly the application
of the method. (See Suggested Readings at end of this chapter for
further details.)
H. SOME PROBLEMS AND LIMITATIONS
OF CEPHALOMETRICS
Although the cephalometric analysis is the single most useful
tool in orthodontic diagnosis and treatment planning, a practical
clinician will nevertheless thoroughly study the limitations of the
method so as to minimize its systematic errors. II To ignore its
Analysis of the Craniofacial Skeleton: Cephalometries 281
CONTROL CERVICAL ACTIV'R FRANKEL
MEN
FIG 12-46.
The use of tensors to show treatment effects.
problems is to deny oneself the full use and advantages of the
system of cephalometries. 17
1. Assumptions
In any method some things must be taken for granted as a
basis for action.
a) Symmetry
Analysis, particularly in the lateral projection, is based on
presumed skeletal symmetry. All faces have minor asymmetries
which are clinically unimportant, but more serious imbalances may
be obscured by the method or neglected by the dentist. Routine
study of the PA projection is a good antidote (see Section G-4-d,
Analysis of Symmetry).
b) Occlusal Position
Cephalograms must be taken in some occlusal pOSItion: it
makes a difference which one (see Chapters 5 and 11). It is con-
ventional to position the mandible in the usual occlusal position
when taking the cephalograms since this is where the patient' 'bites."
In malocclusions with an important functional element this con-
vention may be misleading. One should study carefully the pa-
tient's mandibular functional movements prior to recording the
cephalogram. Suspicions noted visually may be confirmed quan-
titatively in the cephalogram by two procedures:
(1) Use wax bites of both the usual occlusal position (centric
occlusion) and the retruded contact position (centric relation) to
record two lateral cephalograms. In extreme cases the patient may
wear a diagnostic spli'2t.for several days before the cephalogram
is ebtained (see Chapters II and 18).
(2) Use the postural position as well as an occlusal position
for both the lateral and PA projections (see Fig 12-27).
c) Orientation on the Transmeatal Axis
It is convenient to use ear rods to orient the patient's head.
The central ray is supposed to pass along the transmeatal axis. But
of course the external auditory meati are just as apt to be asym-
282 Diagnosis
metric as any other cephalic structures. Special cephalostatic pro-
cedures have been designed without ear rods so the central ray is
90 degrees to the midsagittal plane, but they are not in common
use.
d) Adequacy of One or Two Planar Projections
Almost all routine cephalometric analysis is done using only
the lateral projection. Much can be learned from PA, oblique, and
basalar views. The future may bring a practical true three-dimen-
sional cephalometric method (see Grayson et al. 16).
2. Fallacies
Any method may involve specific miscalculations, omissions,
blunders, oversights, errors, or inaccuracies which are not the fault
of the method itself. We speak here not about such mistakes but
about fallacies: misrepresentations intrinsic to the method.
a) The Fallacy of False Precision
If one makes a series of separate cephalograms of the same
head, traces each cephalogram, locates "A" point, nasion, and
"B" point, and measures the ANB angles, it will be discovered
that the standard error of that measure is greater than 1.5 de-
grees. 11. 20 Therefore, any decision, such as a choice of treatment
procedure, based on the value of ANB angle, alone or in combi-
nation with other measures, must have a gray area of approximately
± 1.5 degrees where the treatment prescription is ambiguous ..
This problem is compounded when a clinician compares a case he
or she has traced to standards developed, and therefore filmed and
traced, by another.
b) The Fallacy of Ignoring the Patient
Means are population averages which have nothing to do with
the specific characteristics of particular patients. A patient's mea-
sure need not be increased by, for example, 4 mm just because it
differs by 4 mm from the mean.
There are many beautiful faces in good occlusion which have
measures far from the norm. It is not necessary to treat maloc-
elusion with relation to a fixed cephalometric goal. Rather,
cephalometrics should provide a range of satisfactory treatment
goals which, combined with other information from dental casts,
case history, and observation of the patient, make possible an
individualized treatment plan.
c) The Fallacy of Superpositioning
Superpositioning, registering of two or more tracings of an
individual on particular structures, occasionally helps one to vi-
sualize growth or treatment changes (see Fig 12-20 and Figs 12-
41 through 12-44). Localized rem6deling can be shown by su-
perpositions nearby. As one moves away from the registration site
the changes observed are a combination of summated growth in
several regions, effects of treatment, enhancement of errors in
positioning, etc. For example, in Figure 12-41, where registration
is in the cranial base region, the chin seems to have "grown"
downward and forward, but one may as well say that the condyle
has been growing upward and the chin has been translated away
from the articular fossae. Little growth occurs at the chin itself.
The many changes between chin and sella are summated and di-
rected downward and forward not by growth but by the artifact of
superpositioning. If one superposed on the symphysis (see Fig 12-
20), it would be misleading to speak of upward and backward
growth of the cranial base! Some of the problems of superposi-
tioning techniques are overcome by the analyses of deformations
(see Sections F-2-c and G-II).
d) The Fallacy of Using Chronologic Age
Although it is conventional to use chronologic age (birth age)
for comparisons and reference, developmental age is a better cri-
terion: it reduces the variance of sizes, angles, and proportions
within age classes. Some orthodontists take routine radiographs
of the wrists of patients to assign their "carpal age," an index of
bone maturation (see Chapter 11, and note several examples of
the use of developmental age throughout this book).
e) The Fallacy of the "Ideal"
Practical problems arise when "ideals" for skeletal relation-
ships are oversimplified into numbers inflexibly and arbitrarily
imposed on every patient. The use of contrived "ideals" as stan-
dards sometimes produces a set of ipso facto findings by setting
up artificial criteria for abnormality and then uncovering the in-
cidence and prevalence of these variations. By definition, abnor-
mal must always refer to the normal, which can only be determined
from an appropriate population. One cannot discover "abnormal-
ity" by comparison with subjective ideals based on personal per-
ceptions of facial esthetics, nor can one label such ideals as normal.
It is one thing to say "I like faces which look like this"; it is quite
another, and most illogical thing to say "any face which doesn't
look like faces I like is abnormal."
3. Misuses of Cephalometric Analyses
Even when we protect ourselves from misleading assumptions
or fallacious misconceptions we may err simply by misuse of any
analysis. The following rather loose listing contains some of the
more common misuses of cephalometrics. It is not intended to be
inclusive, but it does reveal how this splendid and practical method
is abused and misapplied. As we have noted, cephalometrics itself
has limitations. The problems in this list of misuses are not those
of cephalometrics, but of the user.
a) An analysis is misused if to'o rigid aq application of mean
values is made. The total range and variance are more practical
than the mean itself (see Fig 12-22). Because means are population
aveI;ages, they usually are. very poor treatment goals. Occasionally
means'of tooth positions are usefu,l, but only when the array of
skeletal values is close to the means for sex and age. When skeletal
values deviate from the mean, dentitions must adapt. The clever
clinician does not apply the same mean value to all faces but
determines those adaptational compromises to be made in treatment
which are most apt to be pleasing and stable.
b) An analysis is misused when it is applied inappropriately.
 Analysis of the Craniofacial Skeleton: Cephalometries 283

Values derived from 12-year-old North American white boys who

sought orthodontic treatment in a dental school, for example, are
obviously of little use in assessing the specific clinical needs of a
6-year-old black girl in practice: there are too many differences
resulting from age, sex, race, etc. The sample.<;from which many
of our most popular cephalometric analyses were derived have not
been adequately described in the literature, making it very difficult
for the clinician to know whether or not the analysis is appropriately
useful.
c) An analysis is misused when it is applied in a way for
which it was not intended. Analyses contrived to visualize treat- anterior
face
ment goals (e.g., those of Tweed26 or Steiner,25 both designed to height
depict goals of treatment) are used improperly when used for
growth studies.
, d) Standards derived from cross-sectional samples, in most
instances, cannot properly be used in lieu of longitudinal data to
assess expected growth. For establishing growth standards, a small
serial sample is much better than a cross-sectional sample having
the same number of radiographs. (This is true whether or not the
investigator has "smoothed" the annual means.)
e) The substitution of a subjectively derived "ideal" for a
statistically developed population norm misinforms and misleads. FIG 12-47.
"Ideals" represent artificial constructs of faces one clinician likes; Measures of facial height. Anterior and posterior facial height.
norms present real values of a particular group. They cannot be
used interchangeably.

I. THE FUTURE OF CEPHALOMETRICS

There is no theory of cephalometrics; if there were, it would

suggest what to do next. The techniques of cephalometrics are on
call, awaiting conceptual advances in growth and treatment effects.
Progress is dependent on new concepts, but new technology makes
possible the asking and testing of new questions impossible to
conceive just a few years ago.

APPENDIX: A BRIEF CEPHALOMETRIC

ATLAS

Included here are graphic and statistical descriptions of the

cephalometric measures mentioned in the text plus a few others
in common use. The data have all been derived from The Uni-
versity of Michigan Growth Study and are reproduced with per-
mission. All definitions are from Riolo et al.,23 to which the reader
is referred for further information about the many cephalometric
measures not included in this short atlas.
The Appendix is arranged in the following sections for ready
'.
clinical use:
FIG 12-48.
a) overall facial dimensions
Measures of facial height, continued. Maxillary and mandibular height
b) regional anatomic dimensions measures.
c) craniofacial constants
284 Diagnosis

A. OVERALL FACIAL DIMENSIONS C. Anterior Upper Facial Height

SO
NANA
47.17
48.89
3.41
47.89
3.33
48.42
47.07
3.28
48.58
43.28
40.91
39.74
3.62
3.13
44.76
45.84
3.46
41.86
51.48
3.31
2.80
53.38
2.69
MEAN
38.59 SO
MEAN
45.34
44.232.87
2.53
2.33
41.00
3
2
2.41
1.96
49.72
50.09
50.54
2.92 .59 MALE FEMALE
.06
3.18
3.58
4.26
4.17
3.65
3.44
3.66
37.50
43.26
3.25
53.29
50.22
3.32
51.19
53.79
50.34
55.11 .03
.40
3.99
1. Vertical Distances (facial height)
11
13
15
12
58
16
17
14
18
10
497
6
AGE
Facial proportions change with age, and there are significant
sexual differences, particularly from the onset of pubescence. Rules
of thumb about facial height ratios supposed to be I!0rmal may
therefore be quite misleading and seen inappropriate because of
differential regional growth. Because of so many misconceptions
about the achievement of facial height; ignorance about sexual
differences and the wide variances observed; and the frequent,
rather naive use of narrow "ideals" for both sexes and all ages,
these graphs and tables are worthy of study (see also Chapter 4
and Section G of Chapter 12).

• Measurements used: Figures 12-47 and 12-48.

• Graphic data: Figures 12-49 and 12-50.
• Tabular data: Table 12-3.

TABLE 12-3.
Facial Height Measures
D. Anterior Lower Facial Height
A. Anterior Facial Height (SE-Mer SONA
MEANSO MALE FEMALE
MEAN
62.575.94
62.877.12
60.396.58
60.016.42
59.62
57.27
63.05
61.66
58.94
56.67
71.33
6.90
73.70
66.96
5.43
5.85
4.16
4.69
74.98
63.98
6.46
6.12
6.08
5.64
5.35
63.24
61.24
NA 10.13
10.00
8.49
7.75
7.05
7.26
6.16
61.616.23
60.06
62.81
59.52
62.40
59.90
58.73
55.48
75.79
69.63
65.78
5.80
65.29
5.37
8.66
11.93
9.31
8.13
NA NA
SO
MEAN
107.91
107.10
104.89
101.30
6.47
7.61
6.58
7.30
6.37
6.85
6.51
6.40
6.75
7.766.98MALE
SO
105.36
108.32
110.24
112.76
103.70
101.98
124.62
127.08
129.57
130.09
111.15
114.66
117.18
121.11
6.17
98.65
99.75
92.98
97.67
112.91
6.07
5.51
111.58
99.13
114.43
112.94
10.25
6.90
7.19
11.37
10.44
11.25
12.76
7.047.01
7.68
7.23
8.59
9.04
7.79
6.64
MEAN
106.69
113.18 5 FEMALE
17
15
16
14
13
12
18
11
10
49
8
7
6
AGE

• NA = no data available

B. Posterior Facial Height E. Posterior Upper Facial Height

>.
NA NA
SO
MEAN
82.23
86.38
5.72
4.35
4.49
4.587.40MALE
SO
MEAN
76.59
105.99
104.75
103.90
77.79
79.17
92.48
5.93
5.99
94.22
5.24
92.10
4.62
91.87
4.90
88.45
4.80
3.10
3.59
4.28
5.01
74.16
76.39
77.77
84.59
79.89
81.81
83.65
95.39
90.48
4.86
4.76
4.74"
4.52
5.22
5.17
4.56
6.58
5.58
8.89
7.85
7.70
101.12
84.65
92.79
86.54
97.29
91.91
88.26
3.50
6.94 FEMALE 3.15 46.95
so
NANA so
MEAN
MEAN .99 MALE FEMALE
5 " - 42.50
41.58
39.47
2.71
47.99
3.20
2.36
2.45
41.53
42.51
2.89
43.79
2.96
2.70
44.86
44.62
49.64
3.17
48.16
3.27
3.32
3.77
54.02
54.72
54.77
55.47
2.50
50.53
50.66
50.67
40.62
45.742
2.85
3
3.17
1
2.91
46.94
49.03
48.44
2.93 .53
.11
3.31
3.49
3.97
4.20
4.55
3.54
51.32
51.88
2.99
49.97
51.04
3.58
3.95
45.70
. 16
10
11
12
13
18
159
67
4;8
14
17
AGE
 Analysis of the Craniofacial Skeleton: Cephalometries 285

F. Posterior Lower Facial Height I. Posterior Maxillary Height

so
4.97
41.57
40.01
NA
4.82
37.61
36.21
34,10
MEAN
MEAN
44.08
47.10
45.42
3.40
43.18
4.27
3.92
41.21
3.89
5.63
5.30
4.50
50.52
49.98
49.18
41.81
5.59
42.82
NA
39.42
38.916.53
5.56
5.52
41.45
40.27
3.58
37.66
3.48
3.35
3.18
3.32
36.95
36.10
38.39
36.673.59
3.37
3.35
3.39
2.69
35.26·
35.97 .52 MALE FEMALE
so
3.31
3.42
2
2.62
42.28
37.95
3.73
3.25
34.86 so
11.32
21.27
3.12
2.37
3.53
20.50
13.17
8.51
5.02NA
MEAN
MEAN
4.25
5.27
14.15
13.76
10.02
NA
23.76
3.01
22.56
2.50
2.39
2.51
2.73
18.74
19.89
3.35
17.92
15.81
15.46
3.07
2.94
20.62
6.67
9.06
15.71
14.70
14.18
10.86
18.95
19.84
18.88
17.25
4.03
4.59.35 MALE FEMALE
so
5.51
3.17
2.96
2.80
2.67
2
3
43.71
3.47
3.26
3.91
.27
.14
.64
5.38
2.82
18
14
15
16
17
13
12
11
10
496
85
7
AGE

G. Anterior Maxillary Height J. Posterior Mandibular Height

so
23.17
2.63
2.95
23.27
24.41
2.52
23.79
23.25
26.32
NA
MEAN
24.82
24.94
24.72
25.89
25.03
25.52
3.63
3.01
23.85
23.69
2.83
2.79
25.16
NA 2
3
2.92
3.14
29.67
25.18
26.91
26.61
26.21
30.43
30.54
2.54
24.86
2.34
25.00
2.59
2.69
2.81
3.06
24.03
26.04
26.23
MEAN
28.85
26.05 .05 MALE FEMALE
so
.35
.97
.69
3.41
3.44
3.59
3.90
3.18
4.33
3.63
3.60
3.57 so
31.83
24.81
27.42
2.42
3.08
6.25so
32.78
3.25
25.24
NA
4.56
NA
MEAN
MEAN
26.29
28.13
25.27
25.15
27.99
25.64
24.36
25.40
25.52
25.93
26.61
2.46
3.80
5.52
6.40
35.11
3.43
3.34
3.85
4.13
23.78
27.11
2.51
22.67
22.76
23.77
22.96
22.25
22.69
23.24
32
26.76 .56 MALE FEMALE
2.54
7
3.35
5.88
7.66
2.85
3.84
3.89
4.16
21.18
4.64
22.32.69
.42
.64
10
11
12
14
15
16
17
49
8
76
13
185
AGE

H. Anterior Mandibular Height K. Ratio of Total Anterior to Total Posterior Facial Height
so
4.88
37.95
35.46
4.50
3.70
32.26
5.20
6.52
36.37
NA
MEAN
42.71
40.35
38.05
4.56
37.04
37.84
36.79
34.12
35.33
NA 5.61
5.88
38.80
39.07
44.03
39.73
44.55
45.24
3.78
35.67
4.38
35.77
3.82
35.87
4.12
3.20
37.19
2.97
30.31
34.92
5.11
36.16
35.04
34.00.06 MALE FEMALE
so
8.28
3.91
5.24
4.72
4.53
5.35
7.48
5
6.61
MEAN
42.48
4.85
5.33
4.20
6.96
37.87 so
.06
1.25
1.22
.07
MEAN
.04
1.20
1.21
1.22
1.23
1.23
1.24
1.25
• 1.25
1.27
1.28
1.30
.02 so
.05
1.26
1.27
1.261.25
.06
.07
.08
MEAN
.06 •MALE
FEMALE
>. . ~ 11
12
18
16
17
15
13
14
1049
8
7
6
5
AGE
 286 Diagnosis

L. Ratio of Lower Anterior to Total Anterior Facial Height

SO
..MEAN
.01
.02
.03MEAN
.60
.59
.58
.61
.58
.57
.56
.60
.59
.04
60 .03 MALE FEMALE
SO
..03
.55
.57
.5803
.04
10
11
12
13
14
15
16
45
18
176
7
9
8
AGE

M. Ratio of Posterior Mandibular Height to Total Posterior

Facial Height
SO
MEAN
.03
.04
.24
.23
.25
.02.26
.29
.30
.32
.31.03
.27
.26
.28
.29
.31
.30
.28
.27 SO MALE FEMALE
.,02
.02
MEAN
.2504
05
03
16
17
10
12
13
49
18
14
15
117
5
8
6
AGE
 Analysis of the Craniofacial Skeleton: Cephalometries 287

A B

~O, 120

- +
_'40 + _
~ + ~ 110
~
'" + ~
::>

j:~ 130 + j:
~
~
~ ++ ~
~100
-« 120 ~
U u
~
~ ~
~ 90

Q 110 ~

~ + + 'MAlE+1STO ~ + + l.4ALE+1STO

«100 t:..~ 0...80 +++ tJ.tr.4ALE

OF"[IrIlALE
--- + + o~ ---
f5 + Legend ~ ~+ ~ + Legend
90 I I I I I , I -----. + n:'lro4ALE-1STD 70 I + I I I I I I I + F"EMAl[-ISTD
.• 6 8 10 12 14 16 18 .• 6 8 10 12 14 16 18

AGE (YEARS) AGE (YEARS)

C 0

60 65
+
+
~ + ~
~55 + ~60
~ + ~
I I
~ ~
~ 50 ~ 55
-J + 0 -J
«
U
+
+
«
U

~
~
~
<lS
~
~
~ 50

~
~ ~
~

t: '
=> 40 :::J 45

eJ + lr.4ALE+1STD eJ + lIl.ur+1STD

«
~ 35 tJ.
~--_.-
l.4,4,lE

OF"(MALE
U1
0
a...
40
+
+ + D. IolAlE
---
O~MAl[

~ .30 I •I I I I I I C"""
+ fO' •.•.LE-1STD ~ 35 I, " I C."",
+ fEMAlE-ISlD
•• 6 8 ID 12 '4 16 18 •• 6 8 10 12 14 16 18

AGE (YEARS) AGE (YEARS)

E F

~ 60
+
'i" + 'i"
6. + -655
~ + ~
I~ 80 I~
W + W
:r:
~ +
:r: 50
~
« + «
U + + U
~70 + ~45

El + + + es
~ + ~
o 0

c~2 '
....J .....J 40

~ + + + + + + D. WALE __ .2 35 + .~ ''? + 6 l.4AlE_

4: + + + + + ,~ + 0 ~_AL~ 0.....;.", + + + + 0 [El.4ALE __

•g 50"
••
+
I
6
I
8
I
10
I
12
I
14
---.--
16
1
18
' C".~
+ F"(l.lAL[-lSTD
.m••••• ~ 30
•• 6 8 10
I
12
" I
'4
.,I
16
'c."",
I
18
+
, ••""",
fEIr.lALE-1STD

AGE (YEARS) AGE (YEARS)

FIG 12-49.
Graphs of growth in facial height. A, anterior face height. B, posterior height. E, anterior lower face height. F, posterior lower face height.
face height. C, anterior upper face height. 0, posterior upper face (Continued in Fig 12-50.)
 25
IZCD.
-6
'"0 >- 01~
288
....J
'1<
::J w
X zIZI>-"-'...•< 4 35
..•
.'"
is
...
...J
L;j
'"
g
'>-
-6
40
45
30
50
30
Diagnosis
5'
5' 25
20
A 35
55 B
C

'i"
-6 25
>-
I
'-'
W 20
I
>-
'"
..•
:::l 15
X
..•
~
'" 10

Legend
o1< Legend
+ ~ALE+1STD w +
>- l.IALE+1STO

lJ.~ o
<f)

0..
a~
O~ o~
+ fEIoIAL[-lSTD + F[UAlE-1STD
.. -,-------, o ~16
10 12 16 18 4 10 12 18

AGE (YEARS) AGE (YEARS)

>- 25
~ 0is'-'ID
z'"~
5' j
...
<f)
0CD
..
L;j
20
I
::J
~ 30
35

40

_.~
++ .~ ~
.~

Legend Legend
+ MAL£+lSTD + lIlALE+1STD
+
(j,~ + lJ.~

O~ o~

10
T

12
T

14
T

16 18
+ FnU.LE-1STO
15;-------------.--------,
4 6 8
,--~,
10 12
T

14
T

16
1
18
+ f[IoIAl[-lSTD

AGE (YEARS) AGE (YEARS)

FIG 12-50.
Graphs of growth in facial height (continued from Fig 12-49.) A, mandibular height. D, posterior mandibular height.
anterior maxillary height. B, posterior maxillary height. e, anterior

2. AP Distances (Facial Depth)

As Enlow et al. I. 3 have noted, anatomic lengths are often of
less clinical import than effective lengths (i.e., the amount con-
tributed to the profile). Most of the measures contained in this
section quantify the amount by which a given bone or region affects
the profile, incisal, or molar relationship. Actual anatomic lengths
of some bones are given in Section B, Regional Anatomic
Dimensions.

• Measurements used: Figure 12-51

• Graphic data: Figure 12-52 FIG 12-51.
• Tabular data: Table 12-4. The simplified Counterpart Analysis.
r dentoal-
".6I
w
Vl
X
~
35
+
.0
0-' I 50
.5
.5
55
4.5
.0
50
55
40

il
'C'
+ 10 •8,.
,+08, +++,, ++
1,12
1814
'2
+ Legend"
+
+
+ I:J~
+
-'0
:>:
+ + + --.+...
Legend
~ +40
+ I.lAl(+ISTD
--r
+ +.304.5,I ---
w 4U
+
w•.•.•. ~ 0
, +,.
4+,"-
+ lE+1STD
+Z --,-------
+++<0 +
""AL£+ISTO

Graphs of anteroposterior measures. A, maxillary dentoalveolar length

r"
ID
IF
~
'"L \,~--~
++ I + +().~
++-. t.~+ ,
Vl ().~ t ~
o~+
Legend
4.5~
~++o~
+ZLegend
.0.---
:>:
M
'" .•..lE+1STD

FTMAL[-ISTD289
IoIAlE+1STD
MALE
+ Legend
+ Legend
t:. lolALE+1STD
"'''LE
"
..• ..•+ + >!
>-

I
I
0-~
d
'"
:::>
>
.5
(f)
Vl
+•.'- fEWAL[-lSTD
I-'
50,
w+
:::>
"'"r .6 Z
70-
o~
':J
AGE•
55
fEMALE-ISlQ
rnu..LE-1STD
(YEARS)
fective
veolar ~ + of+(depth).
Analysis
posterior
length the
cranial base
D,
+
+, Craniofacial
lengthSkeleton:
(depth).
mandibular F,Cephalometries
skeletal effective ramus
length (depth). depth.
E, ef-
290 Diagnosis

TABLE 12-4.
Measures of Facial Depth ("Length")

A. Maxillary Dentoalveolar Effective "Length" (B-1)

MALE
MEAN
56.
62.
52.40
60.89
54.08
52.30
52.47
53.56
54.06
56.25
57.57
57.88
59.65
60.
67.
64.
15.
51.34
53.54
54.13
55.57
57.39
57.97
60.67
61.83
63.42
64.74
27.
53.
48.
52.
47.
45.
28.
12.
N
30.
23.3.55
3.53
3.06
2.60
5.00
3.16
3.28
3.22
3.38
3.48
3.34
3.74
MEAN
27.
71.
67.
11.
62.43
59.24
61.15
73.
58.
36. 3.17
2.90
3.12
3.63
3.51
3.53
4.20
3.95
3.67
SD
66.49
53.50
53.49
59.62
60.42
49.
63.
61.
15.
NAN
10. SD
2.75
5.03
NA 2.66
3.00
3.26
3.27
3.61 - FEMALE

• NA = no data available.

B. Maxillary Skeletal Effective "Length" (B-2)

SD MALE
MEAN
MEAN
27.
62.
67.
51.52
57.25
56.16
52.56
51.13
51.37
52.81
54.02
54.95
56.80
23.
73.
60.
36.
30.
50.01
61.21
51.98
51.78
52.15
60.15
52.83
54.48
55.97
56.67
56.77
57.87
56.
71.
11.27.
49.
53.
63.
61.
48.
47.
45.
28.
10.
12.
N3.13
2.70
2.66
3.63
4.19
2.74
3.04
3.01
2.61
3.00
N
51.30
54.01
55.62
50.93
67.
58.
64.
15. 2.75
2.98
2.94
2.43
3.20
2.78
3.06
2.71
3.03
3.12
53.82
59.02
52.25
52.
15. SD
3.72
2.39
2.77
NA
NA 2.90
3.04
2.87
2.82
3.19 FEMALE

C. Mandibular Dentoalveolar Effective "Length" (B-4)

.71. MEAN
MEAN
62.
27.
45.91
45.77
48.45
56.
11.49.
27.
N3.12
•23.
~·4.48
63.87
59.71
N48.77
60.43
55.67
55.24
50.95
30.
58.
60.
15.
"63.
61.11
59.05
56.54
53.36
52.05
28.
45.
47.
52.
61.
10.
4.06
7.13
6.42
5.68
4.55
4.69
4.13
48.37
49.186.45
6.10
5.04
4.63
49.01
48.55
'r67.15.
3.63
2.93
58.45
57.40
53.75
36.
64.
67.
73. 4.22
3.43
4.03
3.96
4.45
SD
64.19
60.28
57.12
57.18
53.60
50.14
50.6
48.
53.
12. .SD
8.82
6.32
5.46
NA
NA
.53 3.61
3.11
6.22
6.21
5.09
4.37 MALE FEMALE
 Analysis of the Craniofacial Skeleton: Cephalometries 291

D. Mandibular Skeletal Effective Length (B-5)

MALE
62.
27.
47.75
43.52
56.16
52.28
49.66
54.85
64.03
59.92
57.66
MEAN
MEAN
71.
49.30
46,96
67.
56.
11.NNA
5.00
3.35
49.
7.97
NA
N
48.17
47.57
46.15
63.
27.
5.19
57.00
53.97
53.90
47.33
64.
58.
67.
60.
73. 6.22
4.71
SD
4.87
4.82
3.94
43.55
54.71
54.42
51.04
51.20
50.10
46.73
45.
47.
52.
48.
61.
53.
15.
7.28
6.68
5.68
5.69
4.91
4.32
3.29
59.38
30.
36.
23.
15. 5.84
6.39
5.26
5.28
4.18
3.76
61.37
57.16
57.97
28.
12.
10. SD
11.00
8.32
8.31
7.19
7.59
7.36
7.56 FEMALE

E. Posterior Cranial Base Effective Length (B-3)

NA
MEAN SD
15.
2.50
33.85
49.
2.48
34.29
63.
2.24
35.722.73
2.47
37.48
61.
36.692.78
2.92
38.08
2.59
37.44
39.10
45.
3.20
37.35
38.76
37.56
39.75
40.29SD MALE
NA
MEAN
11.NN
32.30
33.43
27.
56.
33.77
33.94
34.62
71.
62.27.
35.262.36
2.39
2.61
36.13
35.51
67. 2.35
36.89
53.
35.71
73.
36.55
67.
60.
38.26
48.
52.
37.61
65.
59.
23.
30.
37.
15. 2.74
2.79
2.83
2.76
2.93
40.06
47.
2.73
38.91
39.76
28.
10.
12.3.20
2.72
3.11
3.35
2.38
2.81
2.99
2.29 FEMALE

F. Ramus Depth (B-6)

SD MALE
NA
MEAN
27.
37.71
37.39
35.67
36.66
35.10
37.22
36.50
36.19
35.95
38.21
36.35
38.47
36.83
37.64
37.50
58.
30.
40.86
40.70
39.10
41.40
MEAN
56.
11.
71.
62.
67.NA
49.
27.
N2.80
3.32
63.
2.71
2.70
3.54
35.142.96
40.84
45.
3.20
3.72
3.71
3.86
37.19
35.76
73.
37.87
53.
61.
36.80"
60.
39.37
48.
37.76
23.
64.
36.
15.
40.36
41.82
52.
47.
28.
67.N
15. SD
3.03
3.98
4.20
2.94
3.13
2.59
10.
12.3.20
3.66
3.14
3.61
4.04
4.69
3.42
3.16
3.60
3.07•.
2.99 FEMALE
292 Diagnosis

G. Anterior Cranial Base (SE-FMN)

56.46.221.69
45.243.50
11.44.44
60.
MEAN
27.44.53
73. 49.
27.
2.31
3.19
2.75
52.672.19
41.73
67.50.4861.
15.
2.25
3.34
-1.55
NA
46.44 2.72
3.36
71.49.531.16
50.251.14
47.73
54.52
59.
15. 53.
63.
3.35
3.15
2.80
53.75
52.
47.
3.57
10.
4.38
2.98
1.99
3.77
60.421.11
37.56.32-.07
12.
2.16
4.42
57.601.52
56.40
55.54
3.14
2.66
I28.
45.
4.37
4.38
NA
NA
53.671.00
51.631.37
53.121.49
62.48.372.14
67.
23.
61.81
30.
65.
MEAN
N 48.
49.10 1.19
.08
2.82
3.09
2.79
3.33
2.953.00
3.88
56.081.56
54.97
60.94 '
.94
1.37
1.29
.84
.62
.86
N .86
.56
1.22
55.51-.81
59.311.71.52
INCREM.
NA NCREM.
OF MEAS.
MEAS. MALE FEMALE
S.D.

H. Anterior Cranial Base (S-Na)

62
71.18
70.16
56
27 49
3.63
2.63
2.83
2.09
2.72
74.59
74.15
77.16
76.51
60
48
61
3.07
72.77
67
72.50
11
70.98
723
5.34
53
15
76.56
75.41
75.97
80.79
79.74
78.13
37
65
45
3.17
75.24
83.52
76.08
82.29
81.98
79.02
47
10
12
4.23
3.90
N2.99
2.65
3.01
3.42
3.20
70.25
1.78
27
73
67.56
71 4.95
63
3.00
67
28
52
15
76.47
75.74
30
59
3.33
MEAN 3.21
2.80
3.44
3.08
3.32
2.94
1.64
4.17
4.22
1S6.D.
.77
4.15
4.31
3.85
2.45
3.28
MEANS.D. MALE FEMALE

3. Bilateral Distances (Facial Breadth or Width)

The data in this section are from measures in the P A
cephalogram.
• Measurements used: Figure 12-53.
• Graphic data: Figure 12-54.
• Tabular data: Table 12-5.

FIG 12-53.
Measures of width (breadth). 1, bigonial diameter. 2, molar inter-
section diameter. 3, upper molar-alveolar crest diameter. 4, medial
point on condyles, diameter. 5, lateral point on condyles, diameter.
6, bicondylion diameter. ~
 Analysis of the Craniofacial Skeleton: Cephalometries 293

A B

~
u

~ '" I II '''1 ••
~
o 90 g~
~
o 0
z
U
u 80 8
~
~ 70 -+- IolALEt-1STO 80 t- I,U,LEt-ISlO
N "' •••ALE 6~
o frlolUE 0 f[WALE

, 601,
A 6 8 W
"I

12 14 16 ~
",,""
•. HMALE-ISTO
70 [ A 6
"
8 W
,
12 14
,
16
+-
"o~
f[WALE-ISlO

AGE (YEARS) AGE (YEARS)

C 0

'"

w ~ 120
~ 90 ~
oZ z
0
8 u
6 6
~ 80 ~
:i' "-
:i ~
~ 90
6l.l"'LE lJ.~

,· "'- '1'
-~~ -~~
O~ o~
+ fEIolAL[-lSro +FEIolALE-ISTO
" 601,
.• 6 8 m
'"
12 14 16 18
• "'''''10 <t 80
.• 6
I
8 10 12
•• "O~
"'''SlO

E I~

6S

~
g~ ~U
Ct: 50 er.
W <t
~ <5 55

~~~ ~
~
o~ ~
<t

ei 40 ~

·
"
.35

30 I
.•
I
6 8
I
IQ

AGE (YEARS)
I
12
,
14
I
16 18
I
lJ.~

o~

•• "'''SlO
+-

- "r
fEWoI.LE-1STQ
=>

it·
••

40,
.•
+

5
+
6
,
7
,
8
,
9

AGE (YEARS)
,
10
I
11
,
12
,
13
lJ.~

o~

+ ."'
+-

- Fnu..lE-ISTO
••",

FIG ~2-54.
Graphs of width measures. Diameters are shown for the following.
A, zygomatic-coronoid intersection. S, bicondylion. C, medial point
on condyles. D, lateral point on condyles. E, molar fosae intersection.
F, upper molar-alveolar crest. G, bigonial.
Legend
+l.lALE+\STD

o.~
o~

". -----.-- - -.----------.---

W 12 '4
T---------.
16 18

AGE (YEARS)
 TABLE 12-5.
Facial Width Measures

A. Bilateral Zygomatic Coronoid Intersect Distance"

MEAN
MEAN
72.51
67.80
84.83
85.33
45.
35.
28.
17.
86.88
78.37
72.08
84.08
86.89
80.45
76.55
83.82
86.58
85.64
49.
47.
48.
24. SO SO MALE
7NA
57.NA
NA
NA
.•N
N
12.
82.15
76.19
70.77
92.35
95.17
79.64
84.33
85.00
86.25
88.39
90.86
89.49
35.
41.
27.
33.
21.
30.
34.
17.
24.
19.
11.
4.03
5.29
5.13
5.76
5.61
4.92
N
78.49
42.
39.
18.
78.60
92.95
73.54 A
N4.10
6.42
6.43
4.26
4.67
4.86
7.65
4.15
8.
6. 4.90
3.94
5.86
3.95
7.27
5.41
4.38
5.23A
5.29
4.99
5.53
5.35
5.96
6.08
6.09 FEMALE

• NA not available.

B. Bilateral Lateral Point on Condyle Distance

NA
NA
NA
9NA
MEAN
MEAN
117.23
.61.
43.
35.
N
56.
20.
51. SO
NA
115.24
116.90
100.78
94.16
115.72
114.28
112.45
114.48
109.44
111.45
107.10
105.70
104.57
120.91
52.
50.
97.60
120.09
29.
120.80
26.
35
115.95
113.56
111.67
109.64
107.22
106.19
9.
22.
25.
30.
35.
46.
38.
43.
10.
14.
37.
31..N
18.
5.54
11.
5.11 SO
2.97
7.
3.98
4.74
4.65
4.66
5.11
4.77
4.92
4.73
5.29
4.36
6.
3.50
3.85
118.53
117.29
46.
112.80
57.
103.19
99.54
16.N
9.21A4.39
6.03
6.19
5.14
4.65
4.03
4.18
3.85
5.78
5.09
5.22
4.64
5.27 MALE FEMALE

C. Bilateral Condylion Distance

; 104.64
NA
NA
NA
NA
MEAN
MEAN
N
82.89
86.99
43.
35.
9.
9
20.
8
56.
51.
35.
26.
29. SO
NA
N
4.66
87.67
89.69
92.97
31.
11.
4.35
18.
5.01
5.38
94.0&
37.
100.40
57. N
6.
100.45
52.
101.00
50.
95.70
97.03
98.89
46.
38.
30.
99.27
101.54
101.34
46.
103.44
104.55
35.
25.
102.40
105.20
22.
103.40
103.86
107.43
107.70
107.08
16.
14.
10. SO
A ~.
3.94
4.28
4.51
4.713.90
3.81
3.96
5.95
4.70
4.964.60
5.02
4.68
4.71
4.19
5.53
5.58
4.91
7.
5.67
3.99
3.76
5.32
5.16
5.76
8.40
91.82
8.25
4.23
4.81 MALE FEMALE
43. 61.5.6Q
3.93·,

294
 Analysis of the Craniofacial Skeleton: Cephalometries 295

D. Bilateral Medial Point on Condyle Distance

- MALE
MEAN
20. NN
75.17
43.
56.75.35
11.
3.43
76:21
88.56
90.08
80.81
87.36
87.43
79.40
81.14
84.48
82.64
85.70
86.72
46.
57.
50.
26.
29.
15.
91.28
82.52
83.84
86.18
86.25
86.36
88.29
92.70
91.72
80.99
89.71
89.73
NA
38.
46.
37.
43.
30.
35.
25.
22.
18.
14.
NA
10.
3.89
4.77
4.69
4.49
4.74
4.26
5.40
5.22
5.78
MEAN
35.
61.
52.
35.
51.
79.50 SD4.96
31. 4.71
4.16
5.03
5.35
4.46
4.42
SD
3.62
4.72
4.78
4.09
4.08
4.26
5.87
4.95
5.17
5.50 FEMALE

E. Bilateral Upper Molar Aveolar Crest Distance

MEAN
N
MEAN
50.77
46.63
45.49.65
49.63
56.94
55.87
29.
47.
54.
47.79
55.28
49.131.57
57.72
54.83
55.76
56.15
57.17
57.65
45.
35.
NA
5.
53.54
NA
59.00
56.28
57.02
57.49
58.97
58.82
NA
21.
29.
36.
35.
23.
NA
4.
1.
NA
1.
3.93
2.67
2.23
2.61
2.56
2.19
13.
2
4.
8.
5.
NA
N
.13
.52
.67
SD2.05
4.31
3.11
2.54
2.85
3.16
2.94
.SD
NA
A MALE FEMALE
58.91
12.
3.
16.N 2.21
2.90

F. Bilateral Molar Fossae Intersect Distance

MEAN
30.
48.N
12.
45.06
45.88
45.98
47.11
47.87
47.55
36.
21.
28.
42.56
45.84
46.79
47.10
47.68
47.93
47.95
48.17
NA
31.
21.
41.
40.
27.
20.
NA
48.38
48.17
48.92
10.
49.14
7.3.49
2.52
2.81
3.04
2.85
1.88
MEAN
52. N
35.
11.
48.144.53
2.39
2.51
2.49
2.54
2.33
1.95
2.08
8.3.70
2.81
SDSD~. ;.
2.90
2.02'
3.1'3 MALE FEMALE
47.49,
9.
296 Diagnosis

G. Bigonial Distance (mm)

MEAN
78.54
19 11
81.23
84.33
43N
81.87
87.99
32
3.50
102.88
86.32
88.50
92.17
95.39
95.68
445
61
92.13
95.50
98.39
100.13
57
49
23
30
22
43
38
35
91.81
97.91 SO
3.56
4.80
4.77
4.92
4.44
5.64
105.64
16
14
673 SO
4.05
4.28
4.76
9.34
.79 MALE
MEAN
76.21
78.40
32
84.28
90.61
95.89
93.14
56
89.96
94.60
97.01
51
35
103.93
105.82
95.31
29
9N
26
18
36
48
27 .43
5.39
3.79
2.85
3.38
4.75
4.50
4.23
4.35
4.26
4.75
6.05
.84
3.425
6 .13
_4.51
.94
.35 FEMALE

B. REGIONAL ANATOMIC DIMENSIONS

1. Mandible
• Measurements used: see Figure 12-13A and B.
• Graphic and tabular data: Figures 12-55 through 12-59.
2. Maxilla
Measurements used, graphic data, and tabular data are shown
in Figures 12-60 and 12-61. See also Section A-2 of this Ap-
pendix, AP Distances.
3. Anterior Cranial Base (Cranial Floor)
Measurements used and graphic data are shown in Figure 12-
62. Tabular data are found in Table 12-4,G and H.
c. CRANIOFACIAL CONSTANTS
In Section G-5 a method for estimating future morphologic
relationships was presented which utilized certain craniofacial
"constants." The angular relationships in this method persist, but
the landmarks advance along the rays of the angle as growth takes
place (see Fig 12-32). In practice, one adds the average increment
for appropriate age and sex to the patient's starting landmark along
the constant direction.
• Measurements used: see Figure 12-30.
• Plotted data: see Figure 12-63.
• Tabular data: see Tables 12-6.

140

~ '006 z0u
~
06zwI~• 608070
z~
Z
VI Cl)
~130
w
U 50
Z
~120
6
Z
o
~
oo 1W

o~
!
o~ 100
Legend " -+
Legend
••••• LE+1STD

~
o .•.••••••l(+lSTD 6I,U.Lt __
z ~
o lJ.~l[ o ~""'l[ __
u o ~["'_"'_l[ + rnU,lE-lSlO
-+ rnlA.L[-ISTO
eo 10 12 14 16 18
• 10 12 1,( 16 18 AGE (YEARS)
AGE (YEARS)

FIG 12-55. FIG 12-56.

Overall mandibular length (condylion-pogonion) . Mandibular corpus length (conion-pogonion).

.,
 Analysis of the Craniofacial Skeleton: Cephalometries 297

"/"'\
~~rrl
+
U l/50
5070 1012 +
,5
15
,.55 it I
~ Z
:J 8 ,
18 V1::1:
...J
W 0 >- • '" +
0 + Z ++
>5-
AGE (YEARS) + t:.~ .6 '" 0
.•. MAl[+lSTQ
+ FEIr".U[-lSTO
Legend o 30
w U"":::l;
~
'0
-45

Legend
+ "'Al[+lSTD

6~

o~
+ F[WAL[-lSTO

10 12 15 18

AGE (YEARS)

."
FIG 12-57. FIG 12-58.
Ramus height (condylion-gonion). Mandibular corpus height, anterior.

., '0
0 0>-0'"U
'" •30
j
::1: IIl-
W
'i" >! Vl-1
25
:::>
if: '"
2.
~
~ t-iJ ~~)20 '1'-;:f

H
H-· <:....
--./.)
~
...J
40 .r·~~ ~L, '-V"-'-

'" <.
..•
-' 35
:>
Il- ~,L"i,
<Il
is
z
~ 30 ~~~
2 ~ +
'"

~'t· ~-
Legend
•••.•.l[+lSTD + •.•.•.lE+1STO

---
~ +
V1
'"-20 6tr.lW 6~

w
it + 0 Fr•••.•.LE
--- o~
+ FEMALE-ISTD
:3 15 I I I I , I I
+ Fn.lAU-tsTO
4 6 8 10 12 14 16 18 10 12 15 18

AGE (YEARS) AGE (YEARS)

FIG 12-59. FIG 12-60.

Mandibular corpus height, posterior. Maxillary height, anterior.
 298 Diagnosis

+
o~
+ «
et

z0«
-'
-'
er-"
20
Er-B
30
+
,,
,16
8
12
+
+ fEIrolAL[-lSTD
~),,
14
---e-- --e-------€Y"
+ "
+
+
~er
++ + ~~
+40

~ -'~
10 "'- 18 ~_~-€yEr Legend
« '"
6 +D.wl.4AL[+lSTD
l.lALE

FIGAGE
12-61.

; ':r'f{~)
(YEARS)
f2

A B

70 90
+ + , ,
+ +
6
::>

z
65
c
..~
~
6
70
75

! {~/
~
"'-

5
60

55
,(
)
w
85~ u
z
~
V>
6
801 nl?
~'-- -~f
~ z
o
'"
t1 50 «
Vi
z
i3
w
f2 Legend
-'« ..•. l.lAlE

I tJ. l.lAl[
d
V> 65 6.~
f-- 40 ---
W o~ o~
+ ro.U,l[-ISTD + ~"'lE
g~ 35"[ ~ ••••
, . , I , I I I """
",..,0 60,
4 6 6 10 12 14 16 16 o 6 8 10 12 16

AGE (YEARS) AGE (YEARS)

FIG 12-62.
Anterior cranial base. A, sphenoethmoidal registration, fronto-
maxillo-nasal suture (SE-SFM). 8, sella-nasion (S-N).
 Analysis of the Craniofacial Skeleton: Cephalometries 299

A B

"
•
150 10
110 12 ' , ~ Z...I
+ 10
40 ,•".
",
,+12
+ + +
..,
Z . ~ 0~0..I
.., ,..,
'"
•...
0VI<3
•...
Z
120 4 + + 0..
::0 , Legend
AGE (YEARS) '"
~:I:
4 130
10000
f-. 'r'
if' "1.
30 I .6
AGE (YEARS)
~
o+•... n:
l!I.~ rr.W.•.
50,
35~
L£
••.•.u-tSTD
v ~)}
.•. WAL[+fSTD

~\ l' ,(
.~
f "j

Legend
.•.•••.•. U+TSTO

l!I.~

o~
+ rEWAlE-TSTD

16 18

c
70

I
Z
~
65

60
I
•...
0..

~ 55
~
'"
t; so
<3

~I~
I
W

g ·
•... 40

35
~
4
••
,
6
I
8
I
ID
I
12

AGE (YEARS)
I
14 ~
I
~
I
6

o~

~-"'ALE
---

-"",
.•. rn""l[-lSTO

FIG 12-63.
Growth measures along constant rays. A, sphenoethmoidal regis- C, sphenoethmoidal registration point-frontal-maxillo-nasal suture (SE-
tration-menton (SE-ME). 8, frontal-maxillo-nasal-A point (FMN-A). FMN).

"
300 Diagnosis

TABLE 12-6.
A. Ethmoid Registration Point-Menton (SE-Me)
Menton

62.
27.
11.
67.
71.
73.
60.
67.
58.
36.
30.
15.104.082.59
101.482.38
99.80
05.903.56
94.58
99.10
3.77
27.
4.54
44.60
1OF
116.752.48
119.793.04
123.343.55
130.65
121.61
108.982.12
111.372.38
116.042.13
120.97
120.274.23
123.662.68
113.912.53
11.632.29
5.15
48.
53.
61.
52.
47.
28.
12.4.65
6.804.74
3.57
5.21
.89
4.97
4.77
5.74
5.32
5.29
5.49
4.79
6.00
7.42
7.74
7.46
8.08
4.85
NAN.51
.31
.70 MALE
56.
64.
23.97.83
N02.332.52
1MEAN
MEAN 49.
15.
4.61
3.80
137.532.39
114.262.62
125.79
134.04
135.141.09
122.65
106.862.77
09.343.43
63.
45.
10.-2.04
8.40
5.49
5.57
7.50
2.45
3.38
5.53
IINCREM.'
NA NCREM.
NANA 1.03
MEAS.
MEAS. FEMALE
S.D.
S.D.

B. FMN-A PT

62.37.82
56.37.87
30.
37.
65.
59. 2.93
3.94
3.64
3.27
27.36.59
67.39.49
11.35.93
73.39.72
39.64
41.84
37.59 28.
45.
53.
12.
4.13
5.07
40.02
3.05
2.533.96
3.01
2.98
3.73
3.33
52.
27.
10.
NA-.56
-.05
-.3.77
3.04
3.35
3.37
4.72
3.49
NA
NA1.32
1.27
.08
.18
.98
.19
1.16
1.28
1.01
1.37
1.78
N.50
.24
.66 MALE
1543.90
42.58
43.02
42.04
39.12-.59
36.31
39.45
35.87
MEAN
N
MEAN3.41
44.91
. NA
71.38.98
23.
60.
67.
44.76
40.83
39.78 47.
49.
2.82
-.43
38.79-.33
37.12-.47
34.63
38.74
38.49
36.06
4.02
3.19
3.53
63.
48.
61.
3.27
3.66
3.48
2.10
2.69
IINCREM.
NCREM.
OF
15. .43
.14
1.05
1.43
.86
.29
.
MEAS.
MEAS. FEMALE
S.D.

C. SE-FMN

37.59.311.71
55.54
54.97
53.75
61.81
53.671.00
55.51-.81
56.32-.07
27.44.53
11.44.44
41.73
45.243.50
51.63
56.46.221.69
62.48.372.14
71.49.531.16
49.101.37 MALE
59.
67.
30.
23.
60.
15.
73.
65N 2.66
3.14
NA
56.081.56
57.601.52
56.40
54.25
60.421.11
60.94
53.121.49
52.672.19
67.50.48 47.
2.953.77
52.
3.88
48.
10.
4.38
12.
3.57
3.19
27.
2.31
15.
2.25
3.34
-1.55
..47.73
63.
3.35
3.15
NA
NA
"MEANINCREM.
50.25
MEAN 28.
45.
2.98
"53. 1.22
N.86
4.42
3.36
.86
)2.82
1.37
3.33
2.72
3.00
1.14
NA
4.37
4.38
2.16
61.
2.75
49.
53.
2.80
OF .56
.84
.62
1.99
.52
2.79
.08
.94
3.09
46.44-
INCREM.MEAS. ,.
1.19
.29 FEMALE
S.D.

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Gegiss-Anomalien. Berlin, Meusser, 1922.
32. Steiner CC: Cephalometries in clinical practice. Angle Or-
thod 1959; 29:8-29.
33. Tweed CW: Clinical Orthodontics, St Louis, CV Mosby,
1966.
34. Webber RL, Blum H: Angular invariants in developing hu-
man mandibles. Science 1979; 206:689-691.
SUGGESTED READINGS
Baumrind S, Franz R: The reliability of head film measure-
ments. 1. Landmark identification. Am J Orthod 1971;
60:111-127; 2. Conventional angular and linear measure-
ments 1971; 60:505-517.
Broadbent BH: The face of the normal child. Angle Orthod
1937; 7:183.
Horowitz SL, Hixon EH: Nature of Orthodontic Diagnosis. St
Louis, CV Mosby, 1966.
Houston WJB: The analysis of errors in orthodontic measure-
Moyers RE, Bookstein FL: The inappropriateness of conven-
tional cephalometries. Am J Orthod 1979; 75:599-617.
Riolo ML, Moyers RE, McNamara JA Jr, et al. An Atlas of
Craniofacial Growth. Cephalometric Standards from the Uni-
versity of Michigan School Growth Study, monograph 2,
Craniofacial Growth Series. Ann Arbor, Mich, Center for
Human Growth and Development, University of Michigan.
1974.
SECTION III
Treatment
Robert E. Moyers, D.D.S., Ph.D.
TREATMENT
Concepts of treatment in most of dentistry have their roots in
our medical heritage, but malocclusion is not a disease or an injury
and therefore is not "cured," as are tuberculosis, syphilis, or
septicemia, or healed, as is a fracture. Koch's postulates do not
apply to malocclusions for there is no specific organism which
always produces a particular occlusal problem each time it invades
a facial or jaw site. Malocclusions are but unfavorable variations
of normal craniofacial morphology and/or function. Research on
their origins is, therefore, not based in microbiology and pathol-
ogy, but in growth and development. Because there is no theo-
retical possibility of producing a vaccine or providing immunity
against malocclusion, the opportunities for its prevention are much
less than for a disease, and such preventive procedures as are
available are imprecisely implemented in practice.
How do we "treat" or "correct" a mal occlusion when we
undertake. orthodontic therapy? We alter the relationship of parts
of the face, jaws, or occlusion to provide a more "normal" func-
tion or more "ideal" facial appearance. Therefore, "treatment"
is dependent on perceptions of "normal" and "ideal" faces, and
such perceptions define the clinician's goal.
During a visit to China, a friend asked a medical colleague
there, "How do you treat tuberculosis?" "We don't treat tuber-
culosis" was the reply, "We treat the patient." What are we
"treating" when we undertake orthodontic therapy? An abnormal
variation in bony or dental structures which hampers favorable
function? A facial morphology which harms appearance? A face
which fails to meet someone's expectations or perceptions of facial
attractiveness? We may say we are "treating" mandibular defi-
ciency or a deep bite, and we may actually change their meas-
urements; but orthodontics, if it is successful, places such structural
changes in the broad perspective of the person involved: we don't
just treat malocclusion, we treat the patient.
What then constitutes "good" orthodontic treatment? That is
a very difficult question indeed, for it is much harder to quantify
idealized facial beauty than it is to specify the characteristics of
successful surgery, and "normal" comprises a wide morphologic
range. I Surgeons, through precisely controlled clinical studies,
have agreed on the characteristics of successful operations on the
knees, namely, minimal time in bed after surgery, minimal time
before the patient can walk unaided, absence of limping, absence
of pain, etc. Physicians often have sure and measurable signs
indicating the abatement of an infectious disease (e.g., diminished
fever), but there is only convention, general agreement, or personal
opinion describing a few traits of "well-treated" malocclusions,
and none are as reliable as is a thermometer recording of body
temperature. Further, there is a considerable range of acceptable
values for some occlusal traits after treatment. For example, some
clinicians consider minimal incisal overlap ideal, while others es-
tablish sufficient overbite to produce disci us ion of all posterior
teeth during protrusive jaw movements. The definitions of "good"
orthodontics vary with the clinician, the original problem, and the
appliance used. The absence of definitive clinical research makes
universal definitions of "good" or "correct" treatment impossi-
ble, I but that fact offers no excuse for inadequate or "poor"
therapy because there is agreemef1,t on some features of well-treated
mal occlusion .
The following chapters, describing the concepts, goals, and
some methods of dealing with malocclusions, are arranged ac-
cording to the developmental age of the patient, since maturation
is the primary determining factor of both the strategies and tactics
in orthodontic treatment (Figs I and 2). A continual emphasis is
made to help the reader keep the strategies of treatment separate
from the tactics available, since the two are often blatantly con-
fused in the literature. Strategy is planning; tactics are treatment.
303
304 Treatment

--- -
Boney
--
(Chap. Parts
15)
17)
16)
of -Muscles
0+Palatal
0
0
Size
+
Growth 0+ orof
Teeth
Gutdance
of
Growth
Eruption
Translation
of Movement
Parts
Training
Shape
Boney
Expansion
Encouragemen~ Change in Strategies
"Rapid"

Immediate
of Treatment

KEY:
:;-optimal or only period
0, can be done but may not be best tlme
-, poor time or can't be done at this time

FIG 1.
Relationships of developmental ages to strategies of treatment.

Grawth Active skeletal grawth 1 no growth

D!n1ition Primary Mixed Permanent I (lass 01 teeth)

-I
I HH}~_
Oral Health Healthy
f-
.. 1. (Peridantal disorders)

I
Treatment tac1ics
k interception

growth guidance
I
I ..•
correction I
" I " .
Appliances Habit
f
control

arch

I~
devices

control

lunchanal
mechanisms
.HH •• :~

and law orthOpediC appliances

I ~
----r-
camouflage and casmetlC therapy

I
HH.H~

.-
(partial) PrecISion tooth placement.H ••••appliances
+-I ')O>. (complete)
...•...

Surgical correction

Age o
f4

Childhood
5
-.l
10 15

Adolescence
20 r
·i Adulthood
25 .....~..

I
FIG 2.
Timing of different aspects of growth and treatments.
 Treatment 305

2,3 -
-2Size
1- -Parts
34Training
3Boney
1Muscles
Palatal
4Growth orof1- 324-
Boney Parts
2,3
of2 2
1Movement
ofTranslation
Encouragement
Eruption
Expansion
Shape of
1 Teeth
Growth
Guidance Change In Strategies
"Rapid" of Treatment
to
to chin
Crozal.
maxilla
SURGERY
Appl i ances
Bionator,etc.
Frankel,
-extra-oral
to
Appl dentition
separate
(Schwartz,
(Activator,
Appl
Appl
Begg,etc,
Lingual
(Edgewise,
iances
s I) )
Irrrnediate

KEY:
~primary roles
2, secondary roles
3, adjunctive roles
4, usually contraindicated
not appl tcable

FIG 3.
Relationships of strategies of treatment and tactics of treatment.

Strategy is defining goals; tactics are the method, appliance, and
other factors employed to gain success (Fig 3), Precision in timing
and techniques is emphasized, but these alone do not provide
"good" orthodontics, for professional ethics and sensitivity to
each patient's personal needs are also necessary if one is to treat
the patient, not just the malocclusion.
REFERENCE
I, Moyers RE: Good Orthodontics in Singer J, Ribbens KA
(eds), On The Nature of Orthodontics, Los Angeles, The
University of Southern California, School of Dentistry, and
Ann Arbor, Center for Human Growth and Development,
University of Michigan, 1985; also in Graber LW: Ortho-
dontics: State of the Art, Essence of the Science, St Louis,
CV Mosby, 1986, pp 3-11,

"
CHAPTER 13

Force Systems and Tissue

Responses to Forces in
Orthodontics and Facial
Orthopedics
Per Rygh, Dr. Odont.
Robert E. Moyers, D.D.S., Ph.D.

Every body continues in its state .of rest, or of uniform mo-

tion in a straight line, unless it is compelled to change that
state by forces impressed upon it.-SIR ISAAC NEWTON,
Philosophae Naturalis Principia Mathematica, Laws of Mo-
tion I

OUTLINE I) According to the manner of force

application
A. Forces within the masticatory system (a) Simple anchorage
I. Inherent natural forces (b) Stationary anchorage
a) Originating from the action of the muscles of (c) Reciprocal anchorage
mastication 2) According to the jaws involved
b) Originating within the teeth (a) Intramaxillary
c) Originating from the circumoral musculature (b) Intermaxillary
d) Equilibrium theory 3) According to the site of anchorage
2. Abnormal forces (a) Intra-oral
a) Tongue-thrusting (b) Extra-oral
b) Digital sucking (c) Muscular
c) Occlusal dysfunction 4) According to the number of anchorage
d) Traumatic occl~sion . Onits
e) Bruxism (a) Single or primary anchorage
3. Therapeutically introduced forces (b) Compound anchorage
B. Force systems in orthodontic and functional jaw or- (c) Reinforced anchorage
thopedic appliances b) Control of anchorage
I. Classification of therapeutically employed forces 4. Principles of biomechanics in fixed orthodontic
a) Natural appliances
b) Biomechanical a) Some definitions
2. Strategies for controlling forces in clinical practice b) Orthodontic forces and tooth movements
3. Concepts of anchorage I) Types of tooth movement
a) Classification of anchorage 2) Equivalent force systems

306
 Force Systems and Tissue Responses to Forces in Orthodontics and Facial Orthopedics 307

3) Selection and control of orthodontic Orthodontists' and other research workers have probed these
forces matters for nearly a century: the results constitute some of the
c) Some clinical implications and applications brightest and most useful pages in orthodontic history, resulting
I) Translation in a rich and very extensive literature (see Suggested Readings).
2) "Light" wires This chapter is but an introduction to this important subject, it is
3) Intrusion not an exhaustive or definitive presentation.
4) Extra-oral traction
C. Periodontal and other tissue responses to orthodontic A. FORCES WITHIN THE MASTICATORY
forces SYSTEM
I. Physiologic tooth movement
a) Resorptive bone wall 1. Inherent Natural Forces
b) Depository bone wall
a) OrigiTUltingT:rom the Actio~ of the Muscles of Mastication
2. Experimental and orthodontic tooth movement
- The normal activities of mastication, swallowing, breathing,
a) Dentoalveolar tissue reactions
etc., all produce continuous and varied changes in the forces af-
I) Pressure side
fecting the teeth and. bones. Most of the energy for such forces
2) Tension side
originates from contractions of the muscles of the fifth cranial
b) Hyalinization
nerve, the so-called muscle of mastication. One of the most im-
I) Definition
portant of these muscle activities is that of posture, since the
2) Tissue degeneration
continuous pressure of muscle tensions against the teeth and bones
3) Elimination of damaged tissue
likely have more effect than transitory contractions'3 The result
4) Reconstruction of supporting tissues
of all the forces transmitted through the intercuspation of the teeth
3. Factors influencing orthodontic tooth movement
during occlusal function is termed the anterior component offorce
a) Character of bone
(see Chapter 6). Another important and often forgotten combining
b) Physiologic activity
resultant force is that of swallowing, for the repeated effects of
c) Force application
the tooth-together swallow, when the teeth are in correct inter-
I) Tipping
cuspation, is an important element of occlusal stability .64.66
2) Translation
d) Applied force and time b) Originating Within the Teeth
I) Continuous Eruption and the mesial drifting tendency (which must be
2) Interrupted-continuous force carefully differentiated from the anterior component of force) are
3) Intermittent inherent natural forces originating within the teeth and the peri-
4. Root resorption odontiUlJl (see Chapter 6). Although these forces are not thoroughly
D. Controlled alteration of craniofacial growth understood theoretically, clinical advantage is taken of them, par-
I. The nasomaxillary sutural system ticularly in mixed dentition treatment.
a) Posterior forces against the maxilla
b) Anterior forces against the maxilla c) Originating From the Circumoral Musculature
c) Transverse forces in the maxilla The tongue and the lip and cheek muscles impose varying
2. The mandible and temporomandibular joint forces against the crowns and the alveolar process during posture,
a) Functional protrusion swallowing, speech, mastication, and respiration.47. 81.82Posture,
b) Functional restriction and redirection because it is continuous, is considered the most important.82
c) Intermaxillary fixation
E. Other effects of orthodontic treatment d) Equilibrium Theory
The equilibrium theory of tooth position simply holds that
I. Long-term effect on the periodontium and gingivae
although a variety of forces act on the teeth from many directions,
2. Root resorption
in varying amounts and duration, tooth positions remain relatively
3. Tooth malpositions stable. 117
4. Effects of adjunctive surgical procedures
If the inherent natural forces are in equilibrium, when are
5. Temporomandibular function after orthodontic
treatment they in equilibrium? During a moment of function as a single
swa!l0w? Over a reasonaple period of time, for example, a day?
F. Retention, relapse, and occlusal stabilization
Throughout a lifetime? The equilibIjum theory is a useful concept
clinically, but it is difficult to prove or disprove because of (I)
Malocclusions are treated, irrespective of the appliance employed, the simple logistics, experimental design, and sample size of nec-
by a purposeful alteration of the forces within the craniofacial essary studies; (2) the instrumentation necessary to measure all
region. Anyone proposing orthodontic treatment, therefore, must forces at any time-let alone a lifetime-for a satisfactory sample;
understand the natural forces inherent within the masticatory sys- (3) the difficulties of identifying singular abnormal forces in each
tem, comprehend and master the therapeutic application of forces, individual; and (4) many factors beyond practical control in such
appreciate the biologic response of tissues to clinically applied a study.
forces, and be fully aware of the long-term sequelae of orthodontic Proffit,83 examining the equilibrium theory and the research
treatment. thus far bearing on it, concludes the two most important factors
308 Treatment

TABLE 13-1. tongue-thrust and -is associated with some vertical skeletal dys-
Equilibrium Components' plasias (the so-called skeletal open bite). Protracted tongue posture
COMPONENT INTENSITY DURATION is sometimes a residuum of infantile neuromuscular behavior ~see f
Forces of Occlusion Chapters 5, 7, and 10).
Very High Very Short
Lip and/or tongue pressures
Swallow High Short b) Digital Sucking
Speech Low Short Thumb- and finger-sucking can change tooth positions if these
Rest Low Long forces are of appropriate magnitude and duration. Cook 13 identified
Forces of Eruption Very low Long several different patterns of abnormal forces associated with thumb-
• Adapted from Proffit WRB2 sucking, which may account for the variation in appearance and
prevalence of the open bites associated with digital sucking (Fig
in the equilibrium of teeth are (I) the resting pressures of the lip, 13-1).
cheek, and tongue, and (2) the forces produced by metabolic ac-
tivity in the periodontium, since these forces are of low intensity c) Occlusal Dysfunction
for,a long duration (Table 13-1). Little is known, however, about Occlusal interferences and the resultant slide into the inter-
many of the factors in the equilibrium theory over a lifetime, or cuspal position, a slide directed by the cusps of the teeth, has been
their variance in faces of different morphology. The latter is par- shown to produce crowding of the mandibular incisors. 11.22 Or-
ticularly significant clinically. X2 thodontically treated cases which were equilibrated displayed less
The existence of the field of orthodontics is testimony mandibular incisal crowding during and after retention than those
that the equilibrium can be upset and reestablished under new which were not. 65-66
circumstances.
d) Traumatic Occlusion
2. Abnormal Forces
The forces of traumatic occlusion (jiggling occlusal forces)
Abnormal forces originating within the masticatory system, are absorbed by the periodontium, including the supercrestal con-
while natural, may be unsettling to the occlusion, tooth positions, nective tissue, by a combination of compressional and tensional
or temporomandibular joint equilibrium.
inflammation or loss of the atta hment mechanism when there is
a) Tongue-Thrusting counter
a healthyforces. TraumaticNor~Iusion
periodontium. does not
do s traumatic produce aggravate
occlusion gingival
Tongue-thrusting is thought to create
open bites, but inflammation or cause loss of the attachment when gingivitis is
Proffit82-83 holds that tongue swallow pressures, though of high present. However, traumatic occlusion may aggravate active peri-
tensity, are short in duration and are less apt to alter tooth positions odontitis, accelerating the loss of the connective tissue attachment,
than low-intensity forces applied over long duration (e.g., tongue which may result in less regaining of the attachment after ortho-
posture). Abnormal tongue posture accompanies the complex dontic and/or periodontal treatment is over. 112
ALPHA
e) Bruxism
Bruxism mayor may not alter the tooth position depending
on whether or not it is associated with a slide into the intercuspal
position.
+
o
3. Therapeutically Introduced Forces
BETA
Dentists purposely introduce new forces to alter tooth posi-
+ tions, permit changes in the mandibular position, or to affect cra-
o niofacial morphology or growth. Orofacial forces may be altered
by (I) neuromuscular conditioning, (2) functional appliances which
modify and redirect the patient's own neuro)TIuscular activities, or
(3) fixed orthodontic appliances which have stored within them
intentional forces controlled by the clinician.
GAMMA'

B. FORCE SYSTEMS IN 'ORTHODONTIC

AND FUNCTIONAL JAW ORTHOPEDIC
APPLIANCES

TIME 1. Classification of Therapeutically Employed Forces

FIG 13-1.
Three different patterns of forces active against the palate during
thumb-sucking. (From Cook JE: Intraoral Pressures Involved in Thumb
and Finger Sucking, thesis. University of Michigan, Ann Arbor, 1958.
Used by permission.)
a) Natural
Energy generated by contractions of jaw and facial muscles
may be transferred through functional appliances to direct the
 Force Systems and Tissue Responses to Forces in Orthodontics and Facial Orthopedics 309

eruption of teeth, impede eruption, or move an erupted tooth. TABLE 13-2.

Functional appliances are also used to condition, strengthen, or Outline of Kinds of Anchorage
redistribute mus'cle forces against the jaws and dentition. Thus, an
Activator or Bionator might be used to prevent the eruption of the
mandibular incisors and guide the eruption of the cuspids and
--{SINGLEREINFORCED
premolars, while simultaneously repositioning the mandible more
INTRAMAXILLARY STATIONARY
ventrally (see Chapter 18). Synchronously, the lips'are trained by
the appliance to seal more efficiently during the swallow, while RECIPROCAL
{SIMPLE COMPOUND
the tongue learns to assume a correct position during the swallow.
INTRA-ORAL
b) Biomechanical
Biomechanical forces are artificial clinically induced forces
whose energy is derived primarily from contrived mechanical de-
INTERMAXILLARY STATIONARY
vices (e.g., archwires, coil springs, auxiliary springs, vertical loops
in archwires, elastics, screws, etc.) (see Section C-3-d, Applied
{SIMPLE
Force and Time).
EXTRA-ORAL OCCIPITAL
CRANIAL
2. Strategies for Controlling Forces in Clinical Practice
FACIAL
{CERVICAL RECIPROCAL
Orthodontists have devised many ingenious appliance systems
to deploy natural and biomechanical forces, but all use one or
more of the following strategies: (I) elimination of unwanted forces, 2) According to the Jaws Involved.-
as a habit control appliance; (2) redistribution of natural forces,
an approach inherent in all functional appliances; (3) stimulation (a) Intra-Maxillary.-Anchorage established in the same jaw.
or strengthening of natural forces (e. g., lip bumpers, vestibular
shields, and the labial pads of Frankel appliances); or (4) intro- (b) Intermaxillary.- AncC distributed to both jaws.
duction of artificial forces (e.g., those in precision bracketed ap-
pliances, lingual archwires, or screws inserted in "functional 3) According to the Site of Anchorage.-
appliances"). In 1,2, and 3 control of the appliance remains with
the patients' own neuromuscular system. Artificial appliance forces (a) Intra-oral.-Anchorage established within the mouth,
are adjusted for amount and duration of force by the dentist. that is, utilizing the teeth, mucosa or other intra-oral structures.

(b) Extra-oral.- Anchorage obtained outside the oral cavity.

3. Concepts of Anchorage
Anchorage is the word used in orthodontics to mean resistance • Cervical.-Utilizing the neck for anchorage (e.g., neck
to displacement. Every orthodontic appliance consists of two ele- straps).
ments: an active element and a resistance element. The active parts • Occipital.-Utilizing the occipital region for anchorage
of the orthodontic appliance are concerned with tooth movements: (e.g., head gears).
the resistance elements provide the resistance (anchorage) that • Cranial.-Involving the cranium as a source of anchorage
makes tooth movements possible. According to Newton's Third (e.g., high pull head gears).
Law there is an equal and opposite reaction to every action. There- • Facial.-Involving aspects of the face as a source of
fore, in orthodontics, all anchorage is relative and all resistance anchorage (e.g., face masks).
is comparative.
(c) Muscular.-Anchorage derived from action of muscles
a) Classification of Anchorage (e.g., vestibular shields).
Anchorage is classified and named in several ways (Table
13-2). 4) According to the Number of Anchorage Units.-
1) According to the Manner of Force Application.-
. (a) Single or Prim'ary Anchorage.-Anchorage involving
(a) Simple Anchorage.-Resistance to tipping, that is, the only one tooth.
tooth is free to tip during movement.
(b) Compound Anchorage.-Anchorage involving two or
(b) Stationary Anchorage (an absurd designation).- more teeth.
Resistance to bodily movement, that is, the tooth is permitted to
translate only. (c) Reenforced Anchorage.- The addition of nondental
anchorage sites (e.g., mucosa, muscle, head, etc.).
(c) Reciprocal Anchorage.- Two or more teeth moving in
opposite directions and pitted against each other by the appliance. b) Control of Anchorage
Usually, the resistance to each other is equal and opposite. In practice, care is taken to maintain control of anchorage so
310 Treatment

I
F,-D c
i
t
c
t
(0)

(b)

FIG 13-4.
Strain. C = areas of compression; T = tension.

FIG 13-2.
The effect of force on a rigid free body.
that the conditions for movements of teeth are optimal in the active
elements of the appliance and satisfactory for withstanding
movement in the resistance elements. Routine precautions include
(I) securing anchorage as far as possible outside the teeth themselves,
for example, in the mucosa, muscles, cranium, etc.; (2) selecting
larger numbers of teeth in the resistance parts of the appliance;
and (~) varying the amount, direction, and manner of force
application between active and resistance elements. Adherence to
the principles of anchorage control is an essential factor in successful
orthodontics.
4. Principles of Biomechanics in Fixed Orthodontic
Appliances
An orthodontic appliance is a system storing and delivering
forces against the teeth, muscles, or bone and creating a reaction
within the periodontal ligament and alveolar bone that causes
movements of the teeth or alters bone morphology or growth. If
a) Some Defini~
Mechanics is the science which deals with the action of forces
on the form and motion of bodies. In this instance, the bodies are
the teeth, the periodontal ligaments, and the bones. The forces are
those delivered by orthodontic appliances or by muscle contrac-
tions against the teeth, directly or through the intercuspation.
Force is energy or strength brought to bear causing motion
or change in a body-a push or a pull acting in a straight line (Fig
13-2). A force has magnitude, point of application, and direction
(sense and line of action). 10 Therefore, forces are represented and
treated mathematically as vectorslO8 (Fig 13-3).
Strain is a change in form or size of a body as it responds to
an applied force (Fig 13_4).24 A coil spring undergoes strain as
it is stretched; a wire strains as it is bent.
Stress is the internal molecular resistance to the deforming
action of external forces.24 Stress is equivalent, in rigid bodies, to
the strength of the body.
Translation occurs when a force is applied to a body through
the center of resistance.9 Pure bodily movement (translation) ap-
pears in the line of action of the applied force (Fig 13-5). The
greater the force, the greater the translation.
Center of resistance is the term used in orthodontic biome-
chanics in place of the center of mass or center of gravity since
teeth are not free bodies which can be balanced perfectly on a
point for they are constrained by their periodontal attachments to
the roots (see Fig 13_5).108 In single-rooted teeth, the center of
resistance is on the long axis of the tooth one-third to one-half the
way from the alveolar crest to the apex. In multirooted teeth it is
just apically to the furcation.
Rotation occurs when a forcejs applied away from the center
of resistance (Fig 13_6).9 The potential fot rotation is termed a

-
planned tooth movements are to be appreciated, the theoretical
mechanics of the orthodontic force system must be understood. moment and is' measured as the product of the force and the

I
I I • 0
>
'III 1

I!I
1

Line of
F-
Action -z'... - Point of
Sense~ •• ~J---s-Appli'cation
~Magnitude~ FIG 13-5.
Translation is a movement in which crown and root are moved in the
FIG 13-3. same direction.
Forces may be treated as vectors and represented as arrows.
 Force Systems and Tissue Responses to Forces in Orthodontics and Facial Orthopedics 311

/\
" \ A B
" " "" --\ \
,'"
I \
I, I\ I
,""
I
\ I I I
\
\
I
, , / I
\ I , / f

.. \
\\
\ ~::,:~ ,,
I
f

\ ,,"
,,)
,,~'-"'\t/\ ("
t.---,
'l
I

F-- ...l
\
\./ "
\" I
I

\ ..... ,//
,I
~

FIG 13-6. FIG 13-"9.

Moment (gm) = F (force) X distance between point of application TheJo?c'e in A, passing through the center of resistance, will result
and center of resistance. in translation of the tooth. The force in 8, at the bracket, will also
translate the tooth but, in addition, will cause a rotation because of
the moment created at the center of resistance. (From Smith RJ,
Burstone CJ: Mechanics of tooth movements. Am J Orthod 1984;
85:294-307. Used by permission.)

CENTER OF
ROTATION

FIG 13-7.
Equivalent moments with varying forces and distances.

perpendicular distance from the line of action to the center of

resistance (see Fig 13-6).'0 An equivalent moment can be pro-
duced by varying the force and the distance (Fig 13_7).108 A force '--',
.\ ,,\
,\
\

applied away from the center of resistance will cause the same \
\
translation as through the center, but the body will also turn on
an axis (see Fig 13-6). \ 1/
.~-~\
\
A couple is an arrangement of two forces of equal magnitude ,
\I I
,
and opposite parallel but noncollinear lines of action (Fig 13- 8).9 REFERENCE \'- /b
A couple produces pure rotation, since translational tendencies are BASE
canceled.
FIG 13-10.
The center of rotation is the point (or points) around which
The areas a and b represent the cusp tip before and after movement.
a body seems to have rotated. The difference between center of A line has been drawn connecting these points. At the midpoint of
resistance and center of rotation is important in orthodontics. The this line a perpendicular has been constructed. The point at which
center of resistance of a tooth is fixed and not changed by ortho- this perpendicular intersects any other perpendicular constructed in
dontic forces, but the manner of force application can be chosen a similar manner (in this figure, the apex has been selected as the
to determine the instantaneous center of rotation (Figs 13-9 and other point) is the center of rotation. (From Smith RJ, Burstone CJ:
13_10).'08 Further, during most tooth movements a series of dif- Mechanics of tooth movements. Am J Orthod 1984; 85:294-307.
ferent centers of rotation appear. Used by permission.)

appliances (Fig 13_11).108 It must be remembered that each time

b) Orthodontic Forces and Tooth Movements
the teeth are brought together, another complicated temporary force
In practice, teeth are never moved by one simple force; rather,
system intrudes.
the movement is determined by several forces, natural and con-
The parallelogram method (n:membered by all of us from our
trived, acting differently. It is probably impossible to depict math-
first physics course) is used to determine the result or forces within
ematically all the complicated force systems operating against the
orthodontic appliances (see Fig 13_11).108 Sometimes it is useful
teeth; however, it is useful to analyze the'purposeful forces within
to segregate a single force ••into its components in order to determine
sePar.ate horizontal and' vertical effects (Fig 13-12).

1) Types of Tooth Movements.- Theoretically, all tooth

movements fall into one of three categories: (1) translation, (2)
rotation, or (3) a combination of translation and rotation. Trans-
lation simply means that the crown and the root are going in the
F2 same direction at the same time (see Fig 13-5). Tipping is the
'.
orthodontic term for rotation when the crown is going in one
' 50gm direction and the root another (see Fig 13-6). "Rotation," in
FIG 13-8. orthodontic jargon, is restricted to circular motions around the long
A couple. axis of a tooth, as when a buccal cusp is going distally and a
312 Treatment

150g

) C:g
1200g-mm
FIG 13-11 FIG 13-14.
Parallelogram representing forces on the tooth. (From Smith, RJ, Equivalent systems.
Burstone CJ: Mechanics of tooth movements. Am J Orthod 1984;
85:294-307. Used by permission.) • What is the amount of force to be used?
• What is the distance the force must act?
• What is the duration of time the force should act?
• How will the force be dissipated during movements of the
tooth?
• What is the direction of force application desired?
r-------O • What is the distribution of stress created within the perio-
I ---- I
I I dontal ligament by the orthodontic force?
I
I
c :b
I I
When an orthodontic wire is shaped to make a simple spring
I

____________
J and the forces in that spring are measured at different deflections,
FIG 13-12.
Parallelogram of forces, horizontal and vertical.
lingual cusp mesially (Fig 13-13). (See also Section C-3-c, Force
Application. )
2) Equivalent Force Systems.-Most orthodontic forces are
applied by means of a bracket attached to the crown, but it is the
forces at the center of resistance that determines how a tooth
moves. The bracket, being some distance from the center of re-
sistance, produces a large moment causing forces at the bracket
to produce mostly rotational effects (see Fig 13-9,B). One must
analyze the force system at the bracket to determine the equivalent
force system at the center of resistance. Smith and Burstone108
note that two force systems are equivalent if (I) the sums of forces
in the X direction are identical, (2) the sums of forces in the Y
direction are identical, and (3) the sums of moments around any
point are identical (Fig 13-14).
3) Selection and Control of Orthodontic Forces.- When
designing an orthodontic appliance, a number of questions must
be answered:
it will be found that the deflection is proportional to the load
(Hooke's Law).9. 69 Orthodontic springs that have a low load de-
flection rate deliver more constant forces, since there is less change
in force with each unit change in activation.69 This principle un-
derlies the theory of the "light-wire" appliances. The ideal or-
thodontic force application has a large range (the distance through
which the wire can be activated without permanent deformation)
and a low load deflection rate. However, we need to know several
other factors as well, namely, the characteristics of the alloy used,
the cross-sectional size of the wire, and the length of the wire.
In clinical practice, it is desirable to apply known forces over
a predetermined distance for a specified length of time. In order
to achieve these goals, it is necessary to understand how the di-
ameter of the wire and the length of the spring effect the char-
acteristics of the spring. Increasing the length without altering the
diameter of the wire has a dramatic effect on the load, since the
force that is created is reduced to one-eighth when the length is
doubled (Fig 13-15)69 Considerable variation in the force, du-
ration of force expenditure, direction of force application, and

--- .. --
-
,,,,
""
............•.

•...•

A B

FIG 13-15.
Effect of increasing the length of a spring on load (Mulligan's "diving
FIG 13-13. board" effect). (From Mulligan T: Common Sense Mechanics. Phoe-
Rotation around the long axis of the tooth. nix, Ariz, C. S. M., 1982. Used by permission.)
 Force Systems and Tissue Responses to Forces in Orthodontics and Facial Orthopedics 313

Cl 0 0
o 0 Cl
~/

FIG 13-17.
Bypassing teeth to gain advantageous forces for intrusion.

a particular response can only be done by understanding the bio-

mechanical principles involved. The center of resistance of upper
. molars is not in the crown, where the face bow is attached to a
tube, but in the root area (Fig 13-18),'08 If the line of action passes
through the center of resistance, translation will occur (Fig 13-
19) 5. 6. 38 If it passes occlusally, the center of rotation will be
altered and distal crown tipping plus extrusion will result (see Fig
13_19)5.6.38 If the line of action passes apically to the center of
resistance, distal root tipping and intrusion will occur (see Fig 13-
19).5. 6. 38 The line of action is varied in practice by choosing the
site of anchorage (occipital, cervical, "hi-pull," etc.) and chang-
ing the length of the outer bow of the extra-oral traction assembly
FIG 13-16. (see Fig 13-19).
Loops and helices in arch wires: some examples.
C. PERIODONTAL AND OTHER TISSUE
distribution of forces within the periodontal ligament is achieved
by skillful use of loops and helices in the archwires (Fig 13-16).
RESPONSES TO ORTHODONTIC FORCES
The theoretically optimal orthodontic force for any given tooth
movement is that which initiates the maximal tissue response with-
out pain or root resorption and maintains the health of the perio- 1. Physiologic Tooth Movement
dontal ligament throughout the movement of the tooth85.96 (see
Section C). The rate of tooth movement is determined by a number Growth of the craniofacial structures is accompanied by al-
of other variables, for example, the effects of occlusion and in- terations in the position of the teeth as a result of tooth migration.
tercuspation of the teeth, the root surface area of the tooth to be Such changes are seen particularly in the vertical, but also in the
moved, whether the direction of tooth movement is aided by natural sagittal and transversal planes.
tooth drift or not, etc. The dentoalveolar system occupies and fills out the increasing
space formed between the basal parts of the maxilla and mandible
c) Some Clinical Implications and Applications as a result of growth. Two mechanisms seem to be involved: (I)
continuous tooth migration, the rate and amount of which is il-
1) Translation.-If one wishes to move a tooth bodily, the
forc~ system at the bracket must be equivalent to a force with no --- .•...
.•...
"'\
couple of the center of resistance. ]08
\
2) "Light" Wires.- The short distances between brackets
can produce very heavy forces even with small wires.69 "Light"
. "-8 - no tipping
wires alone do not necessarily produce "light"
by increasing interbracket distance, incorporating
forces. However,
loops in the wire, =.
g])..-A- C - clockwise tipping
/
counter-clockwise tipping
f

or bypassing teeth, lighter forces are possible

13-17)69
(Figs 13-16 and

3) Intrusion.-Intrusion is best produced by light, continuous

-- ..- /'
/
/ -,"...

, • = Center of Resistance
- = Tension
forces which can be created by vertical loops between brackets or (line of action
by utilizing the cantilever principle (a pure force acting at the end of force)
of attachment, and an equal and opposite force at the other, ac- FIG 13-18.
companied by a moment) and bypassing teeth (see Figs 13- 15
Extra-oral application of force to upper molars. (After Bowden DEJ:
and 13-17).69
Theoretical considerations of headgear therapy: A literature review.
Part 1, Mechanical principles. Br J Orthod 1978; 5:145-152; Part 2,
4) Extra-Oral Traction. - Various head gears and neck straps Clinical response and usage. BrJ Orthod 1978; 5:173-181. Used
are used for different effects, but selecting the best appliance for by permission.)
314 Treatment

A _ ~ ---........... B

FIG 13-19.
Effects of varying types of head gears on force application to upper
molars. (After Jacobson A: A key to the understanding of extraoral
forces. Am J Orthod 1979; 75:361-386. Used by permission.)

lustrated by deciduous teeth which become ankylosed and where

the bony union between tooth and bone prevents any tooth move-
ment; and (2) tooth eruption with root lengthening.60 Specific
processes within the periodontal ligament in interplay with the
alveolar bone are responsible for tooth eruption, and the perio-
dontium can be looked upon as a growth zone. During active
craniofacial growth the positional changes of the teeth are consid-
erable, and the potential for tissue reconstruction is, therefore,
very high.

a) Resorptive Bone Wall

Alveolar bone resorption occurs on the side toward which the
tooth is moving during the physiologic tooth movements while,
at the same time, reconstruction of the ligamentous support be-
tween tooth and bone is taking place.
On the microscopic level, this situation is characterized by
the presence of osteoclasts residing in scattered resorptive lacunae
on the alveolar bone wall, indicating active resorption (Fig 13-
20). After a while resorption ceases, and the Howship's lacunae
will be occupied by other cells depositing new layers of bone in
which new periodontal fibrils become embedded (Fig 13-21). This
mechanism of reestablishment of the fiber attachment, which was
. demonstrated by means of the electron microscope,91.93 is valid
for both the alveolar bone wall arid root cementum whenever the
fiber attachment has been disrupted (see Fig 13-21). Simultane-
ously, active bone resorption starts in new locations. Thus, the
alveplar wall retracts bt'the occurrence of alternating areas of
resofption and repair. 43Exactly how fiber remodeling and relinking
occur during resorption is still not fully understood. The fibroblasts
have been attributed with the ability of both producing and breaking
down collagen fibers, and it is likely that such cells play an im-
portant role. 113

b) Depository Bone Wall

FIG 13-20.
Osteoclast engaged in active resorption of alveolar bone
On the side opposite the direction in which the tooth is mov-
ing, the tissue reaction is comprised mainly of the apposition of
(x 6,000).
bone, together with the rearrangemenl of the periodontal fibers.
 )
Force Systems and Tissue Responses to Forces in Orthodontics
FIG 13-21.
Deposition of new layers of alveolar bone (nB) in which new fibrils
(F) are embedded. Small arrows indicate demarcation line between
new and old bone (oB). Large arrow indicates direction of tooth
movement. N = osteoblast. (x 20,000). (From Rygh P: Ultrastruc-
tural changes of the periodontal fibers and their attachment in rat
molar periodontium incident to orthodontic tooth movement. Scand
J Dent Res 1973; 81 :467-480. Used by permission.)
Not only are existing fibers in the periodontal ligament entrapped
passively by the advancing front to form Sharpey's fibers, but new
fibers are also secreted simultaneously by fibroblasts migrating
from the bone. New Sharpey's fibers are therefore formed, together
with incorporation of new fibrils into existing fibers.26 The peri-
odontalligament maintains its original width in spite of the tooth's
positional changes.
The human periodontal ligament is about 0.2 to 0.25 mm
wide. This width is a reflection of the cellular activity in the
periodontal space. Teeth which' are under larger functional de-
mands have wider periodontal spaces than teeth under little or no
functional demand. The width of the periodontal ligament of im-
pacted teeth is approximately one-third of that found with erupted
teeth,14 whereas teeth under active orthodontic movement have a
wider than normal ligament.
The components of living tissue are constantly being removed
and replaced. This natural physiologic process, referred to as
"turnover," is especiillly high in the periodontium. This is illus-
trated by the synthesis of collagen, which has been reported as
being higher in periodontal tissue than in any other connective
and Facial Orthopedics 315
tissue in the body. ]07 It is also noteworthy that collagen synthesis
seems to be higher in the periodontal ligament than in gingival
tissue. 109
Petrovic and coworkers have reported that alveolar bone turn-
over is higher during summer than during winter. Furthermore,
the formation rate of alveolar bone in the mandible is associated
with the ..mandibular growth pattern']]
The dentoalveolar structures have an inherent ability to react
to various stimuli. When teeth are exposed to muscular or other
forces of some duration, the periodontal supporting tissues react
by reconstructive adaptations to allow the tooth to establish a more
convenient position. Such functional adjustment is seen both in
the deciduous and permanent dentitions. This adaptive response
is an important baseline factor for the understanding and practice
of orthodontic treatment.
2. Experimental and Orthodo_ntic Tooth Movement
Alterations in the dentoalveolar system account for many of
the changes seen during orthodontic therapy. Tooth movement
goals are often combined with growth adaptation when one aims
not only to move teeth within the alveolar processes but also, for
example, 'to transmit therapeutic forces to the craniofacial suture
system, limiting or enhancing maxillary growth. Recent research
has given us a better histologic picture of the changes that occur
in the circummaxillary suture system, temporomandibular joints,
and the basal parts of the mandible during treatment.
In recent years we have become more aware of the interplay
between force applications and response. Histologic stud-
ies--obtained from both animal and human material--of the basic
mechanisms of cellular changes andfiber reconstruction have pro-
vided valuable information for use in the clinical situation. Or-
thodontic forces that produce tooth movement without damaging
the tooth or related structures are within a relatively small range.
Orthodontic forces are usually much heavier than the natural forces
responsible for physiologic migration, if we disregard mere or-
thodontic guidance of tooth eruption.
.a) Dentoalveolar Tissue Reactions
A distinct pressure and tension zone is developed on either
side of the tooth after the application of force. On the two other
aspects of the roots, more complex situations arise with a com-
bination of pressure and tension reactions, dominated by stretching
of periodontal fibers (Fig 13-22).
Adaptation of the bone is riot restristed to resorption and
apposition around the tooth in the periodontal space. Bone mod-
FIG 13-22.
Orthodontic tooth movement in direction of the arrow with reactions
in the periodontal ligament and in marrow spaces.
316 Treatment
ification is seen in the marrow spaces and under the periosteum
on the external surfaces of the alveolar processes. These changes
occur in order to maintain the structure and thickness of the alveolar
bone. A tooth is not simply moved through bone; one could say
that the supporting structures move with a tooth rhat is moved into
a new position as a response to a change in its environment (see
Figs 13-22, 13-32, and 13-33) ..
1) Pressure Side.-Direct resorption of the alveolar bone
wall is seen on the pressure side of moving teeth. Progenitor cells
have differentiated into specialized cells--osteoclasts-which are
responsible for resorption of the alveolar bone wall. In young
individuals the resorption process may begin as soon as 12 hours
after force application and can be expected after 40 hours.85
. The microscopic picture of the reconstructional changes, es-
pecially on the pressure side, is much more dramatic than that
seen under normal physiologic tooth migration. Figure 13-23 il-
lustrates that the periodontal width on the pressure side has been
greatly increased in order to allow space for a very high cellular
activity and for proliferation of vascular structures. A chain of
osteoclasts is seen along the alveolar wall, and if one were able
to visualize the situation in three dimensions, the osteoclasts would
seem to be attached to the alveolar bone wall like bees in a beehive.
During rapid orthodontic tooth movement the fibrous supporting
apparatus on the pressure side is reconstructed by almost complete
FIG 13-23.
Tissue on pressure side shows increased periodontal membrane
width; proliferation of vascular elements, as indicated by oxytalan
and elastic-like fibrils (small arrows) related to blood vessels; and
bone resorption by osteoclasts (0). Large arrow indicates direction
of tooth movement. T = tooth; B = alveolar bone; bv = blood vessel.
(Rat molar tissue; 10 g continuous force for 14 days; aldehyde fuchsin
Halm; stain.)
FIG 13-24.
Interradicular bone ridge' (B) between pressure side (P), with osteo-
clasts (0) (behind which extensive breakdown an'(j formation of fi-
brous structures have occurred in highly vascularized periodontal
membrane, and tension side (T), with stretched fibrils (F). Note ex-
tensive breakdown and formation of fibrous structures that have oc-
curred in the richly vascularized periodontal membrane on the pressure
side. (Rat molar tissue; 10 g continous force for 28 days.) Insert
indicates site of tissue sample.
breakdown of the old fibers and fiber bundles and by ensuing
formation of new fibrous elements (Fig 13-24). '.
The vascular system provides many of the undifferentiated
cells that are partly responsible for reconstructional changes. The
osteoclasts seem to be derived from cells transported by way of
the blood vessels while osteoblasts and fibroblasts are derived from
local cells.] An abundant blood supply is seen where rapid re-
11
sorption and reconstruction take place (see Figs 13-23 and 13-
24).96
The transmission of mechanical stimuli into specific cellular
activity-such as increased mitotic activity and differentiation of
specialized cells in the periodontal ligament of a tooth that has
been exposed to an external force-is not fully understood. Melcher"9
has postulated that cells of the periodontal tissues secrete sub-
stances capable of stimulating differentiation of specialized cells.
There is reason to believe that prostaglandins play a role. These
polyunsaturated fatty acids are synthesized in the target tissue and
induce such inflammatory reactions as increased vascular perme-
ability and chemotaxis. Increased prostaglandin levels are found
on the pressure side of the periodontal ligament of teeth moved
orthodontically. Such prostaglandins, when taken from orthodontic
pressur~ zones, induce bone re sorption even when transferred to
,
in vitro
. media.96 ,.
The changes that occur in alv~olar bone during tooth move-
ment have also been interpreted in relation to a piezoelectric effect
through strain-generated potentials, arising as a result of mechan-
ically induced deformation of collagen or hydroxyapatite crys-
tals. ]27 Electronegative potentials are generated on the concave
surface, while electropositive potentials are noted on the convex
surface (Fig 13-25). The electrical energy thus produced is be-
lieved to affect the adjacent cells. It has been demonstrated that
when electrodes are placed into bone, osteogenesis wi.ll occur
around the negative electrode while resorption of bone may occur
 Force Systems and Tissue Responses to Forces in Orthodontics
+ +
+
FIG 13-25.
Piezoelectric effect arises as a result of mechanically induced de-
formation of hydroxyapatite or collagen structures.
around the positive electrode.2s In addition, alterations of oxygen
tension and in the availability of circulating hormones, calcium
ions, and cyclic AMP'S have been shown to influence cell
differentiation.
While present histologic techniques provide extensive infor-
mation on the response of cells, fibers, and hard tissue, we know
little about the behavior of the ground substance, blood and tissue
fluids. It has been generally accepted that these elements provide.
FIG 13-26.
Tension side. Stretched fibrous apparatus (F) is reconstructed by
changes of original fibrils, except near blood vessels (BV). Arrow
indicates direction of movement of tooth (T) from alveolar bone ridge
(B). (Rat molar tissue; 10 g continuous force for 28 days.) Insert
indicates site of tissue sample.
and Facial Orthopedics 317
FIG 13-27.
Tension side; Arrows indicate direction of movement of tooth (T). A,
chain of osteoblasts (OB) adjacent to the surface of alveolar bone
(B) produces new bone. B, interface between new bone (nB) and
periodontal membrane with osteoblast (OB), electron microscopic
view (x 7,000).
the teeth with a cushion-like mechanism protecting them against
functional loads. Obviously, new insight into the reactions of tissue
fluids to orthodontic loads is needed.
2) Tension.~Cellular increase occurs after 30 to 40 hours
following application of an orthodontic force.94 Wbile the remod-
eling of fibrous elements on the pressure side is dramatic and
characterized by extensive breakdown and rebuilding, the stretched
periodontal fibers seem to be reconstructed by changes of the
original fibrils (Fig 13-26). It has been suggested that macrophages
contribute to collagen breakdown even by other mechanisms than
phagocytosis: modulation of fibroblast growth and function. Mac-
rophages have been found in great numbers in areas of tension96
There is evidence indicating that an inflammation-like breakdown
and rebuilding process of fibrou.s elements characterize areas of
orthodontic tension. 96
As stretching occurs, new unmineralized material is laid down
around the parts of the fig~rs that are in close relation to the alveolar
bont; wall. After some'hme the whole of the alveolar wall on the
tension side will be covered by'a layer of osteoid, produced by
osteoblasts (Fig 13-27 ,A). Mineralization of the osteoid then oc-
curs in the deepest layers26 (Fig l3~27,B).
b) Hyalinization
The most frequent complication preventing rapid tooth move-
ment occurs when the applied force presses the tooth so hard
against the alveolar bone wall that the periodontal membrane re-
sponds with local degeneration and sterile necrosis instead of pro-
liferation and differentiation of cells that would have been able to
,/

318 Treatment

lage of the contents, which mainly consist of compressed eryth-

FIG 13-28.
Right, hyalinization (H) of the periodontal membrance with indirect
and undermining resorption of bone (B). 0 = osteoclasts. Note wide
periodontal membrance adjacent to hyalinized area. Left, site of
tissue sampling. (Courtesy of K. Reitan.)
perform the necessary reconstructional adaptations. Since this phe-
nomenon is currently almost unavoidable in clinical orthodontics
and since the situation may lead to permanent damage on the
involved tooth and its periodontium, the process will be described
in some detail.
rocytes. If the local force in these areas is not removed, there will
I
then follow breakdown of the blood vessels as well as their contents.
Not only is cell differentiation prevented from taking place
because of increased pressure in the area, but phagocytosis is also
hindered. The breakdown of the blood vessels and their contents
is therefore accomplished by alternative mechanisms to those seen
under normal conditions. Rygh and Selvig98 found that, in rats,
hemoglobin undergoes an intermediate stage of crystallization when
being broken down (Fig 13-29).
While small, constant forces stimulate cellular proliferation,
a strong force, although of short duration, will cause tissue dam-
age, characterized by swelling of the intracellular reticuloendothe-
lial system, followed by disintegration of the mambraneous walls
and, in later phases, by breakdown of the cellular muscle left
isolated within the hyalinized tissue. Studies on human premolars t·
have'shown that most of the cells in a hyalinized zone are reduced
to isolated nuclei after 2 day's exposure to continuous force be-
tween 70 g and 120 g.
Degenerative influences on the fibrous system cannot be rec-
ognized until they have been occurring for several days. Since a
hyalinized zone seldom lasts longer than 2 to 3 weeks, only a
minimal breakdown of the collagen fibrils occurs. When fibril
breakdown is seen, the fibrils split longitudinally.
3) Elimination of Damaged Tissues.- Elimination of the
hyalinized zone occurs by two mechanisms: (I) resorption of the

1) DeJinition.- Evidence for the hyalinization of tissue (the

term generally used to describe the locally compressed and de-
generated periodontal membrane) has been derived from light mi-
croscopy, where the tissue appears glass-like when hematoxylin-
eosin staining has been used. The process of hyalinization is de-
pendent on the local morphology of the compressed area, the
magnitude of the applied force on the tooth, and the duration of
this force, although it may be seen temporarily during physiologic
tooth migration in the interdigitations of the maxillary suture sys-
tem during growth.49
In humans, it takes approximately I to 2 days for a hyalinized
zone to develop. The tooth is not capable of further movement
until this local tissue damage has been removed and the adjacent
alveolar bone wall resorbed. The bone resorption that follows the
hyalinization is of an indirect or undermining nature because there (
are no living cells present within the compressed periodontal mem-
brane to do the job (Fig 13-28).
The periodontal ligament tissue changes associated with a
hyalinization process follow a complex sequential pattern. One is
able to recognize three separate phases: (I) tissue degeneration,
(2) elimination of the damaged tissue, and (3) reconstruction of
the supporting tissue.

2) Tissue Degeneration.- Degeneration of vascular and cel- FIG 13-29.

lular elements are the first signs of a beginning hyalinization. After
a human premolar has been subjected to a continuous orthodontic
force of 70 gm for 2 days, one is able to recognize in the electron
microscope degenerative changes in the endothelial cells lining the
blood vessels. There is breakdown of the walls, followed by spil-
Crystallization of hemoglobin in hyalinized zone. Two sets of parallel
dense bands, a and b, intersect a 50° angle (x 180,000). (From Rygh
P, Selvig KA: Erythrocytic crystallization in rat molar periodontium
incident to tooth movement. Scand J Dent Res 1973; 81 :62-73. Used
by permission.)
 Force Systems and Tissue Responses
FIG 13-30.
Phagocytosis in area of repair. Remnants of cell nucleus (N) and
cell cytoplasm (CC) are engulfed in vacuoles of phagocytes (x 8,000).
alveolar bone by osteoclasts differentiating in the peripheral intact
periodontal membrane and in adjacent marrow spaces, and (2)
invasion of cells and blood vessels from the periphery of the
compressed zone by which the necrotic tissue is r~moved. The
cellular invasion takes 'place quite slowly until the adjacent portion
of the alveolar wall has been removed. The invading cells possess
the ability to penetrate the hyalinizect zone by pushing cellular
extensions into the area. Collagen breakdown occurs around these
extensions as a result of enzymatic attack.
Portions of hyalinized collagen and other debris are included
into the scavenger cell and broken down by phagocytosis (Fig 13-
30). These mechanisms could be clarified by electron microscopy
studies!' It is believed that all tissue that has been damaged by
the compression is removed, including the collagen fibers making
up the periodontal ligament in these areas. This observation should
be borne in mind when considering the development of more
,
extensive damage, such as root resorption.
4) Reconstruction of Supporting Tissues.- Reconstruction
of the fibrous apparatus gradually occurs following the elimination
of the hyalinized remains. New collagen fibrils are produced and
attached to cementum and the alveolar wall by the general mech-
anism described in Section IIl,C, I ,b. Hyalinized zones seen during
treatment with modem orthodontic appliances and moderate force
application are usually small (I mm to 11/2 mm in diameter) and
do usually not last beyond 3 weeks .
• The Periodontal Ligament Following Hyalinization.-When
compared with the periodontal ligament before tooth move-
ment started, the posthyalinized area is wider, richer in
cells, and has an increased blood circulation. If the original
orthodontic force is not reactivated, the periodontal liga-
ment will soon adopt the preexperimental appearance and
width. However, if the force is reactivated, the alveolar
bone wall toward which the tooth is moving will probably
undergo direct resorption.
to Forces in Orthodontics and Facial Orthopedics 319
(From Rygh P, Selvig KA: Erythrocytic crystallization in rat molar
periodontium incident to tooth movement. Scand J Dent Res 1973;
81 :62-73. Used by permission.)
• Alveolar Bone.-Some earlier studies revealed that applica-
tion of extremely high forces to a tooth is capable of pro-
ducing cell death in alveolar bone that is closely associated
with a hyalinized area.72 Electron microscopic findings in-
dicate that with the moderate forces now used clinically,
cell necrosis does not occur in the alveolar bone, and that·
degeneration and necrosis occurring during hyalinization
are restricted to small, localized areas in the periodontal
membrane. 92
3. Factors Influencing Orthodontic Tooth Movement
Local tissue reactions are influenced by the anatomic char-
acteristics of the supporting bone into which the tooth is to be
moved, the physiologic activity of the tissues which surround the
tooth, and the force application.
a) Character of Bone
Remodeling processes in bone depend on the activity of cells
which act upon its surfaces. It is therefore essential that the alveolar
bone is penetrated by many canals that transmit blood vessels and
that its deeper aspects contain cancellous bone with marrow spaces.
The marrow space offers a large surface area for cellular activity,
which is indispensable for tooth movement. 86 On the other hand,
if the bone involved in ,tooth movement is of a compact character
(cortical bone), the surface area where cellular reactions can take
place is vastly reduced. Then tooth movement is more difficult
and much slower, and the chance of creating overcompression and
hyalinization is much greater. When one is planning orthodontic
treatment, the tooth should remain in spongey bone during
movement.
Practically, the tooth should be kept in the ·center of the
alveolar process, as much as possible, rather than being allowed
to move against the compact cortical bone, which occupies a more
superficial position in the alveolar process. It should be kept in
320 Treatment
mind that tooth movement in a labiolingual direction may easily
impinge on the surface layers of cortical bone, for example, through
lingual movement of the root (torque) of upper anterior incisors
in patients with a horizontal overjet.
The anatomic differences between maxilla and-mandible should
not be overlooked. Different rates of bone remodeling may also
be due to the considerable individual variation in the bone character.
Extraction spaces contain tissue undergoing reconstruction,
which is rich in cells and vascular supply. Such an area is ideally
suitable for tooth movement, and due advantage should be taken
of this by commencing treatment as soon as possible following an
extraction. Thereby one also avoids atrophy and narrowing of the
alveolar process, resulting in bone loss and cortical bone formation
at the extraction site.
b) Physiologic Activity
Restructuring of the supra-alveolar fiber system after exper-
imental tooth movement is slower than is the case in the periodontal
ligament. Thus, the strong relapse tendency seen after orthodontic
rotation of teeth is thought to be the result of the lower turnover
of gingival collagen. 106 Turnover varies from one patient to the
next and is dependent on a number of variables such as hormonal
balance, patient age, and health of the patient62 The histologic
picture of the periodontal ligament of a growing person is very
different from that of an adult, arid the readiness for tissue pro-
liferation and cell differentiation into specialized cells seems to
correspond to these differences (Fig 13-31). One therefore has to
consider these variations during treatment planning, especially if
the patient is receiving medication (e.g., cortisone, epileptic med-
ication), as the threshold for tissue changes or cellular reactions
will be influenced.
FIG 13-31.
A, periodontal ligament (control) from buccal apsect of premolar in
12-year-old patient. B, periodontal ligament (control) from buccal
aspect of premolar in 40-year-old patient. (Courtesy of K Reitan.)
FIG 13-32.
Tipping movement with displacement of tooth iri' the periodontal
membrane marginally and, in opposite direction, apically. There is
cellular response on alveolar bone surfaces. Alveloar process moves
with the tooth.
c) Force Application
1) Tipping.-If a force is applied against the crown of a
tooth, and if this force has a "one-point-contact," then a tipping
effect is produced. Tipping, the most simple form of tooth moVe-
ment, tends to concentrate compression on a small periodontal
area. Its greatest effects are usually seen at the marginal root area.
With a small but continuous force a relatively large displacement
of the tooth will occur following tissue changes in the marginal
area. These changes allow the center of rotation to move gradually
toward the middle third of the root. Corresponding tissue changes
are seen apically during tooth tipping with tension and pressure
zones in close proximity to each other but on opposite sides of the
root apex (Fig 13-32). Local pressure zones and areas of hyalin-
ization are a common occurrence in the marginal regions of the
periodontal membrane during tipping movements.
Owing to the development of a fulcrum, the portion of the
root apical to this fulcrum will, of course, move in the opposite
direction to that of the crown. The compressive forces generated
at the root apex can cause extensive hyalinization and therefore
increase the risk for apical root resorption.
In a clinical situation, tipping movements are often used when
moving teeth in a labiolingual direction. The labial and lingual
bone plates consist of dense cortiCal bone (see Fig 13-32) and
compensatory apposition of bone at these sites following initial
tipping movements is comparatively slow. Caution is therefore
essen~i~l when planning such tooth movements.
2) Translation.-Bodily movement of a tooth is usually pro-
duced from a two-point contact of the applied force. It involves
moving the tooth parallel to its long axis; therefore, the force is
distributed over relatively large areas of the alveolar bone wall
(Fig 13-33). When small forces are used, the hyalinized zones
that occur will generally be of shorter duration than those seen
during tipping movements. The reason for this is that the local
forces in these hyalinized zones are smaller, thus allowing direct
resorption of the alveolar bone wall to occur. The tooth movement
 Force Systems and Tissue R€!sponses to Forces in Orthodontics and Facial Orthopedics 321

zones are established, the periodontal ligament has the time to

become reconstructed. There is an increase in cell proliferation
which is suitable for further tissue changes following reactivation
of the force.

3) lntermittent.-An intermittent force (see Fig 13-34) is one

FIG 13-33.
Parallel (bodily) movement. Force is distributed over large areas of
the alveolar bone walls.
following such applied forces is quite favorable since there is
steady bone resorption as well as steady bone apposition along the
stretched periodontal fibers on the tension side.
d) Applied Force and Time
1) Continuous.-Continuous force (Fig 13-34) leads to grad-
ual compression of the periodontal membrane on the pressure side .
of the tooth. If the force is within the limitations where tissue
that affects a tooth periodically or over a time when many inter-
ruptions of the force occur. This type of force occurs when re-
movable appliances are used.
On the pressure side, the circulation will not be as easily
disturbed or hindered unless the force applied is too high. Thus,
hyalinizations that involve only a portion of the periodontal lig-
ament occur more often than with fixed appliances. The intermittent
force is thought to act as an incitement for cell proliferation.
Increase in the cell numbers and direct bone resorption along the
alveolar bone wall are characteristic of this type of tooth move-
ment. The periodontal space increases because the tooth tends to
return to its original position following the removal of the force.
In spite of the favorable condition on the side where resorption
is seen, tooth movement often will be slower than that seen during
application of continuous force, as the time over which the ap-
pliance is used is a very important factor. Formation of new tissue
and apposition of bone are seen to occur more rapidly under active
or constant stretching. Therefore, if the tooth is often allowed to
return to its original apposition, one can expect a limited amount
of apposition to occur.
4. Root Resorption

reactions occur, reconstructional changes of the fibrous element
as well as direct resorption of the alveolar bone wall take place.
If the force is unnecessarily reactivated, the vascular supply is
easily compromised and the result is a "damage-repair" effect.
Elimination of a hyalinized zone occurs between 2 and 4 weeks,
and if reactivation of the force is made before this time, tissue
damage can easily occur.
2) Interrupted-Continuous. - An interrupted-continuous force
(see Fig 13-34) means that the continuous force that is applied to
a tooth is effective over only a small amount of tooth movement,
after which it stops and needs to be reactivated. Even if hyalinized
Although tooth structures generally show considerable re-
sistance against resorption, it is more a question of degree rather
than immunity. Whereas the roots of the permanent teeth are very
resistant, the roots of the deciduous teeth are readily resorbed as
part of the developmental physiologic process of tooth loss.
The root surface is protected by a barrier. Since unmineralized
hard tissue (osteoid, cementoid, predentin) is re~9rbed only with
great difficulty, it is now assumed that the cementoid and the cells
producing cementum constitute a protective covering. However,
the greater resistance to resorption of the teeth as compared to that
of the alveolar bone (which is the premise for all orthodontic
treatment) is explained by the fact that the teeth are permanent

I
W INTERMITTENT
0:: ....... :::
;:.;:»:
..
....
,«:::.::.::. »::.- ::}. .
U ~:,:,:, _'~::
0""'" . __ H __ ,.,_ •• H'
-- ,

o?? rn >? m>

l.L ........................ J..
INTERRuF'.H;6-~ON.tI['Jl!Ql!
l.L
o
W
o
::>
I-
z(9
<I:
L
TIME
FIG 13-34.
Schematic representation of various manners of orthodontic force applications.
/
322 Treatment
depositories of mineral salt, with continuous apposition, while the
bony system is a mineral reservoir for the whole organism, with
physiologic resorption and apposition going on all the time.
The initiation of resorption depends on barrier alterations.
Thus, osteoclasts always appear on a raw bone smface unprotected
by a barrier.
Development of root resorption seems to be an interrelation-
ship between (1) temporary damage of the tooth surface barrier
and (2) general resistance against resorption and remodeling of the
alveolar bone.
Some particular features are common for various situations
leading to root resorption: (I) increase of pressure (tooth eruption,
tumors); (2) tissue damage in the periodontal membrane (me-
chanical, chemical);34.35 (3) increased blood supply (hyperemia
connected with certain types of inflammation, hypertrophy, epu-
lis); (4) infection; and (5) individual predisposition (systemic dis-
eases, endocrine disturbances,' allergy, medication).
Root resorption occurring during orthodontic treatment seems
to be related to local damage of the periodontal ligament-in
particular with hyalinization. During hyalinization the tissue dam-
age in the periodontal ligament alters the biochemical environment.
There is reason to believe that the initial breakthrough of cementum
is connected with the removal of the hyalinized parts of the peri-
FIG 13-35.
Root resorption by odontoclasts (0) in cementum (e) and dentin (D).
Hyalinized necrotic tissue (H) is removed by macrophages (M). Giant
cells (G) are seen, probably formed through fusion of macrophages.
Hyalinized tissue is detached from root surface, as seen by artifact
(A), indicating that osteoid barrier connecting cementum and per-
iodontal fibers is altered. Arrow indicates direction of tooth movement.
(Hem-eosin stain.)
odontal ligament. Biologically active substances are released by
destruction of tissue within the hyalinized zone. These may affect
the development of various cells around the hyalinized zone.
Macrophages in various stages of maturation accumulate
around the hyalinized zone and remove the necrotic tissue (Fig
13-35) while they release prostaglandins, which in turn stimulate
bone resorption. The barrier effect of the cementoid tissue behind
the hyalinized zone seems to be reduced or gone, and macrophages
fuse and become resorbing cells (clasts) (see Fig 13-35). A small
breakthrough is adequate to start the process.
When a re sorption lacuma has been formed, the ensuing events
will depend on whether application of force is continued. If it is,
resorption will continue. The resorption lacuna seems a favorable,
protected environment for the resorbing cells during the application
of a force of a magnitude used in clinical orthodontic treatment.
Once a resorption lacuna is established, the cementum on the edges
of the lacuna is resorbed from the rear, even when the cementum
has a normal periodontal surface.95 If the application of force is
absent or below a certain level, repair will commence in the re-
sorption lacunae with the deposition of cementum.
Root resorption ceases if the orthodontic treatment is inter-
rupted or stopped. The repair taking place will cause new deposits
of precementum on the root surface, thus establishing a new bar-
rier. Rest periods without force application should be included in
treatment of patients with a tendency for root resorption.
The individual's predisposition for root resorption is attributed
to systemic disorders altering bone metabolism. For example, pa-
tients with increased osteoid tissue resorb alveolar bone with great
difficulty, and root resorptions may occur as a result of the ap-
plication of orthodontic force.
D. CONTROLLED ALTERATION OF
CRANIOFACIAL GROWTH
The question of whether craniofacial morphology and growth
could be purposefully altered has been long debated (see Chapter
4). The reasons for the time needed to resolve this argument are
of interest. Many in North America thought it was impossible and
were preoccupied with developing precision bracketed appliances
to move teeth and reshape the alveolar processes. Claims were
made in the European literature concerning the stimulation of man-
dibular growth with functional jaw orthodontic appliances, but
there was no satisfactory scientific evidence.
It seems ironic that the question of whether bone growth and
morphology could be altered should have been argued so heatedly
by orthodontists who have done much of the best research and
routinely apply the biologii: concepts in practice. In fact, if bone
wer~;'not so plastic and adaptable, orthodontics would not exist.
The biologic concepts of this important subject are discussed in
Chapter 4, and the cephalometric analysis of treatment effects and
their segregation from growth is discussed in Chapter 12.
1. The NasomaxilIary Sutural System
Experimental and clinical studies prove that it is possible to
influence sutural adaptation and maxillary growth. A prerequisite
is a patent suture before natural fusion (synostosis) has occurred.
Purposeful nasomaxillary displacement is possible because the su-
 Force Systems and Tissue Responses to Forces in Orthodontics
tures uniting membranous bones depend largely on local conditions
for tbeir growth and physiologic adaptation. The position, orien-
tation, direction, and even number of facial sutures seem to be
closely related to various forces. Their proliferlltion is dictated by
the tensions received from the bones which they unite and the soft
tissue by which they are surrounded: increased tension leads to
increased sutural width and length.
Much of our most basic and practical knowledge of altered
nasomaxillary growth has come from animal experimentation, yet
it may seem difficult to understand what experimental changes
mean clinically, as the laboratory model is so different from dental
practice. In experimental animals a normal craniofacial form is
made abnormal, while in humans the clinician wants tp change an
abnormal skeletal relationship into a more normal one. Further,
animals are often under better control than patients.
During compression by heavy extra-oral forces the sutures
become 2 to 3 times wider than normal and show signs of great
cellular activity. The serpentine configuration with interdigitations
disappears, and the fibers lose their orientation. The bone surfaces
reveal Howship's lacunae with active osteoclasts. This stage of
direct re sorption is frequently preceded by local hyalinization (Fig
13-36). Hyalinization is even observed in control animals during
normal growth.
During tension of a suture, osteoblasts and Sharpey's fibers
are incorporated into the bone surfaces by deposition of new bone
layers. The sutures react to pressure and tension much in the same
way as seen on the alveolar bone surface of the periodontal lig-
ament during tooth movements (Fig 13-37). Reorganization with
normalization of width and formation of new interdigitations occur
when the force recedes.
Yen125 et aI. found that the rate of collagen synthesis in stressed
sutures was reached in 3 days, and higher values were maintained
up to day 14. The rate of noncollagenous protein synthesis peaked
FIG 13-36.
Hyalinization in the intermaxillary suture of the palate of a Rhesus
monkey after experimental compression. (From Linge L: Tissue
Changes in Facial Sutures Incident to Mechanical Influences. An
Experimental Study in Macaca mulatta, thesis. University of Oslo,
1973. Reproduced courtesy of the author.)
and Facial Orthopedics 323
FIG 13-37.
Heavy, rapid expansion of the intermaxillary sutdre of the palate of
a Rhesus monkey. (From Linge L: Tissue Changes in Facial Sutures
Incident to Mechanical Influences. An Experimental Study in Macaca
mulatta, thesis. University of Oslo, 1973. Reproduced courtesy of
the author.)
at 5 days and was significantly different only on day 5. They
suggest, therefore, a more significant role for collagenous protein
synthesis in the control of remodelin&.
a) Posterior Forces Against the Maxilla
Head gears and cervical traction devices can restrain alveolar
process development and inhibit maxillary corpus growth. The
gross" orthopedic effects" of heavy, continuous, extra-oral forces
to the maxilla have been well documented in extensive animal
studies. It has been shown by radiographic techniques that in small
monkeys, during the late deciduous dentition stage, the midfacial
complex can be moved posteriorly into a Class III relationship
within 3 months, using heavy, continuous force (400 g per side)
applied for 24 hours per day, producing a posterior displacement
of up to the width of two teeth.7. 9. 41. 49. 55. 56.115
Posterior movement of the maxilla by external cervical forces
in humans has been demonstrated. 19. ; 1& The response of the maxilla
and maxillary dentition is complicated, depending on several fac-
tors including the direction of force application, mode of attach-
ment of the extra-oral device, amount and duration of force, and
the patient's craniofacial morphology. Class 11intermaxillary elas-
tics are commonly used to move maxillary teeth distally, but their
effect on nasomaxillary skeletal growth and morphology is not
well known. The effect of. intermaxillary Class 11traction on man-
di'tJuJill'growth has been studied. 57. 5&. 77
It has also been demonstrated, in humans, that both tooth
movements and maxillary skeletal alterations can concomitantly
effect the position of the mandible, as the mandibular elevators
must accommodate the mandible to the maxilla during function.
Theoretically, at least, extra-oral traction to the maxilla should
also have an indirect effect on mandibular growth and morphology,
although this point is not fully documented.78
324 Treatment
b) Anterior Forces Against the Maxilla
Face masks can move maxillary teeth forward.17 They can
also promote maxillary growth and sutural adaptation, resulting in
a more ventral positioning of the corpus maxillarus. Heavy ex-
perimental forces of 300 to 400 g produce exten"sive anterior dis-
placement of the maxillary complex on monkey~ after three
months.41 Sutural opening associated with fewer interdigitations
occurs in the circummaxillary sutures. A simultaneous rotation of
the maxilla in an upward direction is often seen associated with
varying reactions in different sutures. 16Histologic studies confirm
that the displacement seen cephalometric ally is mediated by re-
sorption and remodeling of the sutural articulations of the maxilla. 75
Anterior movement of the maxillary complex has been demon-
strated in patients by external forces through facial masks 76 Heavy
forces applied as early as from 5 to 8 years of age seem to render
the best results" (P. Rygh, unpublished data). It has been claimed
that the use of face masks inhibits mandibular growth in the same
way as the use of chin chaps, but no documentation has yet been
presented.
c) Transverse Forces in the Maxilla
Widening of the maxilla by devices which separate the median
palatal and associated sutures is a proven clinical procedure49, 61.75
The sutural response is largely tensional, and the maxillary trans-
lations, after sutural separation, are rapid and dramaticl24 (see also
Chapter 15). Although palatal expansion therapy has been used
for many years to correct transverse inadequacies, only recently
have we benefited from studies of the changes in the teeth and
supporting structures in response to such lateral expansion. 124Strong
reciprocal lateral forces are necessary to separate the median palatal
suture, and some damage should be expected, particularly in the
buccal periodontium of the maxillary molars and bicuspids. Green-
baum and Zachrisson32 compared three groups of patients. The
first underwent rapid maxillary expansion with a fixed split-acrylic
appliance, the second underwent slow maxillary expansion with a
Quad-Helix appliance, while the third or control group underwent
routine edgewise appliance treatment but with no palatal expan-
sion. The expansion groups showed an average mean increase in
distance between the first molars of about 4.5 mm. The perio-
dontial condition was good in all groups and attachment levels
were similar, although there was individual variation in response.
Marked periodontal breakdown occurred in a few individuals
undergoing rapid maxillary expansion because expansion occurs
before molar rotation when this appliance is used. These findings
show that the periodontal condition can remain within acceptable
levels with either rapid or slow expansion but that rotated molars
are at some risk with the rapid maxillary expansion.
The skeletal changes associated with extensive maxillary skel-
etal expansion are surprisingly stal5le, and the periodontium can
be maintained in a healthy state with good oral hygiene. 123-125
However, resorption of the buccal aspects of the roots of which
the palatal widening device has been placed has been demonstrated
histologically.2 Such resorption may not be seen in periapical ra-
diographs until it is quite extensive.
2. The Mandible and Temporomandibular Joint
Most of the arguments about the clinician's ability to alter
craniofacial growth have centered on the mandible and whether
or not its growth could be "stimulated," restricted, or altered. As
the number and quality of research studies improved and cephal-
ometric methods were refined, it became possible to gain per~
spective on this important topic (see also Chapter 4).
a) Functional Protrusion
Extensive experimentation on mandibular functional protru-
sion has been carried out, notably by Petrovic and coworkers77. 78
and by McNamara, Carlson, and colleagues. 55.57.58Using devices
similar to functional orthodontic appliances on rats (Petrovic) and
monkeys (McNamara and Carlson), demonstrable histologic and
radiographic changes have been produced (Fig 13-38). Cephalo-
metric findings in humans are less clear because it is hard to
discriminate dentoalveolar changes from condylar change and the
growth changes which would have happened were appliances not
worn. Pancherz, using Activators73 and Herbst appliances,74 re-
ports significant changes in mandibular corpus a~d overall length.
Others, for example, Janson40 and Bookstein," show that most of
the differences between treated and untreated cases are the result
of alterations localized in the dentoalveolar area. Bookstein4 noted
the importance of shape changes often not discerned with con-
ventional cephalometrics but revealed by tensor analysis. There is
no doubt that functional appliances bring about more significant
alterations in facial growth and morphology than was once thought.
b) Functional Restriction and Redirection
Experimental studies have shown conclusively that orthopedic
forces similar to those used with human chin cup treatment produce
significant alterations in mandibular form and growth. 77Graber30. 31
concluded, after studying the effects of chin cup force on children
during the late primary and early mixed dentition period, that there
was a definite alteration of mandibular growth direction and man-
dibular morphology. Ramus height growth was retarded, and the
direction of mandibular growth was significantly altered. 31
c) Intermaxillary Fixation
Intermaxillary fixation in monkeys rapidly altered the histo-
logic character os the condylar cartilage, resulting in profound
changes in the joint and mandibular growth. 12
E. OTHER EFFECTS OF ORTHODONTIC
TREATMENT
Occasionally anecdotal comments are made about alleged
del~terious effects of .,O'l'thodontic treatment on the perio-
dontihm, roots, and temporomandi,bular joints, but for some time
there were no satisfactory clinical research studies. Research re-
ports on all these matters now provide better perspec-
tive. 1,28,33.79.84.99,102.103.105.123The results are reassuring if me-
ticulous oral hygiene is maintained at all times during orthodontic
treatment and if adherence to established occlusal principles is
maintained during treatment and retention. 79.99The data show that
periodontal health can be maintained during orthodontic treatment
and that periodontal and temporomandibular dysfunctioo are not
correlated with previous orthodontic treatment. 100.101
 Force Systems and Tissue Responses to Forces in Orthodontics and Facial Orthopedics 325

FIG 13-38.
Temporomandibular joint region of a typical growing monkey. A,
magnification, x 12. 8, higher-power (x 40) magnification of the
growing cartilage. C, temporomandibular joint region of an animal
who has been in protrusive function for 6 weeks. Note the increase
in the thickness of the condylar cartilage, particularly along the pos-
terior aspect as compared with A and 8 (magnification at x 12).
(Courtesy of JA McNamara, Jr.)

1. Long-Term Effects on the Periodontium and Gingivae Since root resorption also occurs in patients who have not under-
gone orthodontic treatment, it too has been studied, and root re-
Sadowsky99. 101 studied the long-term periodontal effects of
sorption seems to vary with age between the sexes and among the
orthodontic treatment on adults who had completed full fixed ap-
teeth.'4. 35. 53. 54.70 Some investigators have concluded that patients
pliance therapy during adolescence. Their condition as adults was
showing signs of root resorption prior to orthodontic treatment also
compared with that of control subjects of similar race, sex, age,
experience more resorption than average during treatment. 29. 70
1R.
socioeconomic level, and dental awareness who had similar mal-
In one of the most exhaustive clinical studies on this subject, Linge
occlusions. The data showed that orthodontic treatment during
and Linge5o.51 reported the results of 719 consecutively treated
adolescence did not contribute in any way to the long-term status
orthodontic patients who had been treated with either edgewise
of gingival or periodontal health. No significant amount of either
therapy exclusively (74%), removable appliances exclusively (11 %),
damage or benefit to the periodontal structures could be attributed
or a combination of both (14%). Mean root shortening for the four
directly to the fact that the subjects had undergone orthodontic
maxillary incisors was 0.73 mm and 0.67 mm for girls and boys,
therapy. Nor did the lack of orthodontic therapy during adolescence
respectively. The average most severe single root resorption per
appear to influence subsequent development or nondevelopment
patient was 1.34 mm for both sexes. After a statistical search for
of periodontal disease in adults. Polson79• RO conducted a similar
clinical risk factors with regard to apical root resorption, they found
study noting bacterial plaque, visual gingival inflammation, bleed-
that patients starting treatment later than 11 years of age experi-
ing after probing, location of the gingival margin, periodontal
e~ced significantly mors:-root resorption than patients starting ear-
pocket depth, and loss of attachJT1ents. All of his subjects had
lief.Highly significant risk factsm were previous trauma to the
orthodontic treatments at least 10 years prior to the study and none
teeth, the correction of impacted maxillary cuspids, and the use
was over 36 years of age at the time of the research. He determined,
of rectangular wires and Class 11 elastics. They found that fixed
"When the overall clinical results were considered, it was con-
appliances cause significantly more apical root resorption than
cluded that orthodontic treatment performed during adolescence
removable appliances. They also noted that sex, overbite, overjet,
had no discernible effect upon later periodontal health. "RO
and duration of time the bands were in place were not closely
related to the amount of apical root resorption.50 Postretention
2. Root Resorption observations indicated that apical root resorption usually ceases
Shortening of the roots as a result of external resorption has with the termination of orthodontic treatment.
long been known to be a side effect of orthodontic treatment. 3 Careful taking of the case history prior to beginning ortho-
326 Treatment
don tic treatment and periodic radiographic monitoring during treat~
ment are essential requisites in minimizing root resorption.
3. Tooth Malpositions
Gingival recession and cemental exposure may occur when
teeth are left in extreme positions within the alveolar pro-
cess.27. 110.126Such malpositions result in a thin alveolar bone plate
that is more susceptible to resorption.I26 The gingival recession
that occurs is always accompanied by bone dehiscence. When such
malpositioned teeth with gingival recession are moved orthodont-
ically back into a more favorable position, repair can occur. 114.116
Although the bone dehiscence which appears because of uncon-
trolled expansion of the teeth through the cortical plate may be
repaired in healthy younger patients,23. 42 it is obvious that such
mal positions should not be present at the end of orthodontic
treatment.
4. Effect of Adjunctive Surgical Procedures
Several minor surgical procedures often accompany ortho-
dontic treatment or are used to stabilize orthodontic results. 44.48.90
Edwards21 recommends fibrotomy to help prevent rotational re-
lapse, but it should be avoided on the labial or buccal portions of
very thin gingivae. The removal of gingival papillae in extraction
closure sites enhances the restitution of normal connective tissue. 21
However, excising gingival clefts whenever the tissues are thin,
deficient, or receding is not recommended. 124Gingival deficits and
periodontal defects are sometimes seen around previously impacted
cuspids after their surgical uncovering and repositioning. 120.124
5. Temporomandibular Function After Orthodontic
Treatment
Assertions have been made that orthodontic ally treated pa-
tients have more problems of the temporomandibular joint than
others. Obversely, it has been claimed that orthodontic ally treated
patients have less temporomandibular difficulties. 67.100Obviously,
one of these hypotheses is wrong. Fortunately, several retrospec-
tive studies have tested these divergent hypotheses, and all studies
are in substantial agreement. 39.45.100Sadowsky and BeGole,Ioo for
example, examined subjects between the ages of 25 and 55 years
who had been treated orthodontic ally with full-banded appliances
from 10 to 35 years earlier and compared them with a group of
adults with similar but untreated malocclusions. The orthodonti-
cally treated group had fewer temporomandibular signs and symp-
toms than the untreated group, but the differences· were not
statistically significant. The amount of shift from the retruded
contact to the intercuspal position was significantly greater in the
controls than in the orthodontically treated group. There was no
difference in joint sounds or parafunctional habits, although the
contro; group had significantly more pain and tenderness. Alle-
gations have been made that the extraction of bicuspids accom-
panying orthodontic therapy predisposes to later temperomandibular
dysfunctions, but such claims have not been supported by sound
clinical studies. Further, it has been put forth that second molar
extractions are less apt to lead to the appearance of TMJ signs and
symptoms than are bicuspid extractions. There are no controlled
clinical studies to support or deny this opinion either. What is well
documented, however, in many clinical research studies is the
significant role that occlusal disharmonies can play in the etiology
of TMJ disorders, occlusal disharmonies caused by many factors
including drifting of teeth, poorly contoured restorations, ill fitting
prothesis, etc. Poorly completed orthodontic treatments are just as
apt to cause trouble, but it is the resulting poor occlusion with
which the neuromuscular cannot cope that is the significant etio-
logic factor, just as it is in the other branches of dentistry.
It must be kept in mind that there are significantly more
temporomandibular disturbances in children with mal occlusions
than in the random population.67 If, at the end of orthodontic
treatment, there is little difference between treated and untreated
cases, then the orthodontic treatment has made a significant con-
tribution to the reduction of temporomandibular disorders, because
the treated patients had more disturbances at the start.
F. RETENTION, RELAPSE, AND OCCLUSAL
ST ABILIZA TION
Retention, in orthodontics, is maintaining newly moved teeth
in position long enough to aid in stabilizing their correction.
Relapse is the term applied to the loss of any correction
achieved by orthodontic treatment.
Occlusal stabilization must involve homeostasis; that is, the
masticatory system should be self-stabilizing after orthodontic
therapy.
There have been many ideas about and concepts of retention.
Orthodontic stability has been said to be dependent on the angu-
lation of the mandibular incisors, the relationship of the teeth to
their apical bases, the posterior occlusal relationships, etc. A long-
term study of retention and relapse found diverse causes of re-
lapse, 11.22.37.64.67but two were most important: (I) an occlusion
not harmonious with the mandibular position during the uncon-
scious swallow, and (2) disharmonious growth after orthodontic
therapy. Many studies have described the relapse of individual
tooth positions, whereas these two factors relate to relapse more
generally.
It is very important, when assessing "relapse," to segregate
those changes resulting because of orthodontic intervention from
those which would have appeared if treatment had not oc-
curred.8. 36.46.52 Riedel88 has discussed a number of popular ex-
planations of retention and relapse and the available clinical research
evidence about them.
•
• Theorem i.-Teeth that have been moved tend to return to
their former positions. While this is not true for all tooth
" l!I0vements, it is true'.for rotations.2o. 21.106The concept ap-
plies more to incisors than to posterior teeth, whose inter-
cuspation aids retention.
• Theorem 2.-Elimination of the cause of malocclusion will
prevent recurrence. Many "causes" of mal occlusion are
not known, although this theorem is true for such obvious
single etiologic factors as tongue-thrusting, thumb-sucking,
abnormal lip positions, etc.
• Theorem 3.-Malocclusion should be overcorrected as a
safety factor. This rationale is popular in practice, but there
are few data to support it.
 Force Systems and Tissue Responses to Forces in Orthodontics
• Theorem 4.-Proper occlusion is a potent factor in holding
teeth in their corrected positions. The occlusion usually re-
Jerred to is the intercuspal position. The occlusal relation-
ship obtaining during primitive reflex functions (e. g., the
unconscious swallow) is important in ocelusal stabiliza-
tion.64 Correct intercuspation is an essential factor in occlu-
sal stabilization.67
• Theorem 5.-Bone and adjacent tissues must be allowed
time to reorganize around newly positioned teeth. This is
the rationale for the use of retainers after active tooth
movements. There is good histologic evidence that it takes
some time for the tissues to return to normal after tooth
movements. 85.86.96However, this theorem presumes that
newly moved teeth are no longer the victims of unsettling
forces. If there is occlusal disharmony during the uncon-
scious swallow, it makes very little difference what kind of
retainer is worn or for how 10ng.64. 66 The moment the re-
tainers are removed, relapse will begin until the occlusion
returns to harmony with the muscles. Indeed, when retain-
ers are removed, if an occlusal interference persists, a
"slide into occlusion" will cause the incisors to relapse to
crowdingY Stability will return but at the expense of the
incisal correction.
• Theorem 6.-lf the lower incisors are placed upright over
basal bone they are more likely to remain in good align-
ment. This theorem has some value but has been overex-
tended, since it often avoids the implications of varying
facial types and the mesial migration of the teeth through-
out life. Further, the incisal angle deemed "correct" at 12
years of age may not be so for the same person at age 18,
as the mandible usually grows disproportionately more than
the midface. Finally, the most appropriate incisal angula-
tion varies with skeletal features, for example, the steep-
ness of the mandibular plane (see Chapter 12).
• Theorem 7.--Corrections carried out during periods of
growth are less likely to relapse. This theorem seems valid
and logical, but there is little solid evidence to support it.
Treatment during growth presumably allows the tissues in-
volved to adjust better. 73
• Theorem 8.-The farther the teeth have been moved, the
less is the likelihood of relapse. This theorem is strange in
logic and there is no evidence to support it.
• Theorem 9.-Arch form, particularly the mandibular arch,
cannot be altered permanently by appliance therapy. The
strongest support for this idea comes from the analysis of
cases treated by multi banded therapy after most growth is
over. 89.104Treatment during the mixed dentition with bite
plates, extra-oral traction, or functional jaw orthopedic
appliances73 has shown some natural widening of the man-
dibular arch diameters. The best evidence, though, shows
that purposeful alteration of the bicanine diameter in the
mandibular arch is hazardous to stability irrespective of the
appliance. 89.104Arch form changes occurring in response to
alterations in the muscular environment may be more
stable.
To Riedel's theorems might be added the following:
and Facial Orthopedics 327
• Theorem JO~-Many treated malocclusions require perma-
nent retaining devices. This is less true for cases treated to
meticulous occlusal goals and with respect for the dynam-
ics of growth and occlusal functionM.66 The less the den-
tist knows about occlusal physiology the more will be the
temptation to retain permanently.
Treatment goals are usually stated in cephalometric terms for
individual tooth positions with insufficient attention- to accom-
modating for skeletal variations. Nor are treatment goals often
phrased in terms of occlusal dynamics. Most mal occlusions are
stable before therapy. If they are not at the end of treatment, it
may be the fault of the dentist. All treated malocclusions must
eventually be returned from control by appliances to control by
the patient's own musculature. Proper goals of treatment, careful
mechanotherapy, precise occlusal equilibration, and well-chosen
retention procedures play a role in achieving occlusal homeostasis.
Few clinical research workers have concentrated on the dif-
ficulties of relapse and retention (Riedel and c-oworkers are a no-
table exception,88. 89.104)which is a pity. Though proper studies
are difficult to design and tedious to execute, the rewards are great.
We have much to learn in this important field, and until the research
is completed it is well to be reminded that many confidently held
assumptions about "good" treatment procedures have not been
confirmed by clinical investigations.
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SUGGESTED READINGS
McNamara lA lr, Ribbens KA (eds), Malocclusion and the
Periodontium, monograph 15. Craniofacial Growth Series.
Ann Arbor, Mich, Center for Human Growth and Develop-
ment, University of Michigan, 1984.
McNamara lA lr, Ribbens KA, Howe RP (eds), Clinical Alter-
ation of the Growing Face, monograph 14. Craniofacial
Growth Series. Ann Arbor, Mich, Center for Human Growth
and Development, University of Michigan, 1983.
Barber AF, Sims MR: Rapid maxillary expansion and external
root resorption in man: A scanning electron microscope
study. Am J Orthod 1981; 79:630-652.
Burstone Cl: Biomechanics of the orthodontic appliance, in
Graber TM, Swain B (eds) , Current Orthodontic Concepts
and Techniques, 2nd ed. Philadelphia, WB Saunders, 1975.
Hocevar RA: Understanding, planning, and managing tooth
movement: Orthodontic force system theory. Am J Orthod
1981; 80:457-477.
Linge BO, Linge L: Apical root resorption in the upper front
teeth during orthodontic treatment: a longitudinal radiographic
study of incisor root lengths, in McNamara lA lr, Ribbens
KA (eds), Malocclusion and the periodontium, monograph
15. Craniofacial Growth Series. Ann Arbor, Mich, Center for
Human Growth and Development, University of Michigan,
1984, pp 165-184.
Melcher AH, Beersten W: The physiology of tooth eruption, in
and Facial Orthopedics 331
McNamara lA lr (ed) The Biology of Occlusal Development,
monograph 7. Craniofacial Growth Series. Ann Arbor, Mich,
Center for Human Growth and Development, University of
Michigan, 1977, pp 1-240.
Mulligan T: Common Sense Mechanics, Phoenix, Ariz, C.S.M,
1982.
Proffit WR: Equilibrium theory revisited: factors influencing po-
sition of the teeth. Angle Orthod 1978; 48:175-186,
Reitan K: Biomechanical principles and reactions, in Graber
TM, Swain BF (eds), Current Orthodontic Concepts and
Techniques, Philadelphia, WB Saunders, 1975.
Rygh P: Periodontal responses to orthodontic forces, in
McNamara lA lr, Ribbens KA (eds), Malocclusion and the
Periodontium, monograph 15. Craniofacial Growth Series.
Ann Arbor, Mich, Center for Human Growth and Develop-
ment, University of Michigan, 1984, pp 17-42,
Riedel RA: Post-pubertal occlusal changes, in McNamara lA lr
(ed), The Biology of Occlusal Development, monograph 7.
Craniofacial Growth Series. Ann Arbor, Mich, Center for
Human Growth and Development, University of Michigan,
1977, pp 113-144.
Sadowsky C, BeGole EA: Long-term status of temporomandib-
ular joint function and functional occlusion after orthodontic
treatment. Am J Orthod 1980; 78:201-212.
Sadowsky C, Sakols El: Long-term assessment of orthodontic
relapse. Am J Orthod 1982; 82:456-463.
Smith Rl, Burstone Cl: Mechanics of tooth movements. Am J
Orthod 1984; 85:294-307.
Weinstein S, et aI. On an equilibrium theory of tooth position,
Angle Orthod 1963; 33:1-26.
Zachrisson BU, Alnaes L: Periodontal condition in orthodonti-
cally treated and untreated individuals. 1. Loss of attachment,
gingival pocket depth and clinical crown height. Angle Or-
thod 1973; 43:402-411.
Zachrisson B U, Alnaes L: Periodontal condition in orthodonti-
cally treated and untreated individuals. n. Alveolar bone loss:
Radiographic findings. Angle Orthod 1974; 44:48-55.
"
CHAPTER 14

Planning Orthodontic Treatment

Robert E. Moyers, D.D.S., Ph.D.

"
Always take hold of things by the smooth handle.-THoMAs
JEFFERSON

Nothing in progression can rest on its original plan. We might

as well think of rocking a grown man in the cradle of an
infant.-EDMuND BURKE

OUTLINE 2. Factors related to the individual dentist

a) Aptitude
A. Selection of orthodontic cases in general practice b) Training
I. Is there a problem? c) Experience
2. What is the problem? d) Attitude
3. How is the problem typified? e) Adherence to poor methods
3. Factors related to the nature of orthodontics
a) Timing of treatment
b) Skeletal pattern a) The nature of developmental oral biology
c) Available space b) Patient cooperation and treatment success
4. What treatments are available for this problem? c) Paucity of adequate compromising alternative
treatments
5. Which available treatment is most appropriate?
6. How is successful treatment defined? F. Some common mistakes
a) Ideal treatment
b) Compromise treatment Not all patients with "malocclusion" want or need orthodontic
c) Symptomatic (palliative) treatment treatment. Not all patients needing orthodontic treatment should
7. How will the treatment be stabilized? be treated by the typical family dentist. This chapter is written
B. Treatment planning in the primary dentition assuming that the reader has the interest and desire to treat as many
I. Reasons for treatment orthodontic patients as possible without co~promising the quality
2. Conditions that should be treated of the result. Many dentists have a great desire to extend their
3. Conditions that may be treated orthodontic service to more patients, but most dental schools do
4. Contraindications to treatment in the primary dentition no~ have the time in the,ctlITiculum to teach orthodontics past the
C. Treatment planning in the'transitional dentition introductory level. Short courses a,nd occasional lectures are plen-
I. Reasons for treatment tiful but provide no clinical experience. The dentist skilled in many
2. Conditions that should be treated aspects of dentistry and wishing to further his or her orthodontic
3. Conditions that may be treated abilities is thus stymied by the very nature of orthodontic treat-
D. Treatment planning in the permanent dentition ment--one cannot learn orthodontics in "short" courses because
E. Limiting factors in orthodontic therapy malocclusions cannot be treated in a short time. Ethical dentists
I. Factors related to the individual patient seeking supervised clinical teaching, but unable to leave their
a) Limiting skeletal factors practices for an extended period, are unwilling to try new and
b) Limiting dental factors unfamiliar treatments on patients without supervision. Enthusiasm
c) Limiting neuromuscular factors is no substitute for experience and ability, nor does sincerity

332
 Planning Orthodontic Treatment 333

How Treatments Which How To

Typified? Available? Mastered? Stabilize?

(Dismiss) (Refer)

Classification Treatment Treatment Treatment

9 15, 16, 17 15, 16, 17 15,16, 17

FIG 14-1.
Flow of questions arising at the start of malocclusion treatment. Pertinent chapters in this text are noted below.

guarantee correctness. One must protect oneself and one's patients
f~om well-intentioned but ill-planned therapy. Meticulous planning
before orthodontic treatment actually is begun prevents much mis-
understanding and trouble. Careful orthodontic planning is essen-
tial for every dentist, but especially so for the less experienced or
2. What Is the Problem?
illtrained.
The purposes of this chapter are (I) to provide a procedure
for testing whether one can provide a satisfactory treatment for a
particular problem and (2) to outline a plan for organizing ortho-
dontic treatments.
A. SELECTION OF ORTHODONTIC CASES
IN GENERAL PRACTICE
during the cursory examination (see Chapter 8). Having determined
that a problem exists, one does not place immediately a favorite
appliance but rather asks the next question.
The purpose of the diagnosis is to defin'e and describe in a
definitive manner the nature of the problem (see Chapters 10-12).
Orthodontic problems are not described in terms of the appliance
to be used (e.g., a "head gear case") but rather in terms of
abnormal skeletal morphology, abnormal dentitional and occlusal
features, and atypical neuromuscular function. The more precise
and quantitative the diagnosis, the easier it is to answer the next
question.

The selection of any malocclusion for treatment derives from

the answers to seven questions which follow one another in logical
sequence (Fig 14-1): (I) Is there a problem? (2) What is the
problem? (3) How is the problem typified? (4) What treatments
are available for this problem? (5) Which of the available treat-
ments is most appropriate for me to use? (6) How is successful
treatment defined? and (7) How will the treatment be stabilized?
1. Is There a Problem?
The question of whether a problem exists is in our minds
3. How Is the Problem Typified?
Before starting any treatment, it is useful to typify the case
by its characteristics and possible treatment strategies. The Angle
Classification and many other classification systems are inadequate
for this purpose. The procedure suggested herein consists of asking
three questions sequentially, the answers to which segregate most
malocclusions into 18 categories according to their primary char-
acteristics (Fig 14-2). Such a simple approach does not complete
the diagnosis for it does not include every important variable (e.g.,
the mediolateral and vertical aspects of the malocclusion), it simply

FIG 14-2.
An arborization (decision tree) to segregate various treatment pro- namely, skeletal Classes I,ll, and Ill); and C, the availability of space
tocols. Arborization is based on three decisions: A, timing of treat- in the arch (abundant, sufficient, or deficient).
ment; B, craniofacial skeletal pattern (three choices are available.
 334 Treatment
aids in the screening and grouping of similar cases for ease in
planning treatment. All mal occlusions grouped by this method
have the same fundamental nature with respect to developmental
age, anteroposterior relationships, and available space in the arch
periI]1eter, and they differ only in other aspects of.the malocclusion.
The procedure is designed to keep the dentist's mind on possible
basic treatment strategies to avoid being diverted by trivial and
superficial features. Treatment planning should not necessarily be
directed to the ugliest aspects of the mal occlusion nor to features
most worrisome to the parent or child. Successful therapy is founded
on a thorough understanding of the fundamentals of the maloc-
clusion, not the patient's worries. Superficialities respond easily
if basics are understood and controlled. Figure 14-2 is an arbor-
ization (decision tree) developed from the possible answers to three
questions:
(a) What is the timing of treatment?
(b) What is the facial skeletal pattern?
(c) Is space available within the dental arch alone to correct
the malocclusion?
As each question is asked, the most appropriate available
answer is chosen, and the diagram is followed to the next question.
Finally, one arrives at one of the 18 protocols at the bottom of
the chart. All cases which end in the same category will have
similar basic features with respect to developmental age, skeletal
pattern, and available space, but may differ in other features.
Advanced clinicians probably do something like this intuitively,
but those who are inexperienced need guidance to keep a focus
on the most critical features in determining treatment strategies.
a) Timing of Treatment
The question of timing (line A in Fig 14-2) is asked first
because the strategies and tactics for early; as opposed to late,
treatment are so different. Must the treatment for this patient take
into account facial and dental development, or is most growth
already accomplished? If growth is mostly completed, therapy will
consist largely of tooth movements neither greatly aided nor ham-
pered by growth.
Early treatment is treatment which must cope with active
growth or might utilize its dynamics. A method is required to
assess the stage of occlusal development and estimate the time left
before establishment of the permanent occlusion (i .e., determine
if there will be sufficient time to complete any interceptive and
guidance procedures). After the permanent occlusion is established
(second molars in occlusion), little skeletal growth remains, es-
pecially in girls, and the opportunities for occlusal guidance are
diminished. Furthermore, the mechanotherapy changes at this time
as well as interceptive and guidance appliances (holding arches,
functional appliances, simple extra-oral traction devices, etc.) give
way to the multi bracketed precision appliances necessary for proper
positioning of the permanent teeth.
A crude and arbitrary rule of thumb, based on the calcification
stage of the mandibular cuspid and first premolar, may be used
to separate early from late treatment. When these teeth have not
yet reached calcification stage 7'/2 (roughly one-half the root
formed), the patient may be considered eligible for early treatment
planning (see Chapter 6, Development of the Dentition and the
Occlusion, and Chapter 11, Analysis of the Dentition and Occlu-
sion). Chapter 15 deals with early treatment.
Late treatment, in this context, is defined as treatment begun
too late to be greatly aided, complicated, or confounded by growth.
Of course some facial growth and dentitional development remain
in patients after the cuspids and premolars have reached stage
7'/2, but there may be insufficient time to achieve the basic goals
of treatment without changing the strategy and appliances used
earlier (see Chapter 16 on adolescent treatment). Nor should one
forget that growth and bone remodeling persist throughout life, a
fact which makes orthodontics possible in adults (Chapter 17).
Often we are prone to equate growth solely with the exuberant
changes of childhood and pubescence, whereas it is more proper
to consider all skeletal changes throughout life. With aging, the
bone turnover rate decreases but persists, so treatment is still pos-
sible, but at a much slower rate. One can take quick advantage of
growth only when growth is most active and time is available to
utilize it. Skilled orthodontists with an experienced sense of timing
often can start "early" treatment at a later developmental date.
Diphasic treatment, that is, treating the skeletal problem early
when growth is more active and treating dental mal alignment after
the permanent teeth have erupted, purposefully separates two basic
treatment goals. The concepts of "early" and "late" treatment
are useful working hypotheses only and offer no guarantee that
unexpected late growth will neither disrupt nor disturb.
b) Skeletal Pattern
In Chapter 8, The Orthodontic Examination, a simple non-
cephalometric method was presented for initially assessing the
facial skeleton (the Facial Form Analysis). On the basis of this
analysis or, better, a cephalometric analysis, the Basic Morpho-
logic Analysis (Chapter 12), the patient is arbitrarily assigned to
one of three skeletal categories: Class I, essentially a well-balanced
facial profile; Class II, a retrognathic profile; or Class Ill, a prog-
nathic profile. This step is illustrated in line B of Figure 14-2.
c) Available Space
It is necessary to decide, before, beginning treatment, whether
there is sufficient space to provide for alignment of all teeth, any
necessary occlusal adjustments, and the placement of the teeth
over their bases (see line C in Fig 14-2). In Chapter 11, Analysis
of the Dentition and Occlusion, methods for mixed dentition anal-
yses and "diagnostic setups" were given. The Mixed Dentition
Analysis alone cannot show how the teeth fit in the facial skeletal
profile. Only a combined cephalometric and mixed dentition anal-
yses can be so revealing. Having performed both, the dentist can
now categorize the patient as having "abundant," "sufficient,"
or "deficient" space. Abundant means there is more than enough
space to align all of the teeth properly within the craniofacial
skeleton as well as enougl}. to permit any required developmental
occlus!ll adjustments. Sufficient means that there is only enough
arch perimeter to align the teeth buf none is left to aid in achieving
a Class I occlusion (Le., there is insufficient space for a late mesial
shift). Deficient means there is insufficient arch perimeter to ac-'
commodate all of the teeth. This categorization is based primarily
on the lower arch, since it is more critical in matters of space.
Basic treatment of all cases within the same protocol category
will be similar, though individual cases in the group will vary in
some aspects (e.g., vertical relations). For instance, all malocclu-
sions sorted to protocol 13 wiII show most permanent teeth as

erupted, a Class 11facial skeleton, and inadequate arch space within
which to align the teeth, though there may be dissimilarity in
superficial or localized aspects of the malocclusions. Figure 14-
3 should be studied carefully, for it illustrates the application of
the method to actual cases. One is now in a position to select a
treatment for the malocclusion just typified.
4. What Treatments Are Available for This Problem?
It is impossible even for the most experienced orthodontic
clinician to know all of the available methods of treatment for
each particular malocclusion. We are all limited to those treatments
we have been taught, or have learned on our own. This raises the
qQestion: Of known available treatments, how does one decide
which, if any, is most appropriate for a given patient?
5. Which Available Treatment Is Most Appropriate?
A principal limitation in treatment is the developmental age
of the patient. Certain strategies are appropriate at certain ages
and less useful or even contraindicated at others (Fig 14-4).
All appliances have limitations, but those that have stood the
test of time must have certain virtues for particular, though not
necessarily universal, applications. Treatment can drag on and on
because the dentist fails to recognize the inadequacies of the ap-
pliance chosen or doesn't know another. Many a malocclusion is
finished with an inadequate result because the dentist does not'
know the best appliance or treatment procedure for the case or
refuses to use other than a favorite method. So varied are the
mal occlusions and so complex the details of their corrections that
all clever clinicians are constantly adding to their repertory of
treatment methods. Only the naive and stubborn marry themselves
to but one appliance or method. Those who do so, if their standards
are to remain high, must limit the patients treated, either con-
sciously or unconsciously, to those malocclusions which respond
well to that particular favorite appliance or procedure.
Incompetence* in orthodontics is of two kinds - poor per-
formance and poor thinking. Poor performance may be an innate
inability to complete a task without making a mess of it. Poor
performance also may derive from attempting treatment with an
unfamiliar method or appliance but with no real training in its use.
One does not achieve a competent performance in orthodontics
solely by listening to a persuasive lecturer or by looking at pictures
of treated cases completed by someone else. The second kind of
incompetence in orthodontics, poor thinking, originates when a
person chooses inflexible adherence to rules, formulae, or "phi-
losophies" of treatment over differential analytical treatment plan-
ning. Blind faith in or rigid adherence to one approach to all
problems causes one to fail to discern obvious and meaningful
developmental signs or significant responses to therapy, and thus
one is unable to react practically to them when they appear.
It is generally believed that we know how orthodontic ap-
pliances work and that successful orthodontists use such knowledge
*The ideas on incompetence in this paragraph were much influ-
enced by an article by an eminent American historian, Barbara W.
Tuchman: A nation in decline? New York Times Magazine, Sept 20,
1987, P 20.
Planning Orthodontic Treatment 335
routinely in practice. In the real and practical sense, this simply
is not true, for if it were, the knowledge could be taught more
easily, unexpected difficulties in treatment would not be encoun-
tered, and relapse would be infrequent. Furthermore, there would
have evolved a more universal agreement about treatment methods
and goals. The many, diverse opinions so strongly held by cli-
nicians of integrity are testimony to our ignorance of how appli-
ances really work. Difference of opinion always causes more trouble
than difference of facts. If the facts were well known there would
be more general agreement about treatment.
Let us pursue this point by developing a simple equation of
orthodontic success:
M (malocclusion) + T (treatment) = 5 (success). That is, a
known mal occlusion plus a specific treatment should make it pos-
sible for us to quantify success. As we develop this idea a bit we
might be able to say (where A in the equation is one patient):
M(A) + T(J) = 0.75(5)
M(A) + T(2) = 0.50(5)
M(A) + T(3) = 0.25(5)
M(A) + T(4J = ? (5).
In other words, the same kind of mal occlusion treated four different
ways yields different success ratios varying from unknown or
questionable success to success 75% of the time.
Until we have better clinical research on a wide variety of
malocclusions using several different methods, all of us have dif-
ficulty knowing which is truly the best method for a case. It is
certain, however, that a treatment unknown to us or little known
could hardly be used. In the list above, suppose that only T(3) or
T(4) was known, then there would be much less chance for success
than if treatments T(J) or T(2) had been mastered. Those who
develop treatment methods are rarely able to be objective about
the limitations of their own methods. At present, it is difficult,
quite difficult, to determine which treatment is the best for each
malocclusion. We must fall back on our own experience or listen
to those we trust, but sincerity of view is no guarantee of truth.
When considering treatments one knows for a particular problem,
one must ask, (I) How did I learn about this treatment? and (2)
What are my experiences and skills with it? Few of us are willing
to learn a complicated and difficult method of treatment by' ap-
plying it to our own patients without supervision. So, for a given
malocclusion, though many treatments may be available, we may
know but one or two, but we must assure ourselves that at least
one of those known and mastered is appropriate or we should not
b~gin treatment. _.
6. How Is Successful Treatment Defined?
There are three kinds of orthodontic treatment goals: (I) ideal;
(2) compromise; and (3) symptomatic treatment. In Chapters 15
through 17 it will be noted that the goals of successful treatment
vary widely according to developmental age, severity of the dys-
plasia, history of oral disease, loss of teeth, and other factors.
Treatment planning involves choosing the most appropriate goal
for each case, but that goal-ideal, compromise, or sympto-
336 Treatment

Address _ Porenl

3+4+5
alignment
molar
Space
of 2 and I
adjustment
left ofler
Pred
Spaceicted
'I
left size
tor of
"3. ifI q.f?
L..1:'11

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I I
_L-/,Y.
'"
3

.'

Lower

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Space left
alignment of 2 and I
after
I g.
Pred icted
3 '1- 4

Space
+
left
5

fOf-
size of
-'L
molor adjustment ~ L). 7
Overbile" '1.8~
Remarks:

Molar relationship"
Overjet"

~
3, q
r ,.

I
I I ill]
~------EARLYI~(8)
ITIT

I I-LATE---------
--+-
11

11 Bl
TIMING (Al 11

1
11

I
SKELETAL -!----
PATTERN <B) I .

SPACE (C)

FIG 14-3.
Examples of the arborization applied to actual cases. Look at the check your choices against the chart below each photographic
photographs, make each of the three decisions in sequence, and grouping ...•
 •....
M
M
---tZl
2QSufficient
Q~ -
t;
-I
, I '"
to --Deficient
SuffiCient
Sufficient., ~--TAb~dCmt--
~
Sufficient Abundant
Deficient

__J~__
SuffiCient Abundant
II <:::1
i::
II~
I § -I~I-..J 1Abundant I El ~
DefiCIent
Sufticlen'
Abundant
Deficient '"
IIl:: +~e~i~t ",I
1

12
I
1(3 I
-I 'i;
'!:il ~
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Cl

Cl
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0."'1
1

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-
0.'"

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'QJ~ 8 Abundant
-I
--
Sufficient
SuffiCient
SuffIcienT ---rAbUndOnt--
•...• SuffiCient
Abundant
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S:'! , 0.'"

I
=---J---l
@I <:::1
Il:: Sufficient
UDeficient
1
Abundant
I I El Deficient
I
-I ~ @
~
I~ I-..J Abundant
DeficIent
I Deficient '"
I

0.'"
I 1

I
1(3 -I 0.'" 1

'!:i.1
1

~I
",I
-I
~I
L+
.-.
--
<1'
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....J.-.
<12
1
U
Deficient
0.'"

o.-J
Z-l
wO
1

1 ~
Z
~5;:;
....JI-- U
~g
<11-
=1 ~ ~I- ~
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a'Xl

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u 0.'" 1

L+
-
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J§ --

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o.-J
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Z....J
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338 Treatment

Summary of Treatment Plan

Patient's Name WI'lliflM. B. age 'I_I sex~ dateS~o/cfI "

Child _ Youth Adult
guidance ___ pre-adolescence ___ healthy, little growth
---p phase I of diphasic _~ __ mid-adolescence expected
treatment ___ post-adolescence ___ combined with
__ interception ___ phase 11of diphasic periodontics and
treatment restorative
___ combined with
surgery

Specified Necessary Compromises "

1. NollE" 3.

2. 4.

FIG 14-4.
Summarization of the treatment plan. Under the appropriate age of all four first bicuspids). The goals must be stated simply in order
group, each treatment should be designated properly. Any necessary of importance, but the strategies should be stated in the sequence
compromise with an ideal result should be specified (e. g., extraction in which they will be employed during treatment.

matic--{)ught to be determined by the features of the malocclusion,
not the inclinations or abilities of fhe dentist.
a) Ideal Treatment
First, always define the ideal goal for the case under study
and do not abandon it without clearly being forced to do so. But
what is "ideal" from an esthetic point of view may not be ideal
from the standpoint of periodontal health, occlusal function, or
practicality. The ideal goal often is rejected because such a goal
seems "impractical." In orthodontics, practicality often is deter-
mined largely by stability of result. An unstable occlusion, even
with. teeth apparently ni<.:eiyaligned, is a most impractical result.
The"main reason for abandoning the ideal goal is simply that the
nature of a particular mal occlusion does not permit an ideal result:
for example, extraction of teeth is necessary.
The goals listed here and in Chapters 15 through 17 include
concepts of oral health, function, and cosmetics, whereas the fam-
ily may be concerned largely with esthetics. One must be very
careful not to impose too rigidly one's own concepts and standards
of esthetics. Often a trait has been accepted without question or
even cherished as a family characteristic until the dentist calls
attention to it.

When the nature of the case does not permit ideal treatment,
the only compromise treatment that can be accepted, of course,
is that which most clearly approximates the ideal. If the clinician
does not know how to obtain an ideal result, two alternatives are
available: the patient may be referred to a specialist, or a com-
promise treatment plan must be developed. The latter alternative
cannot be followed ethically unless the first alternative has been
suggested, its superiority explained to and rejected by the patient,
and the nature of the compromise and its difficulties have been
understood and accepted. When patients cannot afford the cost of
ideal treatment, it is well, before suggesting a compromise treat-
ment, to remember that no patient can afford an unstable result
and that most mal occlusions are stable until clinical intervention
be&ins. An alternative procedure under these circumstances may
be 'not to treat at all in the hope that at a later time the ideal
treatment can be achieved.
b) Compromise Treatment
When contemplating compromise treatment, it is well to ask
several questions: "What is being compromised?" "Why is com-
promise treatment considered" and "Who pays how big a price
for the compromise? Some malocclusions simply cannot be treated
ideally, and any therapy is a compromise with perfection. On the
other hand, to compromise the goal because of one's own inability
to treat to the best result may be to ask the patient to pay too high
a price and raises serious questions of professional ethics.
Unfortunately, there are three common problems in ortho-
dontics that do not lend themselves to compromise. A Class II
malocclusion cannot be treated partially toward a Class I relation-
ship or it will be unstable and revert to the original condition, for
occlusal dysfunction tends to destroy partly corrected Class II
occlusions. The second matter difficult to compromise is that of
gross discrepancies in tooth size-available space ratios. If there is
a discrepancy of 3 mm in a quadrant, there is no 3-mm tooth that
can be extracted to alleviate that exact amount of crowding. The
dentist must extract a tooth in each quadrant which is about 7 mm
in width. Although the space is thus easily provided for alignment
of 3 mm of crowding, 4 mm of space closure remains to complete
the treatment. The tooth movements necessary to effect 4 mm of
space closure and a harmonious functional occlusion are much
more difficult than the tooth movements that provided the 3 mm
of alignment. A third uncompromising situation is the inability of
the jaw musculature to adapt to certain occlusal interferences. For
example, some are tempted to extract a single mandibular incisor
to relieve crowding. The incisors are then easily aligned, but they
may now have no antagonistic occlusal stops in the upper arch
and erupt toward the palate, and the posterior intercuspation usually
has been altered so that is cannot be corrected by tooth movements
or even equilibrated into stability.
Unfortunately, there are not as many compromise methods
of treatment in orthodontics as we would like and as many as are
available for other dental services. One of the most difficult tasks
in orthodontics is that of planning sensible and practical compro-
mise treatment. An even more difficult problem is the retreatment
of cases worsened by unfortunate mistakes in compromise therapy.
Sometimes, unwanted compromise treatment is forced on the den-
tist by the failure of the patient and family to carry out their
responsibilities. Some cases are very difficult to terminate under
Planning Orthodontic Treatment 339
such circumstances as minimal patient cooperation after extraction
of teeth. Whatever the compromise, a basic rule to remember is
to compromise stability last of all.
c) Symptomatic (Palliative) Treatment
Treatment of the symptoms of malocclusion rather than the
malocclusion itself is rarely advised except as a temporizing ex-
pedient to be followed by treatment of the basic problem. An
example of acceptable symptomatic therapy is the retraction of
maxillary incisors in extreme labioversion during the early mixed
dentition to minimize their accidental fracture. But even the pal-
liative retraction of procumbent maxillary incisors often may be
done just as easily by simultaneously treating the Class II occlusal
and skeletal relationship which accompanies it.
Figure 14-4 is a form I use in my practice to outline and
summarize the treatment plan. Note that the goals are specified in
order of importance but the steps of treatment are noted in sequence.
Precise definition of goals makes easier the decision con-
cerning disposition of the case. One wants to treat only those
patients one can treat well to a stable result, refer those patients
needing treatment that one cannot provide, and keep under careful
surveillance'those patients for whom the best treatment must come
later. There is no excuse for continued observation of a case be-
cause of ignorance or indecision. Observation alone effects few
improvements: proper intervention is more successful. Referrals
can be made for diagnostic consultation as well as for treatment.
The patient should not have to suffer longer for more expensive
treatment at a later time because of the diagnostic inabilities of
the first dentist he or she consults, nor should a colleague's task
be made more difficult by another's earlier indecision.
7. How Will the Treatment Be Stabilized?
Retention is planned when estimating the probable treatment
result, when setting the goals of treatment. Before a dentist pre-
pares a cavity for an inlay, there is a clear mental image of the
cavity outline, the depth of the preparation, the slope of the cavity
walls, and other details. Without such a mental image as a goal,
one could scarcely begin. In like fashion, before a malocclusion
can be corrected, the clinician must have a precise concept of how
the treated result will appear. Every dentist knows perfect inter-
cuspation of the teeth. That is not what is meant; rather, one must
be aware at the very start of treatment of the detailed deviations
from perfect intercuspation that can be expected in a case because
of the very nature of the problem; for exabple, if the maxillary
incisors are disproportionately wide for the mandibular incisors,
the best mechanotherapYPllnnot effect a perfect posterior occlusion
cO~cUmitant with an ideal overbite and overjet relationship. Under
such circumstances, one treats to ; perfect posterior occlusion and
admits that the nature of the case will require a bit more overjet
than would have appeared had the tooth widths been more har-
monious. It is advisable to write into the treatment plan any ex-
pected difficulties of retention or any tendencies to relapse. Such
a notation serves to remind one, as treatment ends, of details that
were fresh in mind during the thorough study done at the start of
treatment. Retention principles are discussed in Chapter 13. Spe-
cific details are given in Chapters 15 through 18.
340 Treatment
B. TREATMENT PLANNING IN THE
PRIMARY DENTITION
1. Reasons for Treatment*
Treatment in the primary dentition is undertaken for the fol-
lowing reasons: a) To remove obstacles to normal growth of the
face and dentition. b) To maintain or restore normal function.
2. Conditions That Should Be Treated in the Primary
Dentition Are:
a) Anterior and posterior crossbites.
, b) Cases in which primary teeth have been lost and loss of
arch space may result.
c) Unduly retained primary incisors which interfere with
the normal eruption of the permanent incisors.
d) Malpositioned teeth which interfere with normal occlusal
function or induce faulty patterns of mandibular closure.
e) All habits or malfunctions which may distort growth.
3. Conditions That May Be Treated
a) Distoclusions that are at least partly positional. Occlusal
equilibration or tooth movements may restore normal function.
The rest of the problem may be treated at this time or later.
b) Certain distocclusions of a skeletal nature are best treated
at this age, but the patient must be socially mature, and the cases
must be carefully chosen.
c) Open bites due to tongue-thrusting or digital sucking habits.
4. Contraindications to Treatment in the Primary Dentition
Treatment in the primary dentition is contraindicated when:
a) there is no assurance that the results will be sustained,
b) a better result can be achieved with less effort at another
time, and/or
c) the social immaturity of the child makes treatment
impractical.
C. TREATMENT PLANNING IN THE
TRANSITIONAL DENTITION
The mixed dentition period is the time of greatest opportunity
for occlusal guidance and interception of malocclusion. At this
time, the dentist has the greatest challenges and finest opportunities
for efficient orthodontic therapy. ,.
1. Reasons for Treatment
Any case may be treated in the mixed dentition (see Chapter
15) provided that:
a) The treatment does not impede normal growth of the
dentition.
*See also Chapter 15.
b) The malocclusion cannot be treated more efficiently in the
permanent dentition. Emphasis should be placed on guidance of
growth, interception of a developing malocclusion, and elimination
of the first symptoms of what might become more serious mal-
occlusions in the permanent dentition.
2. Conditions That Should Be Treated
Conditions that should be treated in the mixed dentition (see
Chapter 15) are:
a) Loss of primary teeth endangering the available space in
the arch.
b) Closure of space due to the premature loss of primary teeth;
the lost space in the arch must be regained.
c) Malpositions of teeth that interfere with the normal de-
velopment of occlusal function, cause faulty patterns of eruption
or mandibular closure, or endanger the health of the teeth.
d) Supernumerary teeth that may cause malocclusion.
e) Crossbites of permanent teeth.
f) Malocclusions resulting from deleterious habits.
g) Oligodontia, if closure of space is preferable to prosthesis.
h) Localized spacing between the maxillary central incisors
for which orthodontic therapy is indicated.
i) Neutroclusion with extreme labioversion of the maxillary
anterior teeth (maxillary dental protraction).
j) Class II (distoclusion) cases of a functional type.
k) Class II (distoclusion) cases of a dental type.
I) Class II (distoclusion) cases of a skeletal type, particularly
if diphasic treatment is indicated.
m) Space supervision problems.
3. Conditions That May Be Treated
Conditions that may be treated in the mixed dentition (see
Chapter 15) are:
a) Class II malocclusions of a skeletal type, particularly if
diphasia treatment is indicated.
b) Class III malocclusions, where early treatment is feasible.
c) All malocclusions accompanied by extremely large teeth.
If serial extractions are to be undertaken, treatment must be in-
stituted in the mixed dentition.
d) Gross inadequacies or disharmonies of the apical bases.
D. TREATMENT PLANNING IN THE
PERMANENT DENTITION
t
All mal occlusions possible to correct may be treated in the
permanent dentition of the young adult (see Chapter 16), although,
as·,noted earlier, that is- not necessarily the best time for some
problems. Orthodontic therapy can be carried out for older healthy
adults, but the strategies and tactics change radically when peri-
odontal disease and/or loss of teeth has occurred (Chapter 17).
E. LIMITING FACTORS IN ORTHODONTIC
THERAPY
1. Factors Related to the Individual Patient
So much variability is seen among orthodontic patients that

sophisticated diagnostic techniques have been developed for iden-
tifying the individual characteristics of each patient to be treated.
a) Limiting Skeletal Factors
The most limiting skeletal factors are those of gross osseous
dysplasia, wherein one or more parts of the craniofacial skeleton
are disharmonious with other parts. The clinical problem is dis-
harmony within an individual face rather than deviations in ab-
solute size from population norms (see Chapters 4 and 12).
b) Limiting Dental Factors
Primary limiting dental factors include disharmony between
the total tooth size and available space in the arch perimeter,
variations in the number of teeth, intra-arch tooth size dishar-
monies, and interarch tooth size disharmonies. The beSt-planned
orthodontic treatments can go awry because the number and size
of teeth for the patient are not in harmoney with themselves or
other features (see Chapters 6 and I I).
c) Limiting Neuromuscular Factors
The most important and frequent limiting neuromuscular fac-
tors are abnormal reflex activities, including lip functions, tongue-
thrusting, swallowing, and functional mandibular movements
adaptive to occlusal disharmonies. Less frequently seen, but more
severe, neuromuscular factors include the retention of endogenous
orofacial infantile neuromuscular behavior and neuromuscular be-
havior associated with gross developmental syndromes or neuro-
pathologic conditions (see Chapters 5 and 10).
2. Factors Related to the Individual Dentist
Just as patients and malocclusions vary, so there is wide
variation in the aptitude, training, experience, personality, and
attitude of dentists, variations which have a marked effect on the
quality of treatment results.
a) Aptitude
Aptitude, or native ability, is clearly differentiable from train-
ing or experience. The influence of technical aptitudes on dentistry
is well known; less appreciated in orthodontics are intellectual or
conceptual aptitudes. Those who would treat malocclusions must
adopt a long-term view, for treatment awaits biologic responses
and growth. Such a philosophic point of view comes easily to
some but not to all. Successful orthodontics requires a biologic
point of view on the part of the dentist-an aptitude clearly dif-
ferentiated from, but not in conflict with, technical and mechanical
skills. Finally, specific diagnostic capacities are advantageous to
the dentist in orthodontics. For most malocclusions, there are sev-
eral satisfactory treatment plans that might be followed. The dentist
who always demands a clear view of "right" and "wrong," the
identification of an only' 'best" way to treat every case, and similar
certainties will encounter difficulties in orthodontics. Such narrow
views are useful in achieving technical skill; they are handicapping
when developing broad diagnostic and treatment planning capac-
ities in orthodontics.
b) Training
Most dentists in North America have had less undergraduate
Planning Orthodontic Treatment 341
training in orthodontics than in other clinical subjects. Therefore,
the general dentist desiring broader abilities in orthodontics begins
with a handicap of which he or she may not be aware. Furthermore,
though many orthodontic short courses are available for the general
practitioner, few, if any, can include the actual treatment of mal-
occlusions. Furthermore, in many short courses, there are evi-
dences of commercialism and parochialism in teaching. The dentist
who would treat mal occlusions must analyze carefully the advan-
tages and disadvantages of past training and the methods available
for improvement.
c) Experience
The finest graduate training problem in the world is not an
adequate substitute for personal clinical experience, since the cases
treated are completed by adherence to primary diagnostic decisions
and treatment plans of the clinical intructor, not those of the grad-
uate resident. Cases treated in graduate residency programs are
carefully selected for their teaching value: in orthodontic specialty
practice one treats everything and does so alone. In general practice
one has the luxury of referral.
d) Attitude
Any of us may have unconscious personal biases or handi-
capping attitudes toward ourselves and our clinical work. If we
have unjustified self-esteem or overrate the training we have had,
we may be handicapped in our clinical efforts. Perhaps the most
important single attitude for the clinical orthodontist is that of
objective criticism of one's own clinical efforts.
e) Adherence to Poor Methods
One is ethically obligated to use the best method available,
but as new discoveries and innovations are made, the best methods
of one time period become the poorer methods in another. Good
orthodontists are constantly on the lookout for improvements in
treatment methods. Adherence to unfounded or poorly based meth-
ods is inexcusable, as the dissemination of orthodontic knowledge
to the profession through journals and textbooks is now so thorough
and widespread. There is, unfortunately, evidence of "cultism"
still remaining in orthodontics, but such parochial attitudes are
found far less frequently in the experienced and well-trained
practitioner.
3. Factors Related to the Nature of Orthodontics
Orthodontics is a difficult clinical practice with many limiting
factors that are common to the field itself and that apply to all
who treat malocclusions. "The rules of the game" of orthodontics
are somewhat at variance,.with successful principles applicable in
otllerJields of clinical de~tistry. Often the dentist is unaware that
the factors by which one achieves success in restorative and pros-
thetic dentistry are not necessarily the same factors that guarantee
success in orthodontics.
a) The Nature of Developmental Oral Biology
The nature of developmental biology is such that although
there is considerable variation in morphology, the unfolding of the
growth pattern, and the response to orthodontic therapy, the cli-
nician is still limited by the unpredictable nature of growth itself.
342 Treatment
While growth takes place at specific sites, in a specific fashion,
in specific directions, it occurs within a rather specific individ-
ualized time pattern. As yet, we are limited in our predictive
abilities and our control of growth processes, including our in-
ability to condition all neuromuscular reflexes, flroduce growth of
bones at will, stabilize all occlusions exactly where we might wish
them to stabilize, etc.
b) Patient Cooperation and Treatment Success
The finest orthodontic treatment plan and the most meticu-
lously made orthodontic appliance will achieve little if parents and
patient are not enthusiastically supportive of the dentist's efforts.
In orthodontics, as much as in any other clinical field, the patient
determines the success of treatment. Dentists who treat malocclu-
sions must exhibit skill in psychology, patience, and an under-
standing of interpersonal dynamics if they are to be successful.
Compromise treatment to an inadequate result is sometimes the
only recourse when the dentist cannot sustain the patient's interest.
c) Paucity of Adequate Compromising Alternative Treatments
The allure of compromise treatment may arise through in-
experience, willingness to be satisfied with poor results, inadequate
technical skills, or lack of sufficient training. Only in a few specific
instances is compromise treatment best for a patient and those are
defined by the circumstances of the case itself, not the dentist's
abilities. For a discussion of the problems of compromise in or-
thodontic therapy, see Section A-6-b.
F. SOME COMMON MISTAKES
It is my opinion, based on many years of consultations with
general dentists about troublesome cases, that the most common
mistakes are rooted in failure to appreciate initially the serious
complications which may accompany treatment of three rather
common malocclusions: namely, space problems, Class II mal-
occlusions, and severe open bite.
Difficulties in treatment of space problems may arise because
an inadequate diagnosis has been made and the case thus was
classified erroneously (e.g., a gross discrepancy case was treated
as a space supervision case). In other instances, the clinician treat-
ing the patient has had mistaken ideas concerning the growth of
the dental arches and limitations in making more space available.
It is most difficult for the inexperienced clinician to comprehend
just how severe a shortage of 2 to 3 mm in each mandibular
quadrant sometimes really is. Other difficulties arise in the han-
dling of discrepancy cases by extraction of teeth when the clinician
does not have the skills and techniques for closing the spaces
remaining after alignment is achieved while achieving a satisfac-
tory functional occlusion.
It is understandable that the general dentist might have prob-
lems with the Class II syndrome, since all orthodontists recognize
this as a most difficult group of malocclusions. The more inex-
perienced clinicians often fail to respect the dominance of skeletal
morphology on occlusal relationships. To attempt Class II treat-
ment without cephalometric analyses is to run great risks logisti-
cally, ethically, even legally. Some Class II malocclusions are
relatively easy to treat, while others are difficult for the most clever
and experienced orthodontist. Not to be able to differentiate these
at the start of treatment is a serious handicap.
Open bites may be caused by many different factors. As soon
as a thorough differential diagnosis and an understanding of the
etiology of open bite is appreciated, it is quickly seen that some
open bi~es are easy to treat and others are nearly impossible without
surgical intervention.
After teaching undergraduate dental students for a number of
years and counseling many general practitioners concerning or-
thodontic problems, I have bec?me convinced that the key to
orthodontic success in general practice lies in (I) a thorough knowl-
edge of growth and development, on which is based (2) a practical
diagnostic ability. That is to say, success is not based primarily
on the choice of a favorite appliance. The dentist who fails to
recognize the primary role of growth and development and the
overriding importance of the differential diagnosis will have con-
tinual trouble in planning many orthodontic treatments irrespective
of the technical skills mastered, the appliances used, or the short
courses attended.
SUGGESTED READINGS
Feinstein AR: Clinical Epidemiology: The Architecture of Clin-
ical Research, Philadelphia, WB Saunders, 1985.
Horowitz SL, Hixon EH: The Nature of Orthodontic Diagno-
sis, St Louis, CV Mosby, 1966.
Proffit SR, Ackerman JL: Diagnosis and treatment planning in
orthodontics", in Graber TM, Swain BF (eds), Orthodontics,
Current Principles and Techniques, St Louis, CV Mosby,
1985.
Sackett DL,Haynes RB, Tugwell PX, et al: How to read clin-
ical journals. I. Why to read them and how to start reading
them critically. Can Med Assoc J 1981; 124:555-558. Part II,
To learn about a diagnostic test, Can Med Assoc J 1981;
124:703-710. Part Ill, To learn the clinical course and prog-
nosis of disease, Can Med Assoc J 1981; 124:869-872. Part
IV, To determine etiology or causation. Can Med Assoc J
1981; 124:985-990. Part V, To distinguish useful from useless
or even harmful therapy. Can Med Assoc J 1981; 124: 1156-
1162.
Sackett DL, Haynes RB, Tugwell P: Clinical Epidemiology: A
Basic Science for Clinical Medicine. Boston, Little, Brown &
CpIJ1pany, 1985. " ';.
VigPS, Ribbens KA eds. Scienqe and Clinical Judgment in
Orthodontics, monograph 19. Craniofacial Growth Series. Ann
Arbor, Mich, Center for Human Growth and Development,
University of Michigan, 1986.
CHAPTER 15

Early Treatment
Robert E. Moyers, D.D.S., Ph.D.
Michael L. Riolo, D.D.S., M.S.

What you should put first in all the practice of our art is
how to make the patient well; and if he can be made well in
many ways, one should choose the least trouble-
some.-HIPPOCRATES, On Joints

OUTLINE c) Supernumerary teeth

I) Diagnosis
A. Understanding early treatment 2) Treatment
I. Rationale for early treatment (a) In the primary dentition
2. Benefits of early treatment (b) Teeth with conical crowns
3. Difficulties in early treatment (c) Supplemental teeth of normal size
B. Defining goals in early treatment and shape
I. Dentition and occlusion (d) Supernumerary teeth showing
2. Musculature variations in size and shape
3. Craniofacial skeleton 3) Discussion
4. Treatment planning 2. Variations in size and shape of teeth
C. Assessment of the results of early treatment a) Diagnosis
I. Defining a satisfactory response b) Large teeth
2. What to do when early treatment is unsatisfactory c) Small teeth
D. Clinical problems and procedures d) Anomalies of tooth shape
I. Number of teeth I) Maxillary lateral incisors
a) Congenitally missing teeth 2) Mandibular second bicuspids
I) Causes 3) Miscellaneous anomalies of shape
2) Diagnosis 3. Spacing of teeth
3) Treatment a) Localized SPlicing
(a) Maxillary lateral incisors I) Etiology
(b) Mandibular second bicuspids (a) Absent teeth
(c) Multiple absence of teeth (b) Undue retention of primary teeth
b) Loss of permanent teeth (trauma, caries, and .. (c) Sucking habits
other causes) 2) Spacing between maxillary central
I) Treatment of loss of individual teeth inCisors
(a) Maxillary central incisors (a) Examination and differential
(b) Maxillary lateral incisors diagnosis
(c) Cuspids (b) Supernumerary teeth at the
(d) First bicuspids midline
(e) Second bicuspids (c) Congenitally missing lateral
(f) First permanent molars incisors
(g) Mandibular incisors (d) Enlarged or malpos'ed labium
2) Multiple loss of permanent teeth frenum

343
344 Treatment

(e) Imperfect fusion at th~ midline b) Treatment

(f) Spacing as a part of normal growth I) Dental crossbite (individual teeth)
b) Generalized spacing (a) Case analysis
I) Small teeth (b) Appliances
2) Large tongue 2) Dentoalveolar contraction and/or
3) Sucking habits crossbite
4) Abnormal tongue posture (a) Case analysis
4. Problems singular to the transitional dentition (b) Appliances
a) Space management 3) Gross disharmony between osseous bases
I) General considerations (a) Case analysis
2) Maintenance of arch perimeter (b) Appliances
(a) Caries of primary teeth 6. Class 11 (distocclusion, postnormal occlusion)
(b) Loss of individual primary teeth a) Differential diagnosis
(c) Multiple loss of primary teeth I) Skeletal morphology
3) Regaining space in the arch perimeter 2) Dental and occlusal mal positions
(a) Mesial drift of permanent molars 3) Arch form
(b) Distal movement of first perma- 4) Neuromuscular ("functional") features
nent molars b) General strategies for Class 11treatment
4) Space supervision I) Differential restraint and control of skel-
(a) Mesial step (Class I) protocol etal growth
(b) Flush terminal plane (end-to-end) 2) Differential promotion of skeletal growth
protocol 3) Guidance of eruption and alveolar
(c) Distal step (Class 11) protocol development
5) Gross discrepancy problems 4) Movement of teeth and alveolar
(a) Diagnosis processes
(b) General rules 5) Translation of parts during growth
(c) Treatment protocol 6) Training of muscles
(d) Precautions 7) Surgical translation of parts
b) Difficulties in eruption c) Tactics for Class 11therapy
I) Alterations in sequence of eruption I) Functional appliances
(a) Premature eruption of individual 2) Orthopedic devices
teeth (a) Extra-oral traction to the dentition
(b) Delayed eruption of individual (b) Extra-oral traction to the chin
teeth (c) Palatal widening
2) Ectopic eruption of teeth 3) Bracketed appliances
(a) Maxillary first permanent molars 4) Muscle training
(b) Maxillary cuspids 5) Surgery
(c) Mandibular incisors d) Rationale for early Class 11treatment
(d) Other teeth I) Skeletal morphology
3) Transposition of teeth 2) Dental and occlusal aspects
(a) Etiology 3) Neuromuscular features
(b) Diagnosis e) Planning differential early treatment of Class
(c) Treatment 11 mal occlusion
4) Impaction of teeth I) Treatment of horizontal type A
(a) Diagnosis (a) Basic strategy
(b) Mandibular third molars (b) Suggested tactics
(c) Maxillary cuspids (c) Common problems or
(d) Mandibular and maxillary second complications
bicuspids 2) Treatment of horizontal type F
(e) Second molars (a) Basic strategy
(f) Other teeth (b) Suggested tactics
5) Ankylosed primary teeth (c) Common problems or
6) Ankylosed permanent teeth complications
5. Lateral malrelationships of the dental arches (d) Variations
a) Differential diagnosis (e) Retention
I) Dental malrelationships 3) Treatment of horizontal type B
2) Muscular or functional mal relationships (a) Basic strategies
3) Osseous or skeletal dysplasia (skeletal (b) Suggested tactics
crossbite) (c) Common problems or
 Early Treatment 345

complications b) Bimaxillary dental protrusion

(d) Variations 11 . Open bite
(e) Retention a) Definition
4) Treatment of horizontal type D b) Diagnosis
(a) Basic strategieS c) Treatment
(b) Suggested tactics . I) Anterior open bite, simple
(c) Commom problems or 2) Posterior open bite, simple
complications 3) Complex or skeletal open bite
(d) Variations 12. Deep bite (excessive overbite or vertical overlap)
• (e) Retention a) Definition
5) Treatment of horizontal type C b) Diagnosis
(a) Basic strategies c) Treatment
(b) Suggested tactics 13. Craniofacial malformations; Cleft palate
(c) Common p\"oblems or 14. Temporomandibular dysfunction
complications a) Definition
(d) Variations b) Diagnosis
(e) Retention c) Treatment
6) Treatment of horizontal type E Such terms as early treatment, interceptive treatment, tooth guid-
(a) Basic strategies ance, preventive orthodontics, growth guidance, etc., may be more
(b) Suggested tactics obfuscating than useful. They are surely not synonyms.
(c) Common problems or In this chapter the term early treatment means, simply, or-
complications thodontic therapy undertaken during the most active stages of
(d) Variations dentitional and craniofacial skeletal growth. This definition implies
(e) Retention two consequences: (I) it is advantageous to treat some malocclu-
7. Class III (mesiocclusion, prenormal occlusion) and sions during active growth and (2) methods are av~ilable for such
pseudo Class III treatment. Some early treatments are simple and easy, others are
a) Differential diagnosis among the most difficult in orthodontics.
I) Patient examination Too much emphasis has been placed on one-phase "simple"
(a) Profile early treatment in the hope that more comprehensive treatment
(b) Molar relationship could be obviated. This problem has been exacerbated by the
2) Cephalometric analysis conflict between the concepts of functional jaw orthopedic therapy,
(a) Basic morphologic analysis done early when growth is greater, and precision bracketed ap-
(b) Profile analysis, skeletal pliances, which are most efficient in the permanent dentition. There
(c ) Vertical analysis has resulted an unclear perception of the goals of early treatment,
3) Pseudo Class III confusion about the relationships between early and later therapy,
4) Skeletal Class III and misunderstanding about the roles of orthodontists, pedodon-
(a) Midface deficiency tists, and family dentists in early treatment. All dentists need
(b) Mandibular prognathism perspective on the full range of orthodontics. Family dentists must
(c) Midface deficiency and mandib- have explicit details of treatment procedures which they might
ular prognathism provide. The implications of difficult and more comprehensive
b) General strategies for early treatment problems are outlined and explained here diagnostically, but details
c) Rationale for early treatment of their treatment are beyond the mission of this book.
d) Tactics for early treatment
1) Pseudo Class III
2) Midface deficiency A. UNDERSTANDING EARLY TREATMENT
3) Mandibular prognathtsm
4) Midface deficiency and mandibular
prognathism 1. Rationale
,.
for Early Treatment
8. Labioversion of maxillary incisors (excessive overjet)
a) Some malocclusions can be prevented or intercepted.-
with Class I molar relationship
The words "prevent" and "intercept" may lead to misunderstand-
a) Diagnosis
ing. Neither term can be used properly in the generic sense to
b) Treatment
embrace all early orthodontic treatments. It is as misleading to
9. Anterior crossbites, simple
promote enthusiastic advocacy of early treatment of all malocclu-
a) Diagnosis
sions because some might be intercepted as it is to denounce
b) Treatment
interceptive treatment because early development of all malocclu-
I) Single tooth
sions cannot be halted. The theory and rationale underlying the
2) Several teeth
concepts associated with each term vary and are not generally
10. Bimaxillary protrusions
interchangeable, so one should not, as has been done, argue against
a) Bimaxillary prognathism
the practice of one strategy using the theory of another. I All are
346 Treatment
good terms when properly applied, the clinical (and semantiC)
problem is when and to what extent each is appropriate. Only a
few studies give accurate reports on those malocclusions which
can be prevented or intercepted21. 49 Popovitch and Thompson:9
at the Burlington Orthodontic Research Centre in Canada, judge
that while few malocclusions can truly be prevented,. roughly 25%
can be intercepted. One-fourth is a significant amount, and many
can be intercepted with theory; appliances, and knowledge now
readily available to the family dentist.
b) It is the dentist's responsibility to obviate. when possible.
lengthy or complicated treatment.-In the past, some who did not
know how to improve severe skeletal dysplasia in young children
chose to wait and camouflage it later by positioning of teeth. Now,
diphasic treatment is sometimes considered more logical and sen-
sible. During phase one, craniofacial skeletal growth is controlled
and the morphology improved so that later tooth positioning (phase
two) is relatively easier.
c) Treatment is easier in some cases.-Early orthopedic con-
trol of skeletal mOrPhology is easier in some cases than later
correction of the craniofacial skeleton, and often easier than po-
sitioning teeth to camouflage skeletal dysplasia.
d) More alternative methods are available for treating pa-
tients at a young age.-When growth has largely ceased, treatment
options are limited to moving teeth or orthognathic surgery. When
the patient is young, one may be able to remove etiologic factors,
enlist natural growth forces, provide differential growth responses,
and obtain a balanced profile prior to eruption of most permanent
teeth. Appliances used are varied, sophisticated, and practical.
Some of the orthopedic appliances used look simple, and therein
lies a trap for the inexperienced, for guidance of the developing
dentition and growing craniofacial skeleton is a very complicated
matter: the construction may be simple, the applied biology is
generally more sophisticated and difficult than after pubescence.
The traditional precision bracketed appliances used in treatment
during the newly completed adult dentition involve very sophis-
ticated biomechanical theories (see Chapters 13 and 16), and our
knowledge of these appliances is well advanced. Ironically, the
theory and treatment effects of "functional" or "orthopedic" ap-
pliances are less understood. Similarly, we know more about the
biology of tooth movements, which is utilized with precision
bracketed appliances, than we do about the biologic alteration of
facial growth, which is the basis of early functional orthopedics.
e) The clinician can utilize growth better in the young. and
there is more growth available.--Growth can only be controlled
while growth is happening. The earlier one starts treatment, the
more total growth one can effect.
2. Benefits of Early Treatment ,_
Many reasons have been advanced for considering early treat-
ment. The following are some of the more compelling:
a) The possibility of achieving a better result.-With modem
precision bracketed appliances beautiful results are obtained rou-
tinely if the skeletal dysplasia is not too severe. However, it is
difficult to camouflage gross craniofacial morphology by tooth
movements alone.
b) Some forms of treatment can only be done at an early age.
c) Early treatment of serious deleterious habits is easier than
treatment after years of ingrained habit reinforcement.
d) There are psychological advantages to early treatment in
some children.
e) Younger patients are often more cooperative and attentive.
f) Compromise of quality of treatment is less apt to be
necessary.
There are two reasons why early treatment may obviate com-
promise of quality: (1) it may remove etiologic factors and restore
normal growth and (2) it may reduce the severity of the skeletal
pattern, making possible easier and more precise tooth positioning
in the adolescent.
3. Difficulties in Early Treatment
a) Misperceptions exist about the goals of early treat-
ment.- This is an important difficulty in defining clearly the goals.
Early treatment has sometimes been equated with a naive attempt
to "prevent" or intercept all malocclusions. More logical goals
are the removal of primary etiologic factors and"the correction of
skeletal dysplasias prior to the eruption of teeth, neither of which
necessarily results in precise positioning of teeth.
Misperceptions about goals of early treatment arise when the
focus is on the particular appliance itself rather than the purposes
of treatment. It is not a question of functional or orthopedic ap-
pliances versus bracketed appliances but of the goals of early versus
later treatment. Because mistakes are made in either treatment
period or with one appliance system, one cannot argue that the
use of the other is, ipso facto, justified or better. In recent years,
some enthusiastic proponents of functional jaw orthopedics have
urged the use of those appliances by describing alleged deficiencies
and misuses of precision bracketed appliances, implying such prob-
lems do not occur with their favorite systems. But there are prob-
lems with any appliance, which may be related to misperceptions
about the goals of treatment, not the appliance itself.
b) Improper early treatment can be harmful.-Just as growth
can be directed advantageously, it can also be misdirected. It does
no good to drive faster if you're on the wrong road. Nor does it
help to start early if you do not know where you are going or have
no map.
c) Diphasic treatment may lengthen the chronologic treatment
time.-Time of treatment is properly measured by the number of
hours spent by the dentist and patient together: treatment time is
not measured on the calendar. Frequently, diphasic treatment
achieves better results with less' 'clinic time" but longer' 'calendar
time." When the chronologic time is lengthened, patient coop-
eration may wane. Ill-conceived or improph early treatment not
only may do damage or prolong therapy, it may exhaust 'the spirit
of .cooperation, making Later treatment more difficult.
, ;d) The subleties of early ma~occlusion introduce chance in
the diagnosis and treatment plannlng.-When growth has dimin-
ished, the features of a malocclusion are clearly seen and the
diagnosis is more certain. Early diagnosis and treatment planning
are more tentative, and periodic cephalometric reassessment is a
necessity. Too much emphasis has been placed on particular ap-
pliances, and insufficient attention has been paid to the difficulties
of diagnosis and treatment planning for early treatment. There is
a far greater need for better treatment planning than there is for
new functional-appliance" gadgetry. " The best car is useless with-
out a map and a driver who knows where to go. Those who do

no more planning for early treatment than to choose a single {a-
vorite appliance for most treatments do so because they are ignorant
of the subtle variabilities and difficulties of orthodontic practice
in the young patient.
B. DEFINING GOALS IN EARLY
TREATMENT
The general principles of diagnosis and treatment planning
are presented in Section 2, Diagnosis (Chapters 10-14), though a
few specific comments are pertinent here.
1.,Dentition and Occlusion
The several tooth size analyses (Mixed Dentition, Howes',
Bolton, and Sanin-Savara analyses) are useful (see Chapter 11),
but it is difficult to understand fully their varying implications in
faces of widely different shapes. It is also important to realize the
possible effects of time and growth on the results of the analyses.
While time and growth do not alter tooth size, they change tooth
positions and bony and soft tissue relationships which are not part
of the dental analyses. The dentition and occlusion must be ana-
lyzed repeatedly during development.
2. Musculature
Current clinical analysis of muscular function (see Chapter
10) is neither quantitative nor precisely discriminating, making it
difficult to appreciate the clinical implications of the enormous
variability of facial muscle behavior. The facial muscles and the
tongue have been recently rediscovered by some dentists, but the
rediscovery sometimes has been accompanied by a plethora of
biologic and clinical nonsense. Some of the most enthusiastic
promoters of methods of orofacial neuromuscular analysis and
training are neither physiologists nor dentists and lack the knowl-
edge and perspective which comes from being directly responsible
for guiding and correcting occlusal disorders. Dentists, apprecia-
tive of our own ignorance and need for further knowledge in these
matters, should not assume that other disciplines are more ad-
vanced. Scholarly speech scientists, otolaryngologists, and phy-
siotherapists are just as frustrated and cautious as we are and are
just as involved in sound research, which always provides the
ultimate answers.
3. Craniofacial Skeleton
Some cephalometric procedures fail us when we most need
them (i.e., during active growth), Qut this is no excuse for avoiding
cephalometric study of all cases (see Chapter 12). No dentist in-
terested in orthodontic treatment can long afford to be without
cephalometric data, for they most reveal and facilitate understand-
ing of morphology, growth, and the effects of treatment. The
question is often asked, "In which case should one take a ce-
phalogram?" It is proper to procure radiographs routinely to di-
agnose caries and to ascertain the presence and normal development
of all teeth. Is it any less important to be assured of normal skeletal
growth?
It is said that when Christopher Columbus sailed for America
he didn't know where he was going, when he got there he didn't
Early Treatment 347
know where he was, and when he returned to Europe he didn't
know where he had been. Columbus lived prior to the invention
of modem navigational instruments and can be excused. To begin
treatment for a child with a skeletally involved malocclusion with-
out a cephalogram is to start a trip of unknown duration toward
an indeterminate goal without a map. Cephalograms are the maps
of the head, though we are still learning how to read them better
with improving cephalometric growth analyses.
4. Treatment Planning
The essence of early treatment planning is timing, involving
the integration of several kinds of developmental data applied
specifically to one particular patient (see Chapter 14). Anyone can
recognize a full-blown malocclusion; optimal treatment planning
is therefore dependent on the earliest possible diagnosis. Ortho-
dontic treatment deferred until adolescence lessens the difficulty
of treatment planning, for the permanent dentition is completed
and most skeletal growth has ceased, but the delay reduces options,
may complicate treatment, and may compromise results.
c. ASSESSMENT OF THE RESULTS OF
EARL Y TREATMENT
One must take care not to transfer concepts of success which
are valid and useful in adolescence to the younger child. Constant
rediagnosis is the theme of clinical assessment during growth for
that "simple anterior crossbite" may later prove to have been an
early expression of a mild skeletal Class Ill. One asks not just did
I succeed or fail, but what has improved?, which features persist?,
which may worsen with time despite my treatment? etc. The pur-
pose of assessment during diphasic and all early treatment is to
define the improvements obtained and to prescribe what is left to
do. Despite much enthusiasm and "oversell" of some early treat-
ment appliances, particularly various forms of functional jaw or-
thopedic devices, we know very little about how they work and
why response is so varied. Assessment of early treatment results
wilt' continue to be hard until we know about how each type of
appliance works in each specific facial type, at each age, and for
each sex.
1. Defining a Satisfactory Response
Early treatment may be deemed satisfactory if the following
conditions obtain:
a) Primary etiologi~ factors have been removed or are
cOhtrolled .. ,'
b) Tooth positions and space needs are satisfactory and can
be kept there until the end of the mixed dentition.
c) Skeletal deviations originally present have been improved
at the rate and extent originally planned and can be controlled until
the dentition is completed and skeletal growth has diminished.
When evaluating the skeletal response to early treatment, it is
important to identify significant deviations still present (I) due to
those portions of the craniofacial skeleton not affected by the
therapy and (2) which have not responded to treatment as well as
envisaged. In Chapter 12 some methods for assessing the response
to orthodontic treatment are described.
348 Treatment
2. What to Do When Early Treatment Is Unsatisfactory
There is no guarantee that any orthodontic therapy will pro-
ceed as planned. Separation of the effects of treatment and changes
resulting from growth is a difficult and sophisticated analytic prob-
lem not yet completely solved. When early treatment seems to
have gone poorly, three plans of action are available: (I) determine
and try a more appropriate treatment; (2) defer further treatment
until a later time, assuming one knows clearly what to do at that
later time; and (3) refer the patient to a colleague for further
treatment. Specific rules are impossible because of the wide variety
of cases, treatments, and patient responses, but one dictum is
certain, namely, complete diagnostic records prove their worth
when treatment progress must be assessed .
. Early treatment is most apt to fail when there is no clear
reason for starting and no well-defined goals and strategies. One
may be tempted, when confronting a malocclusion, to think of
trying something, and often an appliance or treatment remembered
from a recent conversation, article, or presentation at a dental
meeting comes to mind. "Why not try that?" we say to ourselves.
So it is done without discriminating thought or plan-we just want
to see what will happen. Such cases usually involve months of
stumbling around and wondering why this attractive gadget didn't
"work." It didn't work because we didn't do our work correctly.
And an important ethical principle is involved: no one has the
right to begin treatment without a reasonable understanding of the
treatment process and reasonable expectations of success. When
disappointing results are finally recognized and a clear treatment
plan is still not obvious, referral to a more experienced colleague
is an ethical obligation.
D. CLINICAL PROBLEMS AND
PROCEDURES
1. Number of Teeth
a) Congenitally Missing Teeth
By missing teeth is meant those teeth whose germ did not
develop sufficiently to allow the differentiation of the dental tis-
sues. Somewhat fewer than 4~ of the population have one or more
teeth congenitally missing. Missing teeth constitute a clinical prob-
lem seen more frequently than supernumerary teeth. The teeth
most frequently found congenitally missing are mandibular second
bicuspids, maxillary lateral incisors, and maxillary second bicus-
pids, in that order (see Chapter 6). Complete absence of all teeth,
called anodontia, is seen only rarely. Oligodontia, often-and
incorrectly--called "partial anodontia," is the term used when
some of the teeth are missing.
1) Causes.- There are five principal known causes of con-
genital absence of teeth:
a) Heredity.-There is a familial distribution of congenital
absence of teeth in many instances, and heredity is an etiologic
factor of importance (see Chapter 6).
b) Ectodermal Dysplasia.-Congenitally missing are noted
frequently in conjunction with other clinical manifestations of dis-
turbances in the development of ectodermal tissue; for example,
anhidrosis and absence of the hair follicles.
FIG 15-1.
Tooth sac before calcification. Note that the mandibular second bi-
cuspid tooth sac can be seen clearly even though very little calcifi-
cation has started.
c) Localized lnj7.ammations or Infections.
d) Systemic Conditions.-Rickets, syphilis, and severe intra-
uterine disturbances are claimed by some to lead to the destruction
of developing tooth germs.
e) Expression of Evolutionary Changes in the Denti-
tion.-Some authorities believe that, in the future, man will have
neither third molars nor maxillary lateral incisors, just as we seem
already to have lost fourth molars.
2) Diagnosis.- The diagnosis of congenitally missing teeth
is based wholly on the findings in the radiograph. The differential
problem is one of distinguishing absence of teeth from greatly
delayed calcification, remembering the great individual variations
in their patterns of development. A magnifying lens is very useful
for studying the details of the alveolar bone in the radiographs
when congenital absence of teeth is suspected. Well-taken radi-
ographs will show the tooth sac before calcification begins (Fig
15-1). If, instead of a circumscribed homogeneous area in the
bone (indicative of a tooth germ before calcification begins) there
is trabeculation, one can assume the absence of the germ (Fig 15-
2). There can be no calcification without the germ.
Mandibular second bicuspids show great variation in differ-
entiation and calcification. Often it will seem that the germ is
dorinant (Fig 15-3). So~etimes one can detect minute signs of
activity indicative of delayed or slow calcification rather than fail-
ure of the tissue to differentiate.
Ordinarily it is possible when the patient is 4'/2 to 5 years of
age to discern in well-taken intra-oral radiographs the presence or
absence of all teeth but third molars. For this reason, it is urged
that a complete dental radiographic surveyor panoramic film be
obtained of each patient at this age. Such a survey is one of the
most important single steps in orthodontic diagnosis and early
treatment. Few things are more embarrassing than to discover the

FIG 15-2.
Congenital absence of mandibular second bicuspids. A, note fine
trabeculae of bone of the alveolar process beneath the second pri-
mary molar. B, a similar situation in three of four quadrants. Even
though the bicuspid is present in one quadrant, it is delayed in de-
velopment, malformed, and unerupted.
congenital absence of a tooth in a child who has been under one's
care for several years. If for no other reason than this problem of
congenitally missing teeth, one should have on file for each young
patient a complete radiographic survey at an early age.
One should not forget the relationship between congenital
absence of teeth and generalized tooth size diminution (see Chapter
6). When one tooth is not developing, it is important to measure
FIG 15-3.
Delayed development of second bicuspids. Contrast their root development
Early Treatment 349
all of the other teeth to ascertain any genetic field effects on general
tooth size.
Finally, there are suggestions that congenital absence of teeth
is associated with certain variations in craniofacial morphology,
so a cephalometric analysis is required.
3) Treatment.-( a) Maxillary Laterallncisors.- Two courses
of treatment are available: (I) moving the cuspids mesially for use
in place of lateral incisors and (2) opening space for a pros-
thesis.42. 56. 57 The choice is dependent on:
• Age of the patient.
• Conformation of cuspids.
• Position of cuspids.
• Suitability of central incisors and cuspids as abutments.
• Desires of the patient.
• Depth of bite.
(l) Moving the cuspids to serve as lateral incisors.
Advantages42.67are:
• It is unnecessary to prepare abutment teeth.
• There is less chance for maxillary third molars to become
impacted.
• It is permanent (not necessary to replace at a later date).
Disadvantages are:
• Advanced orthodontic skills and complete precision brack-
eted appliance are required.
• Case selection is more particular than for the prosthetic
procedure.
• More time is required.
• It is more difficult if the cuspids are completely erupted.
Follow this procedure if:
• The cuspids are unerupted or only partially erupted and ap-
pear of normal size and favorable shape.
• The central incisors are of normal mesiodistal diameter.
• The maxillary molars already have drifted mesially.
• There are no contraindications to orthodontic therapy.
Steps in .treatment:
• Remove the maxillary primary cuspids, if still present, to
with that of the first bicuspid and cuspid.
350 Treatment
FIG 15-4.
Directing the eruption of maxillary cuspids when the lateral incisors are congenitally
hasten the eruption of the maxillary permanent cuspids be-
fore the bicuspids. Removal of bone atop the cuspids
sometimes hastens and directs their eruption.
• All erupted maxillary teeth are banded or bracketed and a
labial archwire is placed. The central incisors are brought
together on the midline and the cuspids guided during
eruption against them. The archwire should have no stops
so the permanent molars and bicuspids may drift mesially
and be brought into a full Class II relationship.
• Grind the labial surfaces of the cuspids and flatten their in-
cisal edges in simulation of lateral incisors. Since the cus-
pid is thicker labiolingually than-a lateral incisor, it is also
necessary to reduce the lingual surface significantly to al-
low the cuspid to be placed more lingually in the line of
arch than is usual. It is best to do the reshaping in several
stages to avoid pulpitis. All of the grinding is followed by
thorough polishing and the application of fluoride. Finally,
check the new occlusion for occlusal interferences; there
will always be some, particularly the lingual cusps of bi-
cuspids in lateral excursive movements.
• If satisfactory esthetics have not been obtained by grinding
and reshaping of the cuspids alone-and this sometimes is
seen when the incisal edges are acutely angled-acid etch
the tooth and add composite.
Prognosis: If care is taken in choosing the case, this procedure
can produce satisfactory results (Fig 15-4). It is most likely to be
indicated when early treatment is possible. If there is any doubt
concerning the success of this plan of treatment, do not begin it.
Much depends upon skillful use of the precision bracketed appli-
ance, since exact placement of roots is necessary for esthetics and
stability.
(2) Alternative procedure: Opening prosthesis
Advantages are:
missing. (Courtesy of Dr. William Northway.)
• Ordinarily, less movement of teeth is required.
• Only a short time is required.
• Can be used on all patients.
Disadvantages are:
• It may be necessary to prepare abutment teeth.
• The bridge may have to be redone at a later date.
• Esthetic problems may be difficult, for example, matching
shades, hiding gold margins, pontics, etc.
Steps in treatment: Preliminary treatment is likely to involve
moving the central incisors together and/or moving the lateral
segments of the maxillary arch distally. A retainer with a pontic
may be worn until the appropriate time for a bridge or a bridge
using acid-etched abutments may be placed as a temporary
expedient.
(b) Mandibular Second Biscuspids.-Again, there are two
accepted procedures: (I) holding space for a bridge; and (2) moving
the first permanent molars forward the width of one cusp. The
choice depends largely on the age of the patient and whether the
mandibular second primary molar has been retained. A third choice
often suggested, that of ~~eping the second primary molar per-
ma·ne.ntly in place, is to- be discouraged. To retain the primary
molar is to guarantee a malocclusion and eventually a prosthesis.
Although the crown can be reduced in size, the roots flare so
widely the first molar cannot move mesially as far as is desirable.
To retain the second primary molar unduly results in lack of al-
veolar bone development on the mesial aspect of the mesial root
of the first permanent molar. When a bridge is contemplated, the
correct first permanent molar relationship should be established
by the time of arrival of the first bicuspid and before eruption of
the second molar.

Early diagnosis is the key to t~ problem because it greatly
lessens the amount of work involved and ensures a more satisfac-
tory result.
The following are considerations in choice 2, namely, moving
mandibular first permanent molars mesially. - by a specialist, at least for the orthodontic aspects of the problem.
Advantages are:
• It is unnecessary to prepare abutment teeth.
• There is less chance for impacted mandibular third molars.
• The effect is permanent (need not be redone at a later
date).
Disadvantages are:
• It requires skilled and carefully timed use of a precision
bracket mechanism to obtain proper occlusion and root
parallelism.
• There may be a need for a short subsequent treatment to
position the second molar, especially if the initial treatment
is delayed.
Follow this procedure if: This procedure is indicated in pri-
mary and early mixed dentition cases and in young adults who are
having other orthodontic therapy. It is particularly appropriate
when there is anterior crowding and the first bicuspids must be
moved distally (see Chapter] 6).
Sfeps in treatment-if diagnosed in primary dentition: Re-
move the mandibular primary second molars and allow the man-
dibular first permanent molars to move mesially beneath the gum.
This movement will take place quickly, but these teeth usually
erupt before they are complete]y forward. ]n almost every instance
it is necessary to place an appliance and band the molar to upright
it.
~ Alternatively, a pontic may be placed supported by a wire frame-
Steps in treatment-if diagnoseiin mix2d dentition: After the
first permanent molar has erupted, it is more difficult to move it
mesially without tipping. To do so properly requires bodily move-
ment over a considerable distance and the use of multi banded
techniques. An interesting method developed by Professor van der
Linden involves sequential slicing and sectioning of the second
.1 primary molar, thus permitting more gradual mesial mov~ment of
the permanent molar (Fig ]5-5). It also guarantees full vertical
development of the alveolar process avoiding the typical denude-
ment of the mesial root of the first permanent molar.
Prognosis: The prognosis is favorable in all instances, but
the task is easier when begun earlier. In all cases, occlusal equi-
libration will be necessary, since the final result is a Class III molar
relationship, but this should be of )ittle concern.
Discussion: In the past, I have been much too optimistic
concerning the average dentist's ability to move the first molar
forward properly. In the first edition of this book, mesial movement
of the first molar was recommended with enthusiasm, since I had
done it satisfactorily many times. Unfortunately, there are many
complications here for the unskilled. When this seems the desired
approach, study the problem carefully and approach it with caution.
It is impossible to change your mind and reverse the movements.
(c) Multiple Absence of Teeth.-So many variations appear
Early Treatment 351
in the more severe types of oligodontia that it is difficult to for-
mulate a general rule. Treatment may require a blending of or-
thodontic and prosthetic skills. The problem often is complicated
by small conically shaped teeth. Severe oligodontia is best handled
This problem is discussed in more detail in Chapter 17.
b) Loss of Permanent Teeth (Trauma, Caries, and Other
Causes)
The loss of fully developed, erupted permanent teeth is a
major orthodontic problem. In the anterior region, trauma is the
principal cause, whereas caries is largely responsible for early loss
of the first permanent molars. Important to an understanding of
the effects of loss of permanent teeth is a knowledge of physiologic
tooth drifting after extraction. The tendency to drifting is more
marked in the maxilla, and the process begins more rapidly than
in the mandible. It is difficult to predict reliably, however, the
extent and direction of drifting in any given patient.
The direction and extent of drifting are affected greatly by
the facial form, particularly the steepness of the occlusal plane.
The time of the loss also affects drifting. Occlusal interferences
may appear and exacerbate the drifting.
(1) Treatment of Loss of Individual Teeth.-:-( a) Maxillary
Central Incisors.-Loss of central incisors is a common problem,
particularly in boys, whose baseball bats and hockey sticks are
notable etiologic agents. The opposite central incisor tends to drift
across the midline, and the lateral incisor and cuspid on the affected
side move mesially. Spacing may occur between the lateral incisor
and cuspid or distal to the cuspid. The lateral segments of the
arches do not move mesially until considerable time has elapsed.
An acrylic plate with a pontic of a snug fit may be placed at once
and worn until an age when a permanent restoration can be inserted.
work held in place by acid-etch composite on the lingual of adjacent
teeth (Fig 15-6). If drifting already has begun, treatment with an
appliance is necessary to regain the lost space.
(b) Maxillary Lateral Incisors.-Loss of the lateral incisor
causes mesial drifting of the cuspid and distal tipping of the central
incisor. The treatment is similar to that for the central incisor. It
is possible to move the cuspid forward and use it for a lateral
incisor, a procedure described in the section on congenitally miss-
ing teeth earlier in this chapter.
t
(c) Cuspids.- This condition, seen rarely, gives rise to distal
tipping of the central and lateral incisors with possible mesial
mpvement of the first bicuspid. The suggested course of action is
to move the bicuspid distally an9 the incisors mesially, holding
space until a bridge can be placed.
(d) First Bicuspids.-The loss of a first bicuspid without
control of the rest of the occlusion is a difficult situation to handle.
The incisors and cuspid drift distally and the posterior teeth tip
mesially. Spacing probably will appear in the anterior segment.
Only rarely can the dentist tip the remaining teeth back to near-
normal positions with simple mechanics; more frequently, mul-
tibanded mechanotherapy is required.
 352 Treatment

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FIG 15-5.
Moving the mandibular first molars mesially when the second bicus- men!. When the distal half of the <:;rown is sectioned and its root
pid is congenitally missing. A, diagrammatic representation of a pro- removed (4). a temporary pulp dressing is placed. B. photographs
cedure developed by Professor van der Linden. If started early, the and radiographs of a patient treated by this method. (Courtesy of
natural eruptive and drifting movements bring about most of the Dr. William Northway.)
mesial correction. Later treatment requires more orthodontic move- "

FIG 15-6.
Orthodontic treatment after loss of the maxillary central incisors. A,
the result.S, pontics attached to a Hawley retainer. C and D, tem-
porary bridge of composite resin.
(e) Second Bicuspids.- The same general considerations
ply for the second as for the first bicuspids.
(j) First Permanent Molars.-Special consideration must be
given to the first permanent molars because they often are lost .
early in life as a result of caries. 2. 23. 54. 64 If the first molar is lost
before the eruption of the second bicuspid, the latter may drift
into the space left by the first molar. When first molars are lost,
a dipping in the line of occlusion occurs owing to the change in
the axial inclination of the remaining posterior teeth. There also
may be a concomitant closure of the bite. The result of the loss
of one or more first molars at any age invariably produces a difficult
clinical task. Immediate steps should be taken to control and direct
the drifting of the remaining teeth while an orthodontic plan is
developed.
The loss of one or more first permanent molars requires spe-
FIG 15-7.
Orthodontic movement of mandibular second molars when the first
molars have been lost (db refers to patient identification). (Courtesy
Early Treatment 353
cial, and often complicated, treatment planning. IS. 23 Considera-
tions include:
a) The number of molars lost;
b) The presence and status of the third molars;
c) The status of other first molars;
d) The basic malocclusion, other than that associated with
the loss of the first molars, particularly the depth of the bite; and
e) The eruptive stage of the bicuspids and second molars.
It is impossible to define precise rules of procedure for every
combination of variables. The following suggestions reveal our
bias for avoidance of a bridge if possible, but it should be noted
that the orthodontic skills required vary considerably among the
different clinical conditions listed (Fig 15-7).
When one molar is lost: If the loss is early or there are other
orthodontic problems the preferred treatment is to move the second
molar forward, allowing it to do so by itself as far as possible
prior to insertion of an orthodontic appliance (assuming third mo-
lars are present). Equilibration is always necessary and may be
difficult. If the other first molar in the same arch does not have a
good prognosis, consider its extraction, since it is easier to get a
stable result when both first molars in one arch are missing.
When two first molars are lost in the same arch: If the teeth
ap- are lost early or if there are other orthodontic problems, move the
second molars forward to occupy the position of the first molars.
It is necessary to band both arches and equilibrate the occlusion
carefully when all movements are over. If treatment is completed
very early, the upper third molars may erupt in favorable positions,
although there surely is no guarantee that will do so. Lower third
molars are more apt to erupt reasonably well when the first molar
is lost than when the second is removed.
When opposing first molars are lost: When two first molars
on the same side are lost, one may move the second molars me-
sially, for that is the most conservative procedure, if started early.
It is necessary to bracket all the teeth in both arches, control the
midlines precisely, and manage carefully the difficult biomechan-
ics, particularly if the molars were lost at different times. Careful
equilibration, of course, is required at the end of treatment.
When one upper and one lower molar on opposite sides are
of Or. William Northway.)
354 Treatment
lost: When an upper and lower molar are lost on opposite sides,
treatment planning becomes more complicated than any of the
situations described previously. Local conditions should be deter-
mining and general rules are of less use. The earlier the loss, the
easier it is to decide on moving the second molarS' mesially. When
the problem is associated with a severe malocclusion, extraction
of the remaining two first molars may be considered.
When three molars are lost: If perfect occlusion obtains oth-
erwise and caries is well controlled, then bridges may be indicated.
If the second molars have drifted mesially and/or other malocclu-
sion is present, then moving the second molars mesially may be
indicated. However, the mechanics of this procedure are difficult,
particularly if the bite is closed. The presence or absence of third
mol!trs and their condition are determining factors. One must al-
ways consider the extraction of the last permanent molar since it
is easier to control all factors with symmetric mechanics.
When four molars are lost: The extraction of four first molars
as a prophylactic measure was once routinely recommended, but
this abominable practice is rarely seen. IS However, in caries-prone
children the loss of all four molars may be observed. 2. 64 When all
four first molars are lost, or must be extracted, prior to the eruption
of the second molars, it seems better to move the second molars
mesially, but that decision may be altered if the third molars are
absent. If the third molars are normal in size, position, and de-
velopmental status, and there is not a predisposition to a deep bite,
then moving the second molars mesially may be preferred to using
bridges.
(g) Mandibular Incisors.-The same principles discussed for
maxillary incisors apply for lower incisors, but care must be taken
immediately to prevent the extrusion and/or lingual displacement
of the incisors or cuspids adjacent to the site of loss. A simple
round, labial archwire to maintain the midlines, level the occlusal
plane, and hold space temporarily is often all that is required. An
acid-etched replacement may suffice for some time when all an-
terior teeth have normal centric stops and there is no crowding.
2) Multiple Loss of Permanent Teeth.-When more than
one tooth is lost, the same principles are kept in mind as were
noted for the loss of individual teeth. When the teeth are lost
simultaneously, as in the case of trauma, there is less immediate
drifting of the remaining teeth. Figure 15-6 illustrates a case where
the maxillary central incisors were lost by accident. No simple
rules can be stated, but do not overlook the possibilities of im-
proving the occlusion with orthodontic treatment before inserting
a prosthesis. Multiple and sequential loss of teeth in adults is a
common problem requiring orthodontic attention prior to recon-
structive dentistry (see Chapter 17)."
c) Supernumerary Teeth
Supernumerary teeth are encountered less frequently than con-
genitally missing teeth. Their role in the etiology of malocclusion
is presented in Chapter 7.
1) Diagnosis.-Diagnosis is based on the radiographic find-
ings and on careful measurement of the teeth in question. Occlusal
view radiographs are especially helpful in locating and diagnosing
supernumerary teeth.
2) Treatment:-(a) In the Primary Dentition.-Supernu-
meraries are encountered only rarely in the primary dentition.
When seen, they usually are well-formed supplemental teeth. A
good rule to follow is to leave them in place unless they are causing
some form of malocclusion or malfunction, for example, a func-
tional crossbite because of tooth interference.
(b) Teeth with Conical Crowns.-These teeth only rarely can
have functional use in the mouth. The decision whether to treat is
based on ascertaining whether they may be direct causes of some
form of malocclusion. Often they are so placed that the normal
teeth must change their course of eruption. If such is the case,
remove the supernumerary teeth, taking care not to harm the fol-
licles of the other teeth. If the supernumerary teeth can do no
harm, they may be left in position until a later time. They follow
no set pattern of eruption, so they must be observed at regular
intervals, and removed eventually.
(c) Supplemental Teeth of Normal Size and··Shape.-Maxil-.
lary lateral incisors are the teeth seen most frequently in this cat-
egory, although supplemental maxillary central incisors are observed
as well and one of us (R.E.M.) has seen eight supplemental bi-
cuspids! Rarely is the size of the crown of the supernumerary teeth
exactly that of the normal teeth. If the problem is unilateral, meas-
ure all three teeth: that is, the two normal teeth and the super-
numerary tooth. The mesiodistal diameter of two of the teeth will
be found to be the same. The odd-sized tooth is the accessory
member. Do not remove a tooth until the root formation, crown
size, and position have been studied. To extract the wrong tooth
may cause disharmony and shifting of the midline of the dental
arch. There are uncommon instances in which the supernumerary
tooth is of good formation and in better position to remain in the
arch than the normal tooth.
(d) Supernumerary Teeth Showing Variations in Size and
Shape.-Such teeth should be removed as soon as it is possible
to do so without damaging nearby normal teeth.
3) Discussion.-Early diagnosis and careful observation will
enable one to decide on the timing. Timing is important, since the
supernumerary tooth seldom is a major orthodontic problem if it
is dealt with early in the development of the dentition. To neglect
the condition may create a more severe clinical task. Treatment
with appliances usually is required for alignment after the removal
of the supernumerary tooth, but some cases t are self-corrective.
2. ~ariations in Size an~""Shape of Teeth
Variation is a rule of naturel and teeth are no exception.
Malalignment and jumbling of the teeth frequently are an expres-
sion of a disharmony between the size of teeth and the dimensions
of the basal arch (Fig 15-8). There are limitations to the extent
that the bony arches can be changed to accommodate large teeth.
We are particularly restricted in altering the mandibular arch pe-
rimeter, a perimeter which steadily decreases with time.
Cephalometries provides information concerning variations
in the pattern of growth and dimensions of the facial skeleton;
however, it is impossible to make a set of measurements of the

FIG 15-8.
Dental casts of two mouths with teeth exactly the same in size. As
the ipcisors are markedly crowded in the cast at the left and aligned
facial bones and decide exactly how much tooth substance would
provide an ideal occlusion, nor is this necessarily desirable.
Knowledge concerning variation in size of teeth, however, is avail-
able and is of great assistance in diagnosis. Since there is such
variation in size of teeth from one individual to another, it is
advantageous to learn, in each instance, the dimensions of the
structures with which one must work. The mean mesiodistal widths
of the permanent teeth and their range in size can be found in
Table 6-5. There is a rather high correlation, for biologic data,
among all the widths of teeth. This fact makes it possible to
measure certain of the first teeth to erupt and to predict, with some
reliability, the size of the teeth not yet erupted, a procedure ex-
plained in Chapter 11. The determination of whether teeth will fit
into a given arch is one of the most difficult of all orthodontic
diagnostic decisions. But to try to make it without even knowing
the size of the teeth is to handicap oneself unnecessarily.
a) Diagnosis
Diagnosis is carried out by use of the tooth-measuring gauge
shown in Figure 8-3. A Boley gauge may be used instead, although
its larger size makes it less handy in the mouth. Always record
the measurements of the teeth as part of the written examination
record. Help also will be obtained from the other occlusal diag-
nostic procedures described in Chapter 11. The position of the
teeth within the facial skeleton is learned from the cephalogram.
Leighton and Hunter36 and Hunter25 have shown that crowded
mandibular arches are more likely to be found in faces with steeper
mandibular and occlusal lines, a shorter posterior face height, and
a shorter mandibular corpus. How positions may be altered to
relieve crowding is often a matter of clinical judgment though
certain cephalometric analyses are useful to estimate the best po-
sitions of the teeth to fit the skeletal profile and provide the most
esthetic lip outline (Chapter 12).
Occasionally there will be disharmony of crown sizes within
the same moath, a finding complicating the achievement of good
occlusion regardless of one's orthodontic skills.8 The Sanin-Savara
analysis (see Chapter 11) is invaluable in this instance.
b) Large Teeth
The term "large teeth" is relative, for teeth that are large for
one dental arch may not be large for another (see Fig 15-8). The
Early Treatment 355
in the cast at right, the difference must be the result of the size of
the osseous bases.
problem of teeth that are too large for their arch (or is it an arch
too small for the teeth?) is discussed later under Space Management
(Section D-4-a). In reading the section on space management, pay
particular heed to the sections on space supervision and gross
discrepancy problems.
c) Small Teeth
Always measure the teeth to make sure that the problem is
truly one of small teeth. Small teeth usually result in generalized
diastemata, whereas with the various sucking or tongue habits the
space problem is more localized.
Orthodontic therapy often is contraindicated in cases of gen-
eralized small teeth because the tongue and lips often return the
teeth to their original positions after the spaces have been closed.
Many times this patient is best left alone unless the esthetics are
unusually poor, when a series of jacket crowns sometimes may
be used or the teeth may be built up with acid-etch composites.
In other instances, the arch may be consolidated and bridgework
placed.
d) Anomalies of Crown Shape
Developmental anomalies showing alteration in coronal con-
formation are seen in all of the permanent teeth. The teeth affected
most frequently are the (I) third molars, (2) maxillary lateral in-
cisors, and (3) mandibular second bicuspids. Only the last two
present practical clinical problems.
1) Maxillary Lateral Incisors.- The term "peg lateral" is
applied when only the middle lobecalcifies. Treatment is deter-
mined by two factors: (I) the age at which the condition is dis-
covered; and (2) the size and position of the malformed crown and
its root.
·H. the crown and root 6f the lateral incisor are such that the
placement of a jacket crown is ill~advised, the tooth must be
extracted. If the condition has been noted before eruption of the
cuspids, proceed as in the case of congenitally missing lateral
incisors. When the condition is noted after eruption of cuspids, a
bridge to replace the lateral incisor may be considered instead of
orthodontics.
If the "peg lateral" incisor has a strong root and sufficient
crown for the preparation of a satisfactory jacket crown, this type
of prosthesis is favored. Alternatively the "peg lateral" incisor
356 Treatment
FIG 15-9.
Orthodontic and restorative treatment of a "peg lateral" incisor.
A, at the start. e, before orthodontic treatment. C, after placement
may be built up with composite after orthodontic therapy (Fig 15-
9). At the first observation of a "peg lateral" incisor, care must
be taken to preserve sufficient space in the arch to insert a res-
toration of proper mesiodistal width. An acrylic plate often is of
use in opening space or for centering the tooth in the space between
the central incisor and the cuspid. Banding several anterior teeth
and the first molars will permit the use of a labial archwire to open
spaces with coil springs or elastic chains. It also makes possible
accurate placement of each tooth and provides better root angulation.
2) Mandibular Second Bicuspids.- This tooth frequently
is seen with two lingual cusps. The tooth is thus wider mesio-
distally; otherwise, the extra cusp is of little concern. When such
a tooth is seen in the radiograph before its eruption, take steps to
ensure that a bit more space is available in the arch (by using
higher probability values in the Mixed Dentition Analysis). Bizarre
ovoid or "egg-shaped" crowns (Fig 15-10) also are observed,
and are extremely difficult to place in a satisfactory intercuspation.
3) Miscellaneous Anomalies of Shape.-Many other anom-
alies of coronal shape may be observed. Each anomaly presents a
FIG 15-10.
Abnormally shaped mandibular second bicuspids.
of composite resin.
separate problem requiring singular treatment. Among the anom-
alies that may create orthodontic problems are: claw form incisors,
giant and pygmy forms, dilacerations, odontomas, taurodontia,
germination (twinning), fused teeth, Hutchinson's incisors, dens
indente, hypoplastic teeth, and cone-shaped teeth (Fig 15-11).
Certain developmental defects in the texture of d~.ntal tissues, for
example, amelogenesis imperfecta, result in altered coronary con-
formation because of excessive wearing down of the teeth.
3. Spacing of Teeth
a) Localized Spacing
1) Etiology.-Localized spacing may be due as a result of
many causes other than variations of normal spacing. Treatment
is highly individualized, but a knowledge of the general principles
of etiology and diagnosis is helpful.
Problems in localized spacing and in excessive spacing at one
or a few contact points usually are attributable to (1) missing teeth,
(2) undue retention of primary teeth, or (3) a deleterious sucking
habit. One specific problem, that of spacing between the maxillary
central incisors, is seen so frequently as to merit detailed discussion
later in this section.
(a) Absent Teeth.-
• Congenitally Missing Teeth.-These may cause localized
spacing, but the problem may not be seen in just one spot
because adjacent teeth often drift into the space. (See Sec-
tion D-I-a, Congenitally Missing Teeth, for a discussion
of this problem.)
• Unerupted Teeth.-Sometimes a tooth is impacted or re-
mains unerupted. The spacing problem js then localized,
and the plan of treatment is determined by the chances of
bringing the tooth into its normal relationship. (See Section
.p-4--b-4), Impaction~bf Teeth.)
• p'femature Loss of Permanent,Teeth.-This matter is dis-
cussed in section D-I-b., Loss of Permanent Teeth.
(b) Undue Retention of Primary Teeth.-Belated loss of pri-
mary teeth may force the erupting permanent teeth into unnatural
positions. Later, when the primary tooth is exfoliated, a space
results. This sequence of events is seen most frequently in the
 Early Treatment 357

FIG 15-11.
Treatment of anomalously formed maxillary central incisors. (Courtesy of Dr. William Northway.)

maxillary cuspid region. Obviously, the easiest and most practical
treatment is removal of the primary tooth before it has deflected
the permanent tooth.
(c) Sucking Habits.-The patient's sucking habits may cause
a localized spacing of the teeth. One should read Chapters 7, 10,
and 12 to understand this problem and plan its treatmenL
2) Spacing Between Maxillary Central Incisors.-One of
the mal occlusions of most concern to patients is diastema between
the maxillary central incisors. Excessive spacing in such a prom-
inent place in the dentition is unsightly, although it does little to
reduce masticatory efficiency. Treatment is solely for cosmetic
and psychologic effects.
The data in Table 15-1 suggest that too much emphasis has
been placed on the labium frenum and too little on structures and
development at the midline. It also is of interest that in this series
of patients nearly one-fourth were developing normally.
(a) Examination and Differential Diagnosis.-Because there
are several possible causes of the condition, requiring different
forms of therapy, a careful examination is the only means of
arriving at a correct diagnosis.
The following are the steps in examination:
• Decide definitely whether the spacing is localized between
the central incisors or whether generalized diastemata are
presenL
• Measure the teeth and compare their sizes with the
averages given in Table 6-6.
• Lift the upper lip and, while it is displaced, look for
blanching of the soft tissue lingual to and between the
central incisors. The absence of blanching is not diagnostic;
the presence of blanching points to a malposed labium
frenum.
• Determine, if possible, whether the space is increasing.
• Secure periapical radiographs of the region, including both
lateral incisors. Clarity in the alveolar regions is more
important than interproximal details of the exposed crowns.
It is essential that the central ray be directed perpendicular
to the alveolar septum between the central incisors. If all
the details of the suture are not clearly shown, take
additional radiographs at several atypical angulations on
either side until a diagnosis can be made. Study carefully
Figures 15-12 to 15-15.
(b) Supernumerary Teeth at the Midline.- The diagnosis of
this condition is based solely on radiographic studies unless the
supernumerary tooth has erupted. A supernumerary tooth is the

TABLE 15-1. >.

Percentage of Cases Showing Variou~ Types of Midline Spa.ci·ng

Problems

Supernumerary teeth at the midline (3) 3.7%

Congenitally missing lateral incisors (9) 11.0%
Unusually small teeth (2) 2.4%
Enlarged or malposed labium frenum (20) 24.4%
Spacing a part of normal growth (19) 23.2%
Imperfect fusion at midline of premaxilla (27) 32.9%
Combination of imperfect fusion and congenitally
missing lateral incisors (2) 2.4%
Total (82) 100.0%
358 Treatment
FIG 15-12.
Midline spacing in the maxilla resulting from congenital absence of
lateral incisors.
only condition likely to cause an increase in the space between
the maxillary central incisors. This is discussed in Section D-I-
c, Supernumerary Teeth. Treatment involves removal of such extra
teeth as soon as diagnosed without end~ngering the adjacent teeth.
Early removal may permit the eruptive force of the incisors to
close the space at the midline.
(c) Congenitally Missing Lateral Incisors . - Treatment of this
condition is discussed in Section D-I-a, Congenitally Missing
Teeth. Figure 15-12 illustrates a typical midline diastema resulting
from congenital absence of lateral incisors.
-FIG 15-13.
Spade-shaped interosseous tip between the maxillary central inci-
sors, usually associated with an enlarged maxillary labial frenum.
-
(d) Enlarged or Malposed Labium Frenum.-
• Diagnosis.-The enlarged or malposed labium frenum
occasionally may be diagnosed by observation alone or by
lifting the lip. However, it is impossible to detect all
enlarged or malposed frena in this manner. The final
diagnosis must be based on the radiograph. The normal
osseous septum between the maxillary central incisors is
V-shaped and bisected by the intermaxillary suture, which
sometimes is not visible in the radiograph. When the labial
frenum inserts on the palatal side of the septum, the fibers
of the frenum run across the bone, rounding it over so that
the septum is shaped like a spade (see Fig 15-13). On
occasion, a shallow trough is seen. Even when the fibers
insert so deeply as not to cause blanching when the lip is
displaced, the condition may be diagnosed in the
radiograph .
• Treatment.-Treatment consists of bringing the incisors
together before excising the frenum. The incisors may be
bracketed, a short wire ligated into place, ~nd the teeth
pulled together by ligatures or light elastics. Under no
circumstance should free elastics be used around the necks
of unbanded teeth for this movement. It is much too easy
for the patient to let one of the elastics slip up the neck of
a tooth, destroying the supporting structures and
endangering the tooth itself. After the central incisors have
come into juxtaposition, excise the frenum and maintain,
the orthodontic appliance in position while healing is taking
place. The scar tissue formed will help in retention.
Obversely, if excision is undertaken before orthodontic
movement, the teeth must be moved through the newly
formed scar tissue. Although some prefer to remove the
frenum by cautery, any of the several techniques involving
excision by scalpel are to be preferred because there is
better control and less scar tissue is formed. Sometimes the
orthodontic force itself will cause pressure atrophy of the
frenum fibers, making excision of the frenum unnecessary.
(e) Imperfect Fusion at the Midline.-The midline is a common
site of development faults, such as epithelial rests and inclusion
cysts. The condition illustrated in Figure 15-14 may be related to
imperfect fusion at the midline, for histologic study of the tissue
included within such osseous bifurcations has shown connective
and epithelial tissue. A wide variety of forms will be observed,
all of which must be differentiated from the normal suture. A
distinctly W -shaped osseous septum may be associated with this
condition, as well as a circumscribed irregular ovoid area. The
separation of the osseous septum may be shalloWOD continue well
into t~e alveolar process": ~"
For treatment, one should pro-ceed exactly as for a malposed
or enlarged labium frenum except that the included tissue, rather
than the frenum, must be excised. The excision must be carried
out thoroughly or regeneration will occur, forcing the teeth apart
again. One satisfactory method, after the incisors have been brought
together, is to lift a V -shaped mucosal flap directly over the septum
between the central incisors. The flap should flare well laterally
so that later it will lie easily in place. After the alveolar bone is
exposed, a surgical fissure or tapered fissure bur may be inserted
gently into the cleft in the bone. With the motor turning at a slow

FIG 15-14.
A-C, variations in imperfect fusion are seen at the midline in the
maxilla. The suture is seen clearly above the bifurcation in the in-
terosseous tip. Invaginated epithelial and periosteal tissue will be
found at the split tip. 0 and E, imperfect midline in the dental septum.
Note the split of the septum or the W-shaped osseous tip between
the central incisors in D. E is a view after treatment. The orthodontic
Early Treatment 359
."
appliance brought the teeth together. The invaginated tissue was
removed surgically and the appliance used served as a retainer
during healing. Mere clipping of the labial frenum will not correct this
problem. F-H, views of a septum from three different radiographic
angulations.
360 Treatment
FIG 15-15.
Spacing between maxillary central incisors closing normally, with eruption of the lateral incisors.
speed, the bur will remove the included tissue and will freshen
the edges of the bone as well. After excision, suture the flap into
place. The orthodontic appliance, which has brought the teeth
together, must be replaced during healing (see Fig 15-14).
Occasionally, fibers of the frenum will insert into the suture. The
same procedure may be used for their excision.
(j) Spacing as Part of Normal Growth. - The central incisors
erupt with a space between them (see Fig 6-46). This space is
diminished when the lateral incisors erupt and finally is closed by
the wedging of the erupting cuspids. In the absence of abnormal
midline structures or gross variations in tooth size, it can be assumed
that the midline space will close naturally (Fig 15-15).
b) Generalized Spacing
Any of several etiologic factors may be involved in generalized
spacing of the teeth. It is important to ascertain the presence of
true generalized spacing. More frequently, a localized spacing
problem is encountered.
1) Small Teeth.-If the teeth are unusually small for the size
of the alveolar arch that includes them, generalized spacing may
result. If the teeth, when measured, are very small and there are
no other apparent causative factors, the smallness of the teeth alone
may be at fault. Such a condition is' rare and the best treatment
may be by means of jacket crowns, buildup with acid-etch
composite, or consolidation of the arch and the placement of bridges.
Whether such a heroic measure as a series of jacket crowns is to
be undertaken is an individual matter, dependent on the wishes of
the patient and the cosmetic problem. Some problems of spacing
due to small teeth may best be left alone.
2) Large Tongue (Macroglossia).-Another rather rare cause
of generalized spacing is an unduly large tongue. Diagnosis is
.'
made by careful examination of the tongue when extended as well
as in situ. The lateral edges of the tongue, when it is too large for
the alveolar arch, usually display scalloping where the tongue rests
against the lingual surfaces of the mandibular teeth. Treatment is .
contraindicated unless gross mal occlusion is present, in which case
a wedge of tissue is excised from the tongue. This rather heroic
approach is not advocated unless a debilitating malocclusion is
present.
3) Sucking Habits.-Sucking habits may cause rather
generalized spacing of the teeth, although they are more likely to
cause a localized spacing of the maxillary anterior teeth. See Chapter
7 for a discussion of digital sucking and Chapter 18 for suggested
therapy in thumb-sucking and tongue-thrusting.
4) Abnormal Tongue Posture.-Abnormal tongue posture
may also cause generalized spacing (see Chapter 10). The prognosis
is dependent on the reason for the atypical postural position.
Endogenous protracted postures are most intractable, while those
associated with nasorespiratory dysfunction (e. g., mouth breathing)
often are correctable when normal respiratory function returns.
Tongue-thrust may also create generalized spacing (see Chapters
10 and 18).
4. t~oblems Singular t?"Jhe Transitional Dentition
·a) Space Management
1) General Considerations.-Space management is a gen-
eral term that includes four subdivisions: space maintenance, space
regaining, space supervision, and gross discrepancies. At! prob-
lems in space management fall into one of the four categories.
The differential diagnosis among them is determined primarily by
the Mixed Dentition Analysis (see Chapter 11), but other predis-
positions to crowding must not be overlooked. 19.46 Crowded man-
 Yes
?No
Yes
Yes
No
Yes
No 361 - Yes
SUPERVISION
REGAINING
DISCREPANCY Yes
No
MAINTENANCE
6.
2. Good
Loss
SIGNSprognosis
of space
Dentition
AND in arch
Analysis
SYMPTOMS
Symptoms and Space Management Categories
dibular arches have been shown to be associated with steep
mandibular and occlusal lines, short posterior face height, short
mandibular corpus, lingual inclination of incisors, and mesially
inclined molars. Further, the lower incisors and symphysis are less
protrusive in crowded ca&es. In Table 15-2 the distribution of
symptoms associated with space management problems of the four
subtypes are compared. The effects of molar relationship on arch
perimeter changes during the mixed dentition are discussed under
space supervision, since the problem is more critical in that cat-
egory. However, its significance should not be forgotten when
treating other space problems.
The reader is reminded of the several patterns of occlusal
change described in' Chapter 6, for their identification is important
to the diagnosis and treatment plan. The presence of a "homeostatic
Class II," "homeostatic end-to-end," or "retrusive" pattern of
transitional occlusion alters seriously the strategy and the prognosis.
Note that this section is written assuming a "Protrusive" pattern
from an initial flush terminal plane or a "homeostatic Class I"
pattern from an original mesial step since they constitute the majority
of cases and the treatment is similar. It is also assumed that allowance
for correction of incisal mal positions has been made when compiling
the Mixed Dentition Analysis (see Chapter 11). Before undertaking
any space management therapy, one should understand thoroughly
the contents of Chapter 6, Development of the Dentition and the
Occlusion, and the Mixed Dentition Analysis found in Chapter 11,
Analysis of the Dentition and Occlusion .
2) Maintenance of Arch Perimeter .-Space maintenance
is undertaken only when the following conditions obtain: (I) loss
of one or more primary teeth; (2) no loss of arch perimeter, and
(3) favorable Mixed Dentition Analysis prediction.
The problem of maintenance of arch perimeter is not peculiar
to the mixed dentition, for the arch perimeter is likely to shorten
quickly at any time following the loss of either a primary or a
permanent tooth, and it continues to diminish gradually throughout
life." However, certain difficulties in the mixed dentition are so
singular as to require separate techniques and separate discussion. 46
Here, the explanation will be confined to problems of perimeter
maintenance which may appear in a normally developing dentition
as a result of caries or unwanted loss of teeth.
It is necessary to separate space maintenance cases carefully
from (I) space regaining and (2) space supervision,
(a) Caries of Primary Teeth.- The most frequent cause of
arch perimeter loss in the mixed dentition is caries of the primary
Early Treatment
molars. A carious lesion on the distal surface of the second primary
molar, in particular, allows the first permanent molar to tip mesially,
The first step in maintaining arch perimeters is to preserve intact
the size of the primary molar crowns. A most important preventive
orthodontic appliance is a proper restoration in a primary molar.
In Chapter 7, the role of caries in the etiology of mal occlusion is
discussed. Research affirms the etiologic role of caries in many
space management malocclusions.
(b) Loss of Individual Primary Teeth.-Much attention has
been given to the necessity for placing space-maintainers when a
primary tooth has been lost. 28.29.40,14,16 TQO often, however, the
effect of the tooth loss on the total arch length is not noticed. A
space-maintainer to hold space after the loss of a single tooth is
placed only if the following conditions obtain: (I) the permanent
successor is present and developing normally; (2) the arch length
has not shortened; (3) the space from which the tooth has been
lost has not diminished; (4) the molar or cuspid interdigitation has
been unaffected by the loss; and (5) there is a favorable Mixed
Dentition Analysis prediction. There is no reason to insert a space-
maintainer if the permanent successor is absent, not should one
maintain 4 mm of space for a tooth known to be 7 mm in width.
The type of space-maintainer to be used depends on the site of the
loss and the operator's preference.
• Primary incisors.-Primary incisors may be lost
prematurely as a result of trauma, usually as the infant is
learning to stand and walk. Multiple loss of incisors from
caries is, of course, also seen. Sometimes space-
maintainers are not necessary. in treatment; however, this is
not a rigid rule. Before the permanent teeth have developed
sufficiently to maintain the dimensions of the arch, the loss
of a primary incisor 9.an result in rapid closure of space
" i~ee Fig 7-19). In every case of premature loss of primary
incisors, make a record cast and occlusal plane radiographs
for diagnosis and serial study. In children in whom space
loss is likely to occur, an acid-etch composite pontic not
only serves as a space-maintainer but aids esthetics as well.
It is attached to a mesh or braided wire held in place on
the lingual of the incisors adjacent to the space.63 Leave
this in place until the eruption of the permanent incisor.
Space-maintainers for primary incisors are less apt to be
needed if the primary tooth has been lost after the child is
4 years of age.
362 Treatment
FIG 15-16.
Effect of the loss of primary molars. A, the loss of second primary
molars. In both arches, the first permanent molar has a strong tend-
ency to drift mesially and rotate on its long axis. In the mandibular
arch, it may tip lingually also. e and C, effects of the loss of first
• Primary cuspids.-Although the primary cuspids may be
removed prematurely because of caries, the eruption of
large permanent incisors is a more frequent cause of their
unwanted loss. Not infrequently, a large lateral incisor will
erupt lingually to the central incisors in the mandible, in its
normal eruptive position, but because of its large size there
is no room for it in the arch. The combination of eruptive
force and tongue pressure 'forces the lateral incisor against
FIG 15-17.
A, band and loop space maintainer of correct design. e, a lingual
archwire used as a perimeter space maintainer. C, band and loop
maintainer preventing labial movement of the primary cuspid. The
horizontal section should be straight, not concave.
.'
primary molars. Fm this amount of space to be lost, the first primary
molars must be lost very early (before eruption of the first permanent
molar).
the root of the primary cuspid. Resorption of the primary
cuspid's root is likely, particularly if the cuspids cannot
move labially and distally. Unilateral loss of a mandibular
primary cuspid poses a special problem since the dental
midline can quickly be misplaced. The resultant unilateral
mesial drifting of teeth complicates and stabilizes the
asymmetry. The immediate extraction of the other primary
cuspid should be considered, and close monitoring of
subsequent sequelae is advised. Following the loss of
primary cuspids, the mandibular arch perimeter may be
shortened from the front, since the lips may tip the
. permanent incisors lingually, causing them to lose their
occlusal stops and increasing the overjet and the overbite.
As a result, the erupting mandibular permanent cuspids
may move anteriorly across the roots of the lateral incisors,
finally emerging in labioversion. If other posterior teeth
also move anteriorly, it is more difficult to correct the
cuspid's malposition. Such cuspid malposition is best
averted by prevention of lingual tipping of the incisors with
an appliance as a well-adapted lingual archwire.
Do not tip the mandi~ular incisors labially with any appliance
ahhis time unless you 'are very carefully uprighting them from a
position of linguoversion. In the maxillary arch, the problem is
similar, but the variation in the sequence of eruption and the
permanent cuspid's position enhances its chances to move labially.
The upper arch is more apt to shorten posteriorly, but there also
is a better chance for distal orthodontic movement of the first
permanent molar to provide room in the arch for better placement
of cuspids and premolars.
• First primary molars.-In most cases, the loss of the first
primary molar is not as serious as the loss of the second
 Early Treatment 363

primary molar.50 The severity of the problem is dependent teeth and natural eruptive placement of the permanent teeth. The
on the sequence of eruption of the succeeding teeth, the mixed dentition is a dynamic, rapidly changing entity ill-suited to
molar intercuspation and, most important of all, the dental the application of the static prosthetic approach so successful in
age of the patient. Arch perimeter loss is most likely to oc- aged adults. Appliances used with the mixed dentition must neither
cur when the first primary molar is lost vhy early (Fig 15- inhibit nor divert the growth changes taking place. The design of
16). It also may occur when the cusps of the~permanent any appliance depends on the individual situation. Several sug-
molars are shallow or there is an end-to-end molar relation- gestions will be found in Chapter 18.
ship combined with an unfavorable eruption sequence. 16
Many types of space-maintainers have been designed to 3) Regaining Space in the Arch Perimeter.-Space re-
hold space in this region, but do not insert an appliance gaining, as used in this section, means that all of the following
that locks the position of the primary cuspid position (Fig conditions obtain: (J) one or more primary teeth have been lost;
15-17), which must have the chance to move labially and (2) some space in the arch has been lost to mesial drift of the first
a bit distally. After loss of a first primary molar, one may
insert a removable plate or a lingual archwire if other space
problems are expected in that arch. If the perimeter is not
threatened, a single unit space-maintainer, for example, a
preformed stainless steel crown on the second primary mo-
lar with a loop engaging the cuspid, may be placed. An
alternative is to attach a similar loop to the buccal and/or
lingual surfaces of the second primary molar with compos-
ite.72
• Second primary molars.-The most rapid losses in the pe-
rimeter of the arch usually are due to a mesial tipping and
rotation of the first permanent molar after removal of the
second primary molar (Fig 15-18).16 When this tooth is
lost, always maintain space until the arrival of the second
bicuspid. Before inserting any appliance to maintain the
second primary molar space, determine that no space has
been lost. Never place a space maintainer when space re-
gaining is indicated. If the first permanent molar has
erupted fully, the space maintainer may consist of a pre-
formed stainless steel crown form or a band on the first
primary molar carrying a wire loop to engage the first per-
manent molar or a similar loop held in place by compos-
ite.3 The first permanent molar may be banded and the
strut placed mesially to engage the distal surface of the first
primary molar. Overlays or crown forms for the first per-
manent molar are contraindicated because they prevent the
tooth from erupting to its full clinical crown height. If the
first permanent molar has not yet erupted, the free-end
acrylic block type of maintainer may be used (see Fig 18-
35). The old-fashioned distally extended "shoe" which en-
~ gaged the erupting first permanent molar sub-mucosally is
,contraindicated because it is unhygienic and inflexible.

(c) Multiple Loss of Primary Teeth.-Usually, when sev-

eral primary teeth are lost, the arch perimeter is shortened-and
regaining, not maintenance, is indicated. Sometimes it will be
necessary to extract more than one primary tooth at the same
appointment. If such is necessary, it is best to insert the appliance
the very day the teeth are removed. A lingual archwire or multiple
acrylic space-maintainer will serve well. It is not necessary to cast FIG 15-18.
elaborate frameworks and meticulously carve occlusal patterns for A, effects of early loss of primary molars. Note that the maxillary first
"primary partial dentures." A block of acrylic to provide a smooth molars have rotated, tipped, and translated mesially. B, the lower
occluding surface, maintain the vertical height, and prevent ex- arch in the same mouth. In the mandibular arch, the first permanent
trusion of the opposite teeth will suffice. Many of these appliances molars, in addition to translating and rotating as they tip mesially,
also have tipped lingually. The lingual tipping of the mandibular mo-
will not even require clasps. Indeed, the occlusal carvings or acrylic
lars during mesial drifting often is due to the effects of occlusion.
tooth pontics may interfere with the normal exfoliation of primary
364 Treatment
permanent molar; and (3) the Mixed Dentition Analysis shows that
if one could recapture what was once there, there would be ade-
quate room for all the teeth and the normal mixed dentition ad-
justments. Regaining what was once there is entirely different from
creating that which has never been present. - lation. Actually, tipping and rotation back into position usually
Loss of arch perimeter usually is the result of caries or pre-
mature loss of primary teeth (see Chapter 7).61 Such cases must
be differentiated carefully from those in which the tooth size-
osseous base relationship is so poor that there is insufficient space
for the permanent teeth. The discussion at this point is centered
on patients who once had sufficient length of the arch perimeter
but, because of environmental reasons, had it shortened by mesial
movement of the first permanent molars or by lingual tipping of
the incisors. Correction should be where the loss has occurred.
Note the molar relationship, cuspid interdigitation, and overjet,
since they provide the key to the site of the shortening.
After locating where the arch has shortened, determine, by
means of the Analysis described in Chapter 11, the exact amount
of space that must be regained and the most logical tooth move-
ments to recover that space. Usually, distal movement of first
permanent molars is required. But before moving first permanent
molars distally it is necessary to understand the nature of the mesial
movements that caused the shortening of the arch perimeter.
(a) Mesial Drift of Permanent Molars.-Mesial drift of the
first permanent molars involves three separate kinds of tooth move-
ments, namely, mesial crown tipping, rotation, and translation.
There are distinct differences in the mode of mesial movement
between the upper and lower first molars, differences caused by
variations in the crown shape, number of roots, and occlusal re-
lationships. Furthermore, the time of loss of the crown of the
primary second molar is a determining factor in the type of move-
ment seen. Maxillary first permanent molars quickly tip mesially
with the loss of crown substance of the maxillary second primary
molars (see Figs 15-16 and 15-18). Mesial tipping causes the
distobuccal cusp to become more· prominent occlusally. Because
of the large lingual root of the maxillary first permanent molar,
rotation of the crown also is seen with mesial tipping, the disto-
buccal cusp becoming more prominent buccally as well. When the
second primary molar is lost prior to the eruption of the first
permanent molar, translation of the first permanent molar during
its eruption may be seen. Mandibular first permanent molars dis-
play mesial tipping, crown rotation, and translation as well but
they are more likely to show lingual tipping during mesial move-
ment. The lingual tipping is caused by the absence of a lingual
root and the fact that occlusal function occurs buccally to the center
of mass of the lower molar, a condition aggravated as the first
molar drifts mesially. Figure 15-18 illustrates clearly the differ-
ences in mesial drifting of maxillary and mandibular first per-
manent molars.
(b) Distal Movement of First Permanent Molars.- The basic
tooth movement necessary in space regaining is distal movement
of first permanent molars, which must recapitulate in reverse the
movements that occurred as the teeth drifted mesially. Therefore,
the selection of the space-regaining appliance is dependent on
whether tipping, rotation, translation, or combinations of these
movements are required. Some common mistakes in choosing
space-regaining appliances should be noted. (1) Often, too com-
plicated an appliance is chosen when a simple appliance would
let the tooth fall back more easily into its former position. (2) A
firm purchase on the tooth often is not necessary except for trans-
occur more readily with the use of finger springs rather than a
banded appliance. (3) There is failure to achieve all of the necessary
movements. It should be noted that surprising amounts of arch
perimeter space often are created just by distal tipping and rotation
of the first molar. Therefore, tipping and rotation should be achieved
prior to attempting translation. Although this sequence may ne-
cessitate the use of two space-regaining appliances, it often will
save months of treatment time and frequently permits the use of
simpler appliances.
A wide variety of space-regaining appliances are available
(see Fig 15-19). No more complicated appliance should be used
than is required to achieve the necessary space. Do not overextend
the space-regaining appliance. Simple finger springs cannot move
molars bodily nor can they easily lengthen an ar~h perimeter past
its original dimensions and retain a permanent result. Space-re-
gaining appliances are intended to be used solely for recovering
space that once was there. Space regaining is not space creating.
The timing of space regaining is important, since the position
and stage of development of the second permanent molar often is
a limiting factor. When the simpler space-regaining appliances
cannot complete the task, one may resort to extra-oral traction,
but before using extra-oral traction, the patient's case should be
reassessed completely to make certain that the original diagnosis
still obtains.
When the loss of perimeter length is so extensive as to be
beyond the scope of the simpler appliances, or when there is
insufficient time to recover the space before the eruption of the
bicuspids and second permanent molars, a far more difficult clin-
ical situation is present, and comprehensive multi banded appliance
therapy usually is indicated.
The construction and adjustment of several popular space-
regaining appliances are described in Chapter 18. It should be
noted that similar appliances also are useful when constructing
bridges to replace lost first permanent molars, as they may be used
for the uprighting and distal movement of second molars prior to
their preparations as abutments (see Chapter '17). Figure 15-19
illustrates typical cases where space regaining was needed.
4) Space Supervision.-Space supervision is the term ap-
plied when it is doubtful, according to the ~ixed Dentition Anal-
ysis, whether there will be room for all the teeth. The prognosis
for space supervision is always questionable, whereas prognosis
is ,!lways good for regaining space and for space maintenance.
Space-supervision cases are those}hat will have a better chance
of getting through the mixed dentition with clinical guidance than
they will without.44 Each case involves a calculated risk; therefore,
space supervision is not to be undertaken without patient coop-
eration and parental understanding. Successfully treated, such cases
are among the most comforting victories in interceptive orthodon-
tics; but when fought through and lost, they provide some most
disheartening moments, since, if extractions of permanent teeth
ultimately are necessary, large amounts of space closure will be
required. Misdiagnosed space supervision cases that require ex-
 Early Treatment 365

.'

PASSIVE BEND BEND BEND

NO.I N02 N03

FIG 15-19.
Examples of space-regainers. A, recurved helical spring regainer
(courtesy of Dr. Fred DuPrai). Note the use of the Adams clasp on
the opposite side. e, knee spring for use in tipping molars distally.
C, split-saddle acrylic space-regainer, useful when greater distances
must be regained than in e. Note another type of regainer on the
opposite side of the arch, a coil spring lying beneath acrylic and
acting against the first molar. D, method of adjusting the spring on
the split-saddle regainer. E, method of increasing the adjustment in
a split-saddle regainer. As the molar moves distally, the appliance
becomes more fragile. It is then possible to tie the distal portion
forward with a piece of dental floss or stainless steel ligature to permit
the addition of acrylic posteriorly. In this way the appliance is reac-
tivated without adjustment of the spring. (Continued.)

~-.
.',
366 Treatment

..

FIG 15-19 (cont.).

F and G, slingshot regainer. Note the use of a light elastic joined to
buccal lingual hooks (courtesy of Or. Fred DuPrai). H and I, the sliding
yoke space-regainer. H, buccal view. A steel edgewise wire 0.022
inch x 0.028 inch is used. A ball of solder is placed mesial to the
cuspid bend of the wire. A coil spring is then threaded onto the wire,
the sliding yoke is added, and the wire is bent well distal to the molar
to be moved. I, the sliding yoke is an edgewise buccal tube the inside
diameter of which is exactly that of the wire. To the buccal tube is
soldered at a right angle a small piece of stiff wire to engage the
mesial of the molar. Note that the acrylic must be trimmed in a straight
line on the lingual. This appliance is best anchored on the opposite
side by an Adams clasp. It is more efficient in the maxillary than in
the mandibular arch. J, the expansion screw regainer. These units
are bought prefabricated and inserted into the acrylic appliance (cour-
tesy of Dr. Fred DuPrai). K, an example of a removable acrylic
regainer followed by a lingual archwire as a maintainer (courtesy of
Dr. William Northway). (Continued).
 Early Treatment 367

tractions of permanent teeth are more difficult to treat than gross

discrepancy cases because (I) more space closure is needed and
(2) the patient's cooperation often lags after the planned intercep-
tive procedure has failed. Do not oversell space supervision to the
parents. Select space supervision cases with great care and maintain
careful records, since help from a colleague may be required later.
Success is greatly dependent on the clinician's knowledge of the
details of mixed dentition development. 17.5062 (See Chapter 6.)
Because of the critical effect of the skeletal pattern on molar
relationship and the utilization of available space (Fig 15-20),
three space sur;;rvision protocols are needed. However, several
basic principles obtain in all three: (I) space supervision is not
begun until the mandibular cuspid and first premolar show ap-
proximately one-quarter to one-third of the root formed; (2) pri-
mary teeth are extracted serially to provide an eruption sequence
of cuspid, first premolar, and second premolar in the mandible
and of first pr5:molar, cuspid, and second premolar in the maxilla;
(3) an effort is made to keep the mandibular teeth erupting well
ahead of the maxillary; (4) one takes care that a late mesial shift
of the mandibular first permanent molar does not occur.

(a) Mesial Step (Class /) Protocol.- This protocol (Table 15-

FIG 15-19 (cont.).
L, the use of a maxillary plate (Cetlin) as a regainer. Note the palatal
anchorage and eyelets in the archwire for placement of extra-oral
anchorage (courtesy of Dr. William Northway). M, use of a screw for
space regaining. N, a combination of appliances to achieve space
regaining (courtesy of Dr. William Northway).
3) is used when there is a normal skeletal profile and the first
permanent molar has alread)' achieved a Class I molar relationship
at the time of instituting space supervision (Fig 15-21 ,A). Figures
15-21 ,A-H depict diagrammatically the various steps in the mesial
step protocol, and Figure 15-22 illustrates cases treated in this
manner.
The first step, the removal of the mandibular primary cuspids,
is begun when the mandibular permanent cuspid has clearly begun
root formation (Fig 15-21,C). The purpose of the first step is to
provide space in the arch for the alignment of the mandibular
incisors and to' induce the mandibular cuspid to erupt before the
first bicuspid. One of the most- important single steps in space
supervision is the correct placement of the mandibular permanent
cuspid after alignment of the incisors. Several months after the
primary cuspids have been removed, it will be found by palpation
that the permanent cuspid can no longer erupt normally without

CLASS I END TO END CLASS IT

SPACE SHORTAGE -1.Omm - 1.0 - 1.0

NEEDED FOR MOLAR

ADJUSTMENT -O.Omm -7.0

TOTAL SHORTAGE - 10 mm - 4 5mm 8.0mm

FIG 15-20.
Effect of the molar relationship on the available space. Three hy-
pothetical situations are shown in which it is predicted that there will
be a shortage of 1 mm on each side in the mandible. Where there
for the 1-mm shortage plus the width of an entire cusp (approximately
7 mm). Naturally, under such circumstances, both the end-to-end
and the Class molar relationships are treated by Class mechanics
11 11

is a Class Imolar relationship, the only problem is the 1-mm shortage. (Le., moving the maxillary dentition distally while preserving the man-
However, where there is an end-to-end molar relationship, one must dibular dentition intact). Further, such patients are poor candidates
account for the width of half a cusp (approximately 3.5 mm) in ad- for intermaxillary elastics, since the elastic traction tends to shorten
dition. Where there is a Class II molar relationship, one must allow the mandibular arch length while moving the maxillary molars distally.
 368 Treatment

TABLE 15-3.
Space Supervision Protocol for Mesial Step or Class I Cases
STEPS PURPOSES TIMING

1. Removal of C 1.
2~ (a) Align
3. Allow:3incisors
Prevent mesial
to erruptdr\ft of 6
distally 1. 3 is stage 6 + or 7
of and extraction
D, slicing of E of E . (b) Erupt 5 eruption
(b) Erupt:3
Hasten before 47 of 4
2 When:3 can no longer erupt normally

3. When 4's eruption is halted by E

moving into labioversion. It is now time for the second step (Fig
15- 21 ,E)--the removal of the primary first molar and the slicing
of the mesial surface of the second primary molar. The purpose
()f the second step is to allow the cuspid to erupt distally into the
line of arch and to hasten the eruption of the first bicuspid. After
the cuspids have arrived in the arch there usually is insufficient
space for the eruption of the first premolar, since it becomes halted
at the mesial surface of the second primary molar. A holding
archwire is now inserted and the mandibular second primary molars
are extracted. A lingual archwire may be used (Fig 15-21 ,H) but
a utility archwire is often more satisfactory since it provides precise
incisor control and positioning (Fig 15-23). A lip bumper is also
a handy device for maintaining the lower arch perimeter and has
two additional advantages:4•7.ll (I) it helps correct excessive
mentalis muscle activity and (2) it can increase the arch perimeter
in some instances. The purposes of this third step are to prevent
the mesial drift of the first permanent molar and to cause the second
premolar to erupt before the second permanent molar. All of the
steps in space supervision are shown in sequence in Table 15-3.
(b) Flush Terminal Plane (End-ta-End) Protocol.-The
protocol for space supervision with a flush terminal plane (end-
to-end) relationship (Table 15-4) is quite similar to that for a
mesial step-with one important exception. Since the molars are
not in a Class I relationship and a late mesial shift cannot be allowed
to occur, it is necessary to achieve a Class I molar relationship by
guidance of the eruption of the maxillary first permanent molar or
its movement distally. Figure 15-24 diagrams how the distal tipping
of a maxillary molar during the transitional dentition helps achieve
a Class I molar relationship without a late mesial shift in the
mandible. A Sved plate with helical springs may be used. The
Sved plate frees the occlusion, which aids in the distal tipping of
the maxillary first permanent molar, helps flatten the mandibular
occlusal plane, and removes any occlusal interferences. The Cetlin
appliance, a modification of the Sved plate, is also quite satisfactory.
Study Figure 15-25 carefully, for the details of each step of treatment
are depicted in the diagrams. Note that this protocol in its simplest
form is proper only with a straight (Class I) profile and a flat
occlusal plane. The presence of a flush terminal plane or end-to-
end first permanent molars can be quite deceptive if one thinks of
these occlusal features only as defining "normal." As the
craniofacial skeleton becomes more retrognathic, the occlusal plane
steepens, or one suspects a "retrusive" transitional occlusal pattern,
this protocol must be modified. When all the skeletal features are
Class 11, even though the occlusion is end-to-end, the distal step
(Class 11) protocol is used. Study the several cases shown in Figure
15- 26; they are of varying severity utilizing treatments appropriate
to the difficulties seen. Figure 15-26 illustrates cases treated by
this protocol.
(c) Distal Step (Class 1/) Protocol.-In the preceding space
supervision protocols it has been assumed that the problem is seen
in a balanced or nearly balanced facial skeleton. A space supervision
problem combined with a distal step is a much more serious matter,
and the space problem is quite secondary to the skeletal contributions
to the Class 11(distal step). Many other problems are encountered
in addition to that of the space shortage. The basic skeletal dysplasia
must be treated and the teeth positioned in the best possible way
to accommodate after the skeletal correction is over. Furthermore,
there usually are vertical occlusal problems to be corrected, and
abnormal tongue and lip contractions are frequently seen. Of
particular importance is the necessity to retract the incisors to fit
the skeletal profile, a move which shortens the arch perimeter from
the front. Leveling the occlusal curve, which is often necessary,
also shortens the arch perimeter.
Distal step space supervision is the first part of a diphasic
treatment begun at the same time as the flush terminal plane and
mesial step protocols. However, 9istal step space supervision therapy

TABLE 15-4.
Space Supervision
STEPS
.. Protocol for Flush Terminal Plane
PURPOSES
Of End-to-End Cases " ":"
TIMING

1. Max.-appliance. 3.
1. of
3. 6:3 +4noordrift
(b)
by
2. (a)
1.
(a)
(c)E Tip
Align
2.
(a) isincisors
When
When:3 6stage
Prevent
Allow:3
Erupt:3 distally
4'sto 6erupt
mesial
eruption
can
before 7 is halted
longer
distally
n5 eruption
andibular
before
emove of 4 E
5, 7lingual
slice erupt normally

,.
FIG 15-21.
Space supervision protocol for Class I or mesial step cases. A, the
mesial step. B, typical crowding in the mandibular arch. Note that
the primate space is closed. C, the first step-removal of mandibular
primary cuspids. D, the effects of the first step. E, the second step-
removal of the first primary molar and slicing of the mesial surface
of the second primary molar. F, the effects of the second step, re-
.'
moving the first primary molar and slicing the second primary molar.
Note, too, that the mesial surface of the second primary molar may
be shaped by a small finishing stone to facilitate the eruption of the
first bicuspid. G, the third step-placement of a lingual archwire and
removal of the· second primary molars. H, the results of the third
step.
369
 370 Treatment

A
MIXED DENTITION ANALYSIS
A90!iL!:L Su _M__
Dole _~ Address _ Poren' _

I
, I Ri hi
~:.
lift
L.ft
:).3. (.
.S-
Space lert after
.n.
aliC)nment of 2 ..ond I
Low., ~.2.(,
~O.~
~~.~
RIQhI

Pred ieled size of - I. L{

3"4"5
Space 'eft for
molar adjustment

Spoce left after

olionmenl of 2 and I

Predicted size of
3" 4 .• 5
Spoce left for
molor adjustmenl

'I./ ~ .
.3. J. ~.
r
RemOlks: Overjet" Ov••.bil.·

Molar relationship" ~J..AAAr ~ ~~.r-r

FIG 15-22.
Space supervision with a Class I molar relationship. A, the Mixed
Dentition Analysis for the patient. B, at the start of treatment. C, at
the time of extraction of the mandibular primary cuspids. D, a re-
movable acrylic arch-holding appliance was inserted immediately
after extraction of the primary cuspid because the patient had a
hyperactive mentalis muscle which might have collapsed the incisors
lingually. Ordinarily, it is better practice to place a lingual archwire
in such cases. E, 9 months later, at the time of extraction of the first
primary molars. F, after the loss of the second primary molars. Note
the spontaneous improvement in the incisor region, although the
contact is not correct between the right lateraHncisor and the cuspid.
This photograph was taken 2 years after the beginning of treatment.
G, 1 year later than F. H, 1_ year later than G-or 4 years after the
start pf space supervision-'procedures. Compare H with A_ It is doubt-
ful thai such a result would have oc€urred spontaneously by chance
alone. Only the intervention and careful supervision of the loss of
the primary teeth and the eruption of the permanent teeth could have
guided such a result.
 Early Treatment 371

FIG 15-23.
Space supervision utilizing lip bumpers and a maxillary utility wire.
(Courtesy of Dr. William Northway.)

..

FIG 15-24.
Molar correction during space supervision in flush terminal plane
cases. A, the maxillary molar is restrained during the downward and
forward growth of the maxilla. Thus, it comes to occupy a relatively
different occlusal relationship with the mandibular first permanent
molar. B, the maxillary first molar is tipped distally a slight amount,
thus changing the axial inclination of the tooth during subsequent
vertical development. The tooth is not moved distally in a translatory
fashion; rather, its angle of.yertical development is changed so that
it cl3mes to occupy a relatively different occlusal relationship with the
mandibular first molar after some time has passed.
 ..

FIG 15-25.
(Legend appears on facing page.)

,.

372

is secondary to the treatment of the facial skeleton and must be
accompanied or followed by a period of precision bracketed
appliance therapy to finish the alignment of the permanent teeth.
Figure 15-27 illustrates the treatment of a distal step supervision
case. Read carefully Section D-6-e on early treatment of Class 11
maJocclusions before undertaking any distal step space supervision.
Class 11 mal occlusion accompanied by space problems is one of
the most difficult categories in early treatment.
5) Gross Discrepancy Problems.-Gross discrepancy
problems are those in which there is a great and significant difference
between the sizes of all the permanent teeth and the space available
for them within the alveolar arch perimeter. Gross discrepancy
problems ordinarily cannot be diagnosed until the early mixed
dentition, as no clinically useful correlation has been shown to
exist between the size of the primary teeth and those of the permanent
dentition. Gross discrepancy cases are treated at several ages, often
too dependent on the time the problem is first observed. The
protocol and rationale described here relate to the early treatment
of gross discrepancy cases (i.e., during the mixed dentition).
Treatment in adolescence is discussed in Chapter 16; in adulthood,
in Chapter 17.
Gross discrepancy problems have been erroneously termed
"serial extractions" in the American literature. Concepts of serial
extraction were developed first by Kjellgren in Sweden and Hotz
in Switzerland who used the term to embrace all planned sequential
extractions of any teeth in order to take advantage of eruption and
natural drifting. Thus, serial extraction truly includes space
supervision, as well as gross discrepancy therapy. The original use
of the term serial extraction is thus preferred to the more restrictive
North American usage.
Table 15-2 data establish clearly how different gross
discrepancy problems are from those of space maintenance and
space regaining. The difference between space supervision cases
and gross discrepancy problems is largely one of strategy. In space
supervision, the goal is to squeeze all permanent teeth into what
obviously is minimal space. In the gross discrepancy problem, it
is accepted at the start that insufficient space is available and
therefore extraction of permanent teeth is ultimately necessary.
Those skilled in space management can obviate the need for some
FIG 15-25.
Protocol for flush terminal plane supervision. A, the developing flush
terminal plane. 8, the typical incisal configuration at the start of
treatment. C, the first step-removal of the mandibular primary cus-
pids and tipping of the maxillary first molar distally. D, the results in
the mandibular arch of the first step. E, the second step-removal
of the first primary molar and slicing of the mesial surface of the
second primary molar. Note that by this time there is some improve-
ment in the first permanent molar relationship. F, the results in the
mandibular denture of removal of the first primary molar and slicing
and contouring of the second primary molar. G, the third step-
placing the lingual archwire and removal of the second primary man-
dibular molars. By this time, the first permanent molars often have
a Class I molar relationship. H, the results of the third step while
awaiting the eruption of the second bicuspid.
Early Treatment 373
gross discrepancy cases, but many problems defy the best mixed
dentition treatment irrespective of the appliance used.
(a) Diagnosis.-A most meticulous Mixed Dentition Analysis
is necessary (see Chapter 11); however, it must be remembered
that the skeletal pattern has a significant effect on the alignment
of teeth within the dental arch. The discussion herein assumes a
balanced facial skeleton. A Mixed Dentition Analysis provides
insufficient evidence on which to base a Class 11 mal occlusion
treatment plan. One must also study the facial skeleton to determine
how the orthodontic treatment will correct or camouflage the skel-
etal dysplasia and to quantify what effects the comprehensive or-
thodontic therapy will have on the available space.68 Tooth
movements undertaken to overcome a Class 11 skeletal dysplasia
ordinarily shorten the arch perimeter signifiCantly.
(b) General Rules.-No one undertakes the extraction of per-
manent teeth casually. 53.41 Nor should dentists extract permanent
teeth as a part of orthodontic therapy unless they have the technical
skills to correct all the sequelae of those extractions. Extraction
itself provides space, only some of which may be absorbed by
spontaneous alignment of crowded teeth. The remaining space
closure is critical to success. Therefore, most cases in which per-
manent teeth are extracted require comprehensive precision ap-
pliance therapy to close the remaining spaces, to parallel the roots,
to establish the occlusal plane, and to correct the intercuspation.
A few general rules for less experienced clinicians provide
insurance against involvement in unwanted complications. The
following were suggested by Eisner. The more a case deviates
from them the more comprehensive is the mechanotherapy required
to complete the case. When a case satisfies the requirements of
all the rules, it may be treated by the protocol that follows with
a reasonable chance for success and a minimum chance of trouble.
• Rule J: There must be a Class I molar relationship
bilaterally.
• Rule 2: The facial skeleton must be balanced anteroposter-
iorly, vertically, and mediolaterally.
• R.ule 3: The discrepancy must be at least 5 mm in all four
quadrants.
• Rule 4: The dental midlines must coincide.
• Rule 5: There must be neither an open bite nor a deep bite.
Only a few discrepancy cases will meet all the requirements
of these rules, and the more a case··deviates from them the more
difficult it will be to treat.
,.(c) Treatment Protocol.;;- These procedures involve the planned
sequ~fitial removal of primary and p,ermanent teeth to alleviate the
major dental aspects of the malocclusion seen in some gross dis-
crepancy problems. Treatment may be started when the mandibular
first bicuspid has at least a portion of its root forming (Fig 15-
28,A). The first active step in treatment is the removal of the
mandibular first primary molar, which is executed when approx-
imately one-third of the root of the mandibular first bicuspid has
formed (Fig 15-28,B). As soon as the mandibular first bicuspids
are seen erupting into the extraction site, the maxillary first primary
molar may be removed (Fig 15-28,C). Delaying the extraction of
 A
Pulienl 'a l"I'I \{,'
MIXED DENTITION ANALYSIS

Dote _ Address _ Porent _

FIG 15-26.
Riaht
Space supervision with an end-to-end molar relationship. A, the Mixed
Space left after
Dentition Analysis. Note that there is scarcely enough room to align alignment of 2 and I
the incisors and no available space is predicted for molar adjustment. Pred icted size of
B, the casts at the start of treatment. Note that the patient's right 3+4+5
side showed a Class 11molar relationship whereas on the left the Space left for
molar adjustment
molars tend toward Class I. Because the midlines do not coincide,
it usually is found in such cases of disparate molar relationship in Lower
the mixed dentition that such patients have an end-to-end molar
3+4+5
relationship molar
when a functional
alignment of 2 and Iwax bite record is taken. C, the Sved
adjustment
Space left ofter
Space
1.0
,S
Predictedleft size
for of
-
~C'I'
J.J.
'-:. Q
S' -~:.S'
'"'1'"
,HS
plate was used to tip the maxillary molars distally during typical serial
extractions of the primary teeth in the mandible. (Continued).

Remarks: Overjet. 3. S" """"" Overbile· L/ . .:( ~ .

Molar

~aN~~~~M.
relationship' ~ It ¥.d..:.lQ~ ~ r W~
,q.NI..A - "ti -.t-vJ.. ~ .R~ ~.

374
 .'

FIG 15-26 (cont.).

0, later, after the third step in treatment. Note that
all mandibular teeth have erupted well ahead of the
maxillary, as was planned. Now both molar rela-
tionships tend toward Class I. Further, there is just
barely enough room to align all the mandibular teeth,
so none of the molar correction has Been achieved
by a late mesial shift. E, after complete eruption of
all the cuspids, bicuspids, and molars.

375
376 Treatment

.'

FIG 15-27. ,_.~.

Space supervision in Class 11. A, the developing distal step. B, the casts treatment. (Continued).
 Early Treatment 377

FIG 15-27 (cont.).

e, after 1 year of treatment. An Activator appliance was used to hold successfully. To ensure that the Activator did not jeopardize the
the mandible arch perimeter, aid in correcting the open bite, and integrity of the mandibular arch perimeter, treatment was changed
optimize mandibular growth. Note that a Class I molar relationship to extra-oral traction, which served to restrain the Class II growth of
has been achieved and the space situation is better, although the the midface and hold the maxillary arch perimeter during eruption of
open bit is not yet corrected completely. D, views obtained after the the cuspids. Note that the maxillary second primary molar has been
mandibular cuspids had all erupted and the open bite had closed sliced to allow the first bicuspid to drop into occlusion. (Continued).
378 Treatment

FtB
61

FIG 15-27 (cont.).

E, casts of the patients after eruption of the second permanent molars
and after the retention period was over. F, 20 years after activ.~
treatment. Note maintenance of the postetior occlusion but relapse
of the incisal correction ...
 Early Treatment 379

FIG 15-28.
One protocol for serial extraction of primary and permanent teeth in
cases of gross discrepancy. A, at the start of treatment. Note the
Class I molar relationship and the beginning of root development of
the cuspid and the first bicuspid. 8, the first step-removal of the
lower first primary molar. C, the second step-removal of the upper
first primary molar. 0, the results of steps 1 and 2. Note that the first
bicuspid erupts quickly, ahead of the cuspid. As it does so, its root
develops and the alveolar process is completely formed in the region.
This alveolar development provides bone into which the cuspids may
naturally move distally. E, the third step-removal of the mandibular
first bicuspid. This tooth is removed after it has erupted into the
mouth, delaying the extraction until intra-oral eruption permits the
formation of normal alveolar height in the region. F, the fourth step-
removal of the maxillary first bicuspid. G, the results of steps 3 and
4. The permanent cuspids now move distally into the extraction site
readily, since there is sufficient bone for them. As they erupt and
drift distally, they often upright themselves, although it is always
necessary to bracket them in order to close the spaces and make
the roots perpendicular. H, schematic presentation of the results of
the serial extraction procedures. One hopes the teeth will look like
this at the time of bracket placement.
380 Treatment
FIG 15-29.
Oblique cephalograms showing the excellent vertical position of the
cuspids that can be achieved by careful timing of serial extraction
the maxillary first primary molar guarantees the earlier arrival of
the mandibular first bicuspid, allowing the mandibular arch to
progress ahead of the upper (Fig 15-28,D). When the mandibular
first bicuspid has erupted to its approximate clinical crown height,
it may be extracted. It is not advisable to extract the bicuspid
earlier, since the eruption of the bicuspid forms alveolar bone in
the area into which the cuspid eventually will move. To enucleate
the first bicuspid is to delay the natural distal drifting of the cuspid,
since the alveolar process will resorb and new alveolar bone will
not appear until the cuspid is in position to erupt. 73 Paradoxically,
FIG 15-30.
(Legend appears on facing page.)
procedures.
waiting for the eruption of the first bicuspid before it is extracted
actually hastens the treatment (Fig 15-28,E). In similar fashion,
when the maxillary first bicuspid has erupted to full height, it may
be extracted (Fig 15-28,F). The results of the preceding steps are
shown in Figure 15-28,G. Usually, the alignment of the incisors
improves spontaneously and the cuspid eruption is delayed slightly
but, as the cuspid erupts, its root often is in a surprisingly good
vertical position (Fig 15-29). Indeed, one of the primary reasons
for treatment of gross discrepancy problems in the mixed dentition
is to ease difficulties in cuspid positioning, a significant problem
'"'
 Early Treatment 381

MIXED DENTITION ANALYSIS

Oot~ Address _ Parent _

~" r\:HJTII

3+4+5
allonment
molar
Space
of 2 and I
odjustment
left ofter Pred icted
Space left size
for of
"3. PIf
Iq.
-~. Co '7. I3
-)3,
Jq, 'I

Lower

Rlaht Left

:rt:~~~~:t OfQf~e~ndI 11· 1.1.

Pred icted size of
3+4"1"5 J.3. ~
Space left for
molar adjustment -s-.~ - 4·7
3, q
r ,.
Overbite =
Remark" Overjet' 4.8,.,.........

Molar relationship z ~

FIG 15-30.
A, records of a patient treated by serial extraction. B, serial radio- of Dr. William Northway). c-I, gross discrepancy treated in the mixed
,
graphs of the patient shown in A (JS refers to patient data; courtesy d~n!ition. C, the Mixed Dentition Analysis. (Continued.)

in later treatment. The amount of space closure that will be required
after the incisors and cuspids are in position is, of course, deter-
mined by the extent of the original discrepancy.
Only rarely does one encounter a case in which the discrep-
ancy in each quadrant is exactly the same as the width of the tooth
extracted in that quadrant. Some natural spontaneous space closure
can be obtained by slicing the proximal surfaces of the second
primary molars, but only small amounts of spontaneous closure
ordinarily occur without tipping of the teeth, loss of parallelism
of the roots, and loss of vertical dimension. Hence, there is a need
for precise control of the teeth during the finishing stages of treat-
ment of a gross discrepancy problem. Figure 15-30 illustrates
cases treated by the protocol just described.
A.variety of protocols for planned extractions of primary and
permanent teeth in early treatment of gross discrepancies have
been reported in the literature. 68 That presented here is one of the
most common and frequently used. Other sequences involve serial
removal of combinations of first and second premolars, .all second
premolars,26 or a lower premolar and upper second permanent
molar, according to the demands of the case. The removal of all
382 Treatment

,.

FIG 15-30 (cont,).

D and E, intra-oral views at the start of treatment. F and G, intra-
oral photographs after removal of the bands. H, facial profile at the
start of treatment. I, profile at the end of treatment.

four second permanent molars in discrepancy cases has recently

been enthusiastically revived and advocated but is not recom-
mended as a routine treatment for gross discrepancy problems.
Second molar extraction is an old strategy with specific util-
ity.35.37.52The procedure has special problems which are discussed
in Chapter 16, since the removal of second permanent molars,
when indicated, is part of adolescent gross discrepancy treatment.
It must be noted that there is a quite different response of maxillary
third molars to second molar extractions than there is for mandib-
ular third molars.24. 34.65.75 Mandibular third molars rarely attain
satisfactory positions after second molar extractions without an
additional period of necessary bracketed appliance therapy several
years after the extractions (Fig 15-31).

(d) Precautions.-It must be borne in mind that discrepancy
cases are the most frequent ones in orthodontics in which extraction
of permanent teeth plays a routine therapeutic role. When the
diagnosis suggests removal of teeth, extraction alone does not solve
all the problems of treatment at once. It provides space in the arch,
but extraction cases usually require extensive movements of teeth
and precision appliancing to complete a perfect result. Unfortu-
FIG 15-31.
Typical effect of extraction of second molars. A, before orthodontic
treatment; patient was 13 years, 2 months of age. B, after treatment;
patient was 17 years, 5 months of age. C, patient at 18 years, 11
months of age. These studies show an unusually good response,
yet note the inperfect position of the mandibular third molars. Ordi-
narily, another period of orthodontic treatment is required. (Courtesy
of Dr. George Eastman.)

FIG 15-32.
Premature eruption of the second bicuspids resulting from early loss
of the second primary molars during root development of the bicus-
pids. Had these molars been lost before the start of root development,
nately, one can remove only a whole tooth in each quadrant and
far too often the clinician removes approximately 7 mm of space
to permit alignment, which absorbs only a fraction of the space
created. Some consider it good clinical judgment never to extract
unless an appreciable percentage of the width of the bicuspid is
needed for alignment in each quadrant.
Many cases tempt one to extract asymmetrically yet attempt
to absorb the space provided on both sides of the arch. It is a
sound policy to avoid extraction---or to extract bilaterally except
in the presence of malocclusions that are distinctly unilateral.
Dentists who have mastered the manipulation of a precision
multibracketed appliance have distinct advantages when treating
extraction cases, for they can, by their technical skills, more sat-
isfactorily close the spaces and consolidate the arch without cre- .
ating traumatic occlusion and possible periodontal problems.
Dentists who have only removable appliances in their armamen-
tarium must necessarily adopt more conservative attitudes toward
the extraction of the permanent teeth.
FIG 15-33.
Idiopathic failure of teeth to erupt.
Early Treatment 383
eruption of the second bicuspids might have been delayed, rather
than hastened.
There is entirely too much loose wntmg on the subject of
extractions. Such cases should not be undertaken unless the dentist
is prepared to give each case the study and careful attention it
demands. 14 There are not as many places for compromise in or-
thodontic therapy as we might desire. Unfortunately, the gross
discrepancy problem is one of those uncompromising situations,
for there is simply no easy way to deal with the problem of large
teeth. One either leaves them in place or treats the problem com-
prehensively. Any other course of action is likely to leave the
mouth in worse shape than it was at the start. The gross discrepancy
problem is a common one in practice, and there is no one safe
practical approach that universally guarantees easy success in treat-
ment.39 Early diagnosis makes it possible to treat the case at an
optimal time. It is good policy never to begin the treatment of a
gross discrepancy case unless you are prepared to follow it through
to a final result.
b) Difficulties in Eruption
1) Alterations in Sequence of Eruption.-Certain variations
in the order of eruption of the teeth have been shown to be symp-
tomatic of certain malocclusions (see Chapters 6 and 7).55 It also
is true that the normal sequence of eruption provides the best
chance for maintaining the arch perimeter intact. Class II cases
often show upper molars erupting ahead of the corresponding lower
molars. A serious problem occurs in difficult space management
situations when the second permanent molar erupts ahead of any
cuspids or bicuspids. If noted early, a holding arch will prevent
premature shortening of the arch perimeter. If noted only after a
loss of arch perimeter, use of extra-oral traction or a lip bumper
may be necessary to recover the loss.
(a) Premature Eruption of Individual Teeth.-Permanent teeth
may erupt unusually early if the primary predecessor has lost a
considerable amount of bone from around its roots. Periapical
lesions may result in eafly loss of the primary tooth, extensive
bon~'resorption, and increased circulation in the region. All of
these conditions hasten the arrival of the permanent tooth (Fig 15-
32).
When a tooth arrives so early as to have insufficient root
length to maintain itself in position, instruct the patient to avoid,
temporarily, eating tough, chewy foods and take steps to stabilize
the tooth. A bracketed appliance, if used, should be made with
great care lest the tooth be inadvertently extracted. An easier method
employs composite which is placed in all embrasures after acid-
etching the enamel of !,he problem tooth and adjacent teeth. Such
384 Treatment

FIG 15-34.
A and B, radiographs of a patient treated orthodontically to elevate molar permitted caries on the mesial root on the first permanent
a mandibular second premolar whose normal eruption was impeded molar and the orthodontist's heroic efforts to move the bicuspid oc-
by the retention of an ankylosed second primary molar. The first clusally did not cause normal bony attachment to the denuded mesial
bicuspid and the ankylosed second primary were extracted, and surface of the first molar. (Courtesy of Dr. Gloria Kerry, periodontist
orthodontic forces moved the second bicuspid up to the plane of who treated the sequelae of this procedure).
occlusion. Note, however, that the prolonged retention of the primary
"

FIG 15-35.
A case of ectopically erupting maxillary first permanent molars. This molars, and the Class 11relationship of the permanent molars. B,
case is a bit atypical, since ectopic eruption of maxillary first per- left, occlusal view of the maxillary case; right, side view to show the
manent molars often is an indication of a shortage of space in the tipping of the maxillary first molar and an anterior crossbite.
arch. A, note the undermining of the distal surface of the second (Continued).
primary molars, the tipped position of the maxillary first permanent

splinting cannot be left in position very long. Check the growth
of the root and alveolar bone by taking serial radiographs, and
remove the plastic when increased root growth assures stability.
(b) Delayed Eruption of Individual Teeth~-Individual teeth
may be delayed in eruption because of retarded tooth development,
idiopathic failure to erupt (Fig 15-33), obstructions occlusally (Fig
15-34), or premature loss of the primary predecessor. When a
primary tooth is removed prior to the initiation of root formation
of the permanent successor, and hence the start of its eruption,
bone may reform atop the permanent .tooth before eruptive move-
ments can begin; thus, eruption actually is delayed by the pre-
mature loss of the primary tooth. The critical factor is the amount
of. root formation of the permanent tooth at the time of loss of its
predecessor. 17.22
The mandibular second bicuspid is the tooth most likely to
develop in a manner disharmonious with adjacent teeth, and thus
its eruptive development must be watched more carefully (see
Chapter 11). Unduly retained primary second molars or their root
fragments may be obstructive impediments to eruption.
Idiopathic failure to erupt is also seen and may be difficult
to diagnose. It is usually tediously difficult to treat (see Fig 15-
33). All such cases in delayed eruption must, of course, be dif-
ferentiated from ankylosed permanent teeth.
2) Ectopic Eruption of Teeth.- The word "ectopia" and
its adjective "ectopic" are terms sometimes misused in dentistry.
FIG 15-35 (cont.).
C, results of carving the second primary molars off the work casts
to reproduce the mesial anatomy of the first permanent molars. D,
left, the completed space-regain er, which has been made on the
prepared cast shown in C, right, the same appliance after the saddle
Early Treatment 385
Ectopia means out of the normal position, or misplaced. It means
this and nothing more. Wrong therapy sometimes is advocated
simply because the incorrect use of a word leads to incorrect ideas
concerning treatment. Any tooth may be in ectopia during eruption,
although some are more frequently so than others. Only those teeth
in which ectopic eruptions most often are a clinical problem will
be dealt with here.
(a) Maxillary First Permanent Molar.- The following, In
combination, usually account for the abnormality. 6. 12.51
• The teeth in ectopia are significantly larger than normal.
• The maxillary first permanent molar is erupting at an ab-
normal angle, indicating that the tooth germ probably was
abnormally placed.
• The maxillary length (depth) is shorter, and tuberosity
growth may lag significantly.
• The morphology of the distal surface of the maxillary sec-
ond primary molar and of the mesial surface of the maxil-.
lary first permanent molar are ideally suited for locking of
the latter tooth during its eruption.
In the typical case, the erupting maxillary first permanent
molar is tipped mesially to engage closely the distal surface of the
primary second molar and becomes caught at the cervix of the
primary tooth. Destruction of the primary tooth crown may proceed
unless the permanent tooth becomes freed (Fig 15-35,A). Ectopia
areas have been sliced to permit activation. E, the treatment result.
The appliance can now be worn as a space-maintainer simply by
filling the cracks with self-curing acrylic resin. Note the spontaneous
correction of the incisor crossbite.
386 Treatment
of the maxillary first permanent molar frequently is bilateral. When
it is unilateral, excessive tooth width is not as important an etiologic
factor <\sthe misplacement of the developing tooth germ.
Treatment consists of the following:
• Separating wire procedure:
a) The first consideration is preservation of the length of the
arch. The fate of the second primary molar crown is not as im-
portant as the fate of the space that the primary crown occupies.
As the permanent tooth erupts ectopically, it can quickly shorten
the amount of space into which the cuspid and bicuspids must
erupt.
. b) Do not slice the distal surface of the second primary molar.
Such slicing will allow the first permanent molar to erupt, but the
tooth will tip even farther out of position. Malocclusion will always
result, for the slicing will guarantee insufficient room for the cuspid
and bicuspids.
c) Insert brass separating wire between the second primary
and the first permanent molar as the first step in treatment. Tighten
the wire every few days, forcing the permanent tooth distally.
Later, you may have to use a doubled separating wire. When the
permanent molar is freed, it will erupt to normal position. Re-
member that a second primary molar that has been damaged, as
it usually is in this situation, is more likely to be lost early. There-
fore, there is still a chance for the arch length to shorten when the
primary molars are lost.
If the separating wire procedure fails to dislodge the per-
manent molar or if you are unable to insert a separating wire,
follow these steps. Figure 15-35,A-E shows the steps in treatment
of a typical case by this method.
• Alternative procedure:
a) On the maxillary work cast remove the second primary
molar, carving the plaster to simulate the mesial surface of the
first permanent molar (Fig 15-35,C).
b) Construct an acrylic appliance of the split-saddle type,
allowing the plastic to fit into the carved portion of the cast so
that it may meet snugly the mesial surface of the first permanent
molar as that tooth is freed (Fig 15-35,0) ..
c) Extract both maxillary second primary molars and insert
the appliance after having split it with a separating disk. The
appliance must be placed at once following the extractions, as one
would insert an immediate denture.
d) At subsequent appointments, adjust the springs until the
desired amount of regaining is obtained (Fig 15-35,E).
e) When the regaining is cOlIlpleted, fill the crack in the
appliance with quick-curing acrylic resin.
The plate now may be worn as a space-maintainer adjusting
it to permit eruption of the cuspid and bicuspids. Details of con-
struction and adjustment of this appliance are given in Chapter 18.
(b) Maxillary Cuspids.-Maxillary cuspids may develop ec-
topically, in which case they may become impacted. 70 (See Section
0-4-b-4, Impaction of Teeth). Cuspids also are forced into ectopic
eruption when there is insufficient space in the arch (see Section
0-4-a, Space Management).
(c) Mandibular Incisors.-Only rarely are the mandibular
incisors in ectopic eruption, although the lateral incisor frequently
is thought to be. When an incisor in the lower arch is or seems
to be in ectopia, the condition is most likely caused by the pro-
longed retention of a primary predecessor or excessively large
permanent teeth. Mandibular lateral incisors normally erupt lin-
gually to their final position. However, they soon are moved into
the line of arch by the tongue unless there is insufficient room for
them.
(d) Other Teeth.-Although any tooth may erupt ectopically
due to local causes, the most serious ectopias are those in which
the tooth germ itself forms ectopically.
When planning treatment, always keep in mind three objec-
tives: (I) placement of the tooth in its normal position; (2) retention
of a favorable sequence of eruption; and (3) maintenance of arch
perimeter.
3) Transpositions of Teeth.- Transposition of teeth, a rare.
but clinically difficult developmental anomaly, almost invariably
involves the permanent cuspid.40 Transpositions may occur in either
jaw and may be unilateral or bilateral. In the maxilla, three times
as many transpositions are reported with the first bicuspid as with
the lateral incisor. Almost all mandibular transpositions are with
the lateral incisor.
4R
(a) Etiology.-The causes of all transpositions have not yet
been fully explained, although retained primary cuspids are the
best documented single etiologic factor. 58 This is a significant
practical point since the timing of primary cuspid removal is critical
to several aspects of mixed dentition treatment, for example space
management (see Section 0-4-a). The eruptive path of the max-
illary permanent cuspid is more variable than that of any other
tooth and it is more frequently impacted. The relationships between
impaction and transposition are not to be overlooked (see Section
0-4-b-4, Impaction of Teeth). The roots of retained primary cus-
pids may deflect permanent cuspids to impactions or transposi-
tions. It is also possible that there may be an actual transposition
of the anlage of the teeth. There is no evidence of sexual or racial
5R
differences in transposition of cuspids.
(b) Diagnosis.-Oiagnosis consists of two steps (I) identi-
fication and (2) classification into complete or incomplete trans-
position. Incomplete transpositions display crown misplacement
only; complete transpositions involve the whple tooth. Incomplete
transpositions left unattended may develop into complete, or nearly
complete, transpositions. Radiographs taken at several angulations
and, 'Careful palpation oLttre roots are essential to diagnosis and
treatment planning. Do not delay, a diagnosis and concomitant
treatment plan for these cases. If uncertain about either the di-
agnosis or how to proceed, refer at once to an orthodontist, for
development worsens some incomplete transpositional problems.
(c) Treatment.-Early recognition makes possible a change
in the eruptive path of the permanent cuspid by removal of the
retained primary tooth, opening space in the arch, surgical un-
covering of the transposed permanent tooth, and its orthodontic
placement into position."

FIG 15-36.
Transposed maxillary cuspid and first bicuspid.
When the cuspid is completely transposed, either from the
start or neglect of the case, treatment to correct arch positions is
far more difficult. 60 Leaving the teeth transposed is then sometimes
a prudent alternative. However, all teeth must still be positioned
well, and occlusal equilibration and shaping of crowns for esthetics
is required. Individual conditions determine whether to treat to the
normal or transposed positions (Fig 15-36).31
4) Impaction of Teeth.-Impactions are teeth so closely
lodged in the alveolar bone they are unable to erupt. Unfortunate
common misusage applies the term to any tooth that does not
erupt.
Although there are hereditary patterns leading to impacted
teeth, the etiologic factors of most concern are malposed tooth
germs, prolonged retention of primary teeth, localized pathologic
lesions, and shortening of the length of the arch.
Any tooth can be impacted, but the teeth involved most fre-
quently are the mandibular third molar, maxillary cuspid, maxillary
third molar, mandibular and maxillary second bicuspids, and max-
illary central incisor, in that order. The cause varies greatly with
the tooth. Thus, mandibular third molar impactions are said to be
due largely to evolutionary changes whereas those of the mandib-
ular second bicuspids usually are the result of space closure.
(a) Diagnosis.-Impaction is diagnosed most frequently and
easily when a tooth is long delayed in erupting, yet every effort
should be made to make a diagnosis at an earlier date. For this
FIG 15-37.
A, a maxillary cuspid impacted but not ectopic. B, maxillary cuspid both impacted and ectopic.
Early Treatment 387
purpose, routine early radiographs are invaluable. Impacted teeth
mayor may not be in ectopia (Fig 15-37): maxillary cuspids, for
example, frequently are; mandibular second bicuspids seldom are.
It is important to observe in each case whether the impacted tooth
is also misplaced.
(b) Mandibular Third Molars.-The clinical implications of
third molar development and incisal crowding are discussed more
thoroughly in Chapter 16, since adolescence is the age at which
their prophylactic removal has been advocated. 32. 38.45 Two im-
portant questions are as yet incompletely answered: (I) does the
eruption of lower third molars cause incisal crowding? and (2)
how does one predict the eruptive positioning of lower third mo-
lars? Although eruption of this tooth often is indicted as a primary
cause of anterior crowding, one should remember that, even if its
eruption is a factor, it cannot exert any effect until the patient is
about 15 to 16 years of age. Most problems in crowding appear
before this time. See Chapters 6 and 7 for discussions of current
views on the role of mandibular third molars in"incisor alignment.
Several methods for predicting the final position of a lower
third molar from study of an earlier relationship have been ad-
vanced. Such an analysis, if accurate, would be very useful. Un-
fortunately, no method so far has been proven sufficiently valid,
when tested on serial growth data, to recommend it for routine
clinical use. Figure 15-38 illustrates the problems. The present
methods, some of which are most ingenious, do not account suf-
ficiently for several critical factors, for example, mandibular
morphology.
(c) Maxillary Cuspids.- This tooth may be simply impacted,
as sometimes happens when the primary cuspid fails to resorb, or
it may be impacted ectopically.
When the case is a simple impaction, follow these steps:
a) Measure the space available for the tooth. If insufficient,
space must be gained as the first step in treatment. The size of
the impacted tooth may be learned by measuring the cuspid on the
opposite side of the arch or estimated by using the average width
when the other teeth are average in size.
b) Uncover the impacted tooth. Remove the primary tooth,
if present, and carefully expose the crown of the permanent cuspid.
The tendency is to uncover the cuspid crown insufficiently. 5. 10.71
To the portion of the crown exposed to the oral cavity a bracket
388 Treatment
FIG 15-38.
Variability in the developmental position of third molars. A, favorable development. 8, unfavorable development.
or eyelet may be bonded and used to connect the tooth by elastic
chain or steel ligatures to a labial archwire.9.59 Later, the bracket
usually must be repositioned.
Occasionally, the oral surgeon can selectively remove bone
and gently reposition the impacted tooth, stabilizing it with surgical
cement. 33 Several months of treatment time may be saved when
this surgical repositioning is possible.20 Figure 15-39 illustrates
cuspid impaction treatment.
In recent years the advantages of autogenous transplantation
of impacted maxillary cuspids has been appreciated and the surgical
techniques have been perfected principally through the work of
lames Moss43 and other clinicians in the United Kingdom. A brief
discussion of this will be found in Chapter 16 since, though the
transplantation can be undertaken at any age, it is more applicable
at adolescence when full-bracketed orthodontic therapy is
undertaken.
(d) Mandibular and Maxillary Second Bicuspids.-The im-
paction of these teeth is largely a matter of loss of arch perimeter.
They will erupt spontaneously only if the molars are moved distally
before the root length of the bicuspids is too advanced. After their
roots are formed, they will no longer erupt spontaneously and
traction must be applied. Figure 15-34 shows the problems that
may arise when a primary molar is retained too long and an im-
pacted lower bicuspid is brought to the occlusion after vertical
alveolar development is mostly completed.
(e) Second Molars.-Mandibular second molars may be im-
pacted or severely malposed; their repositioning at the earliest
opportunity is usually advantageous. Study carefully the position
of the crowns of the lower second molar in all cases as soon as
possible and monitor its developmental changes carefully during
treatment. When it is badly malposed, it may worsen when anterior
teeth are extracted. It may be caught under the crown of the first
molar and become more firmly locked in place if that tooth is
uprighted or moved distally in mixed dentition space management.
Usually second molar impactions may be freed rather easily if
treatment is begun early (i.e. while active root development is
under way). Special wire separating springs are sometimes used,
but we usually prefer to insert a wire into a buccal tube on the
first molar imbedding the distal extension in a mass of composite
placed on any convenient surface. After the crown is somewhat
uprighted and erupted, a compressed coil spring may be placed
between the first and second molars (Fig ]';;-40). (Figure 16-5
shows the treatment methods and results of the case shown in
Figure] 5-40.)
-.
"
--#,".
if) Other Teeth.-When other teeth are impacted, the follow-
ing principles should be held in mind when planning treatment:
remove interferences to eruption before root formation is com-
pleted, hold sufficient space in the arch, and bring appliance forces
to bear in a gentle manner.
5) Ankylosed Primary Teeth.-Occasionally, a primary
molar fails to maintain itself at the level of occlusion (Fig 15-
41). This condition has been erroneously called "submergence."
 Early Treatment 389

FIG 15-39.
Orthodontic treatment of impacted maxillary cuspids.

FIG 15-40.
Impaction of second molars. (See also Fig 16-5.) A, radiographs in
the early mixed dentition. B, the same patient at age 14 years, 2
months.
390 Treatment

FIG 15-41. ,
Ankylosed mandibular primary molars. A, typical examples. B, serial illustration there is no evidence of ankylosis. No appliance therapy
intra-oral radiographs. Note the progressive loss of occlusal height was used, only the carefully timed removal of the primary molars to
in the mandibular second molar region. All the other teeth grow coincide with the rapidly developing eruptive period of their successor
vertically, but the ankylosed second primary molar cannot. C, serial teeth.
casts of a patient with eight ankylosed primary molars. In the top
 Early Treatment 391

Great variations are seen, and although many are of no practical

significance, it is not unusual to see a primary molar buried beneath
the cervix of adjacent teeth and partially covered by soft tissue.
Investigators believe that most "submerged" teeth are anky losed
to the alveolar process. Treatment is planned a's if all such primary
molars were ankylosed. When a primary molar becomes anky-
losed, there is a localized arrest of eruption and alveolar growth,
adjacent teeth then proceed to greater occlusal heights. At times,
first permanent molars tip mesially over the crowns of ankylosed
second primary molars.
In treatment, four possibilities must be avoided: (l) loss of
the length of the arch; (2) extrusion of teeth in the opposite arch;
(3) interference with the eruption of succeeding permanent teeth;
apd (4) inhibition and permanent reduction of vertical alveolar
bone development. Judicious use of space-maintainers and re-
gainers is advisable. Never permit the presence of an ankylosed
tooth to jeopardize the length of the arch. Should opposing teeth
begin to extrude, the ankylosed tooth may be built up with com-
posite resin to restore its occlusal height until it is time for it to
be extracted. Some ankylosed primary molars cause no harm ex-
cept possible eventual interference with the eruption of their suc-
cessors-which may be avoided by timely extraction of the
ankylosed teeth. Ankylosed primary molars may be left in place FIG 15-43.
until the proper time for the eruption of the teeth beneath them. A-F, example of dental crossbite treatment combined with space
Extraction of each ankylosed primary molar is timed to coincide supervision. (Courtesy of Dr. William Northway.)
with the early stages of acceleration in eruption (see Chapter 6)
as is done in space supervision (see Section D-4-a-4). Indeed;
with careful supervision, ankylosed primary molars may serve as
6) Ankylosed Permanent Teeth.-First molars are the per-
excellent maintainers of the length of the arch. Figure 15-41, B
manent teeth most apt to become ankylosed. When an ankylosed
shows an interesting series of casts of a case with all primary permanent molar is retained into adulthood, the effects can be
molars ankylosed. Each ankylosed primary molar was extracted
devastating, since local vertical alveolar growth has been inhibited.
on a schedule permitting a normal sequence of eruption of the
Two courses of action are available: (I) loosening and repositioning
permanent successors.
the tooth with forceps; and (2) extraction. Routine success with
the loosening method should not be expected even when the tooth
is retained by a complete orthodontic appliance. Still, one should
first try loosening the tooth for the alternative, extraction, creates
a major treatment problem. Figure 15-42 illustrates some of the
problems of ankylosed permanent molars.

5. Lateral Malrelationships of Dental Arches

Failure of the two dental arches to occlude normally in lateral

relationship, known as lateral or posterior crossbite, may be due
to localized problems of tooth position or alveolar growth, or to
gross disharmony between maxilla and mandible. It may involve
one or more teeth in the lateral segments, and it may be unilateral
or bilateral (Fig 15-43). Regardless of the cause or the severity
of,the malocclusion, some neuromuscular adjustment of the man-
dible must occur to provide satisfactory function. Crossbites may
originate in the dentition and alveolar process, the craniofacial
skeleton, the temporomandibular musculature, or combinations of
any of these (see Chapter 7). The importance of lateral mal reIa-
tionships in the etiology of some temporomandibular disorders
must not be overloaded.

FIG 15-42. a) Differential Diagnosis

Ankylosis of permanent molars. Views of monozygotic twins, one The principal concern of the examiner is to localize precisely
with (A) and one without (B) an anklyosed permanent molar. where the primary aberration lies. Is it confined to the maxilla?
192 Treatment
.1andible? Both? Does it involve only the alveolar process or is
t a gross discrepancy in the "fit" of one jaw to the other? Is it
lnilateral malpositioning of teeth or bilateral contraction of the
ntire dental arch? Occlusal dysfunction and temporomandibular
ymptoms often accompany early crossbite, so thorough exami-
lation of the joints and their function is indicated (see Chapters 7
nd 10).
1) Dental Malrelationships.-Dental crossbite involves only
he localized tipping of a tooth or teeth (see Fig 15-43) initially
ausing little effect on the size or shape of the basal bone. Muscular
ldjustments must be made to provide an adequate accommodative
lcelusion. The midlines coincide when the jaws are apart and
liverge as the te<;th come into occlusion. Some of the teeth in
Tossbite will not be centered buccolingually in the alveolar pro-
:ess; therefore, the most important single diagnostic point is to
ocalize asymmetry of the dentoalveolar arch.
2) Muscular or Functional Malrelationships.-"Muscular
Tossbites" display functional adjustment to tooth interferences.
[hey are similar to the dental cross bites except that muscular
idjustment is more significant than mal positioning of teeth (Fig
5-44)27 A functional analysis of the occlusal relationship pro-
'ides both the differential diagnosis and identification of interfering
eeth (see Chapter 11). There is no clear-cut differentiation between
he dental and muscular types of crossbite except, perhaps, the
reatment. In one (dental), teeth must be moved; in the other
muscular), the occlusal adjustments can be gained by equilibra-
ion, which permits reflex changes in mandibular positioning (see
:hapter 18). The pure muscular type is seen most often in young
:hildren. Both dental and muscular types require occlusal and
nuscular adjustments to complete their correction. Although many
nuscular crossbites are corrected solely with occlusal equilibra-
ion, it is insufficient for some. For these, a lingual archwire
=IG 15-44.
\ functional or muscular type of cross bite of the primary dentition.
~, intra-oral view. e, the casts before (above) and after (below)
designed for expansion (e.g., the Quad Helix archwire) is indicated
(see Chapter 18). Figure 15-45 illustrates a case of functional
crossbite treated by a combination of dentoalveolar expansion and
equilibration.
3) Osseous or Skeletal Dysplasia (Skeletal Crossbite).-
Aberrations in bony growth and/or morphology may give rise to
crossbites in two ways: (1) asymmetric growth of the maxilla or
mandible; and (2) lack of agreement in the basic widths of the
maxilla and mandible (Figs 15-46 and 15-47).
Asymmetric growth of the maxilla or mandible may be the
result of inherited growth patterns, trauma which impedes the
normal growth on the affected side, or a long-standing functional
mandibular displacement. Crossbites due to asymmetric bony growth
are most difficult to treat, particularly when the condition has
advanced untended for many years. The teeth are moved to provide
the best possible occlusion in the circumstances, the maxilla is
made wider by a palatal separating appliance, or, in extreme cas~s,
orthognathic surgery is necessary at a later date.
Lack of harmony between the maxillary and mandibular widths
usually is due to a bilaterally contracted maxilla. In such cases,
the muscles shift the mandible to one side to acquire sufficient
occlusal contact for mastication (see Fig 15-46). For this reason,
cross bites associated with skeletal dysplasia can be expected to
have associated signs and symptoms of temporomandibular
dysfunction.
A more severe condition is that in which the mandibular
denture occludes completely within the maxillary arch (see Fig
15-47). When this mediolateral problem is combined with a skel- F
etal Class 11 malocclusion, it produced one of the most severe of ~
all malocclusions (Fig 15-48). In mandibular hypertrophy and
prognathism, the mandible is excessively 'wide for 'the maxilla as
well as unduly long; therefore, a mediolateral occlusal problem
exists in addition to the Class III malocclusion.
occlusal equilibration.
 Early Treatment 393

FIG 15-45.
A crossbite of the primary dentition treated by equilibration and the use of a Porter ("w"- shaped) lingual appliance.

FIG 15-46.
Maxillary dental arch contraction producing a functional crossbite. A, that the contraction is bilateral. a, the usual occlusal position, which
the cast placed so that the midlines are together, thus demonstrating seems to portray a unilateral crossbite.
394 Treatment

FIG 15-47 .
..
Osseous disharmony between the mandible and the maxilla, pro-
ducing a typical bilateral skeletal-type crossbite. Often, in such cases,
the mandibular teeth occlude completely inside the maxillary teeth.

FIG 15-48.
(Legend appears on facing page.)
 Early Treatment 395

.'

FIG 15-48.
Case of severe mediolateral osseous dysplasia in conjunction with
mandibular insufficiency. This boy was first seen for neuromuscular
analysis when he was 2 years old. tie could eat nothing but "pappy"
baby food and had not learned to chew. The }esults of the first phase
of therapy, with an Activator, are shown in A-C (left, before; right,
after). Note that although.there is now bilateral occlusal function, a
severe Class I1 relationship remains. At this time, he could chew
adequately. D, the original lateral tephalogram. E, cephalogram of
patient at 9 years of age after first stage of orthodontic therapy with
Activator. F, cephalogram of patient at 19 years, 0 months of age
when all skeletal measurements were well within normal range for
his age and sex.
396 Treatment
FIG 15-49.
Method of using dividers to measure from the medium raphe to estimate asymmetries of the dental arch.
Study carefully the closure pattern of the mandible, noting at
which stage of closure lateral deviations occur. When the lateral
shifting occurs late in closure, it usually is the result of a tooth
interference (see Chapter 10).
If the deviation of the midlines of the lower and upper face
increases throughout opening, the primary fault is likely to be
skeletal asymmetry. In cases of bilaterally symmetric dental arches
in each jaw with one arch grossly wider than the other, the patient
may demonstrate several different closure paths and several ~c-
clusal relationships. Place the mandible so that the midlines of the
upper and lower face coincide. Many patients who show a crossbite
on one side only will thus exhibit bilateral dental arch contrac'tions
(see Fig 15-46). One also may use a set of dividers on the dental
cast for more precise localization of the asymmetrically placed
teeth (Fig 15-49). A symmetrograph is also useful for analysis of
crossbite (see Chapter 11). A posteroanterior cephalogra~ is a
necessity in all but the most obvious and simple of the muscular
and dental types of posterior crossbite. A cephalometric method
for localizing skeletal and dental asymmetries is described in Chap-
ter 12.
FIG 15-50.
Diagram of through-the-bite elastics.
b) Treatment
There is sound clinical research to support the earliest possible
treatment of all posterior crossbites. (See Suggested Readings.)
1) Dental Crossbite (Individual Teeth).-(a) Case Analy-
sis.-Rarely is one tooth alone tipped. In most cases, its antagonist
in the opposite arch is out of position also. Thus, the maxillary
first molar may be tipped lingually and the mandibular first molar
is tipped slightly buccally, so both teeth must be moved.
Always measure the amount of space into which the tooth is
to be moved. Many individually malposed teeth are wider than
the space for them in the arch. If such is the case, that space must
be increased before the crossbite can be corrected.
(b) Appliances.-Simpl~ through-the-biteela~tics (Fig 15-
50) are sometimes effective formolars in crossbite when both teeth
are out of position and there is adequate space' for them: If the
problem is largely a matter of tipping a single tooth rather than
reciprocal tipping of two teeth, an acrylic plate with auxiliary
spring· will serve well. Lingual archwires with recurved auxiliary
springs also are satisfactory in some cases. 13 On occasion, a labial
archwire is the most efficient.
2) Dentoalveolar Contraction and/or Crossbite.-Cross-
bites in this category usually involve several posterior teeth (see
Fig 15-46).
·(a) Case Analysis.-It is important to learn how much of the
cond.it!on is due to actual dehtoalveolar contraction and how much
to muse'ular adaptive positioning of the mandible (see Chapter 10).
The more it is a matter of the mandible adopting a new position
of closure for more efficient functioning, the better the prognosis. 30
If the midline.s ar:.~together when the pl!tient occludes in his
or her accustomed position, there usually is very little muscular
adaptation, and the case is purely one of narrowing of the maxillary
alveolar arch (see Chapter 8).
If the mJdlines are not together when the patient occludes in
his or her accustomed position, some functional adaptation prob-
ably has taken place.

FIG 15-51.
A-F, use of the Quad Helix appliance for the correction of a cross bite in the early mixed dentition.
(b) Appliances.-After locating any tooth interferences when
the midlines coincide, remove by grinding those interferences in-
volving primary teeth (see Chapter 18). In such cases, the primary
cuspids are likely to be the offenders. Do not hesitate to grind
contacting inclined planes on these teeth so that, as they meet, the
mandible will tend to return to its normal position (see Fig 15-
44,B). When only the primary dentition is present, sometimes one'
can correct minor problems by occlusal adjustment alone.
• Bilateral contraction of the maxillary arch.-For this con-
dition, the Quad Helix lingual arch wire or Rapid Palatal
Expander are excellent (see Chapter 18). Although these
appliances may widen the osseous base, they may also
move teeth and remodel the alveolar processes. Figure 15-
51 illustrates a case of this type.
• Unilateral contraction of the maxillary arch.- True unilat-
eral contraction seldom is seen, which is fortunate, for it is
more difficult to treat than when reciprocal action may be
used. Gross unilateral maxillary development problems
may be very difficult. The Quad Helix lingual wire may be
adjusted for unilateral arch expansion.
• Mandibular dentoalveolar contraction.-Unilateral contrac-
tion in the mandible is rare. Bilateral narrowing caused by
lingual tipping of teeth is well handled by a Quad Helix
1 lingual archwire (see Chapter 18).
3) Gross Disharmony Between Osseous Bases.-(a) Case
Analysis.- These cases are of two {ypes: those in which the maxilla
is relatively narrow and those with excessive maxillary width and/or
mandibular narrowness. In either the basic problem may be com-
plicated by a skeletal Class II or Class III morphology. Sometimes
the cast analysis alone makes obvious where the primary problem
lies, but a posteroanterior cephalogram is still a necessity. If a
Class 11 is present, it is important to complete the Class 11 ce-
phalometric analysis to localize the anteroposterior dysplasia. Often
the treatment of the mediolaterat osseous disharmony' is but the
first step in a complicated treatment of skeletal Class 11. Whatever
Early Treatment 397
"
the condition, early analysis and treatment is advantageous, since
this condition is more difficult to handle when growth is largely
complete. A functional wax bite aids in both the cast and ce-
phalometric analysis (see Chapters 10-12). Careful cephalometric
evaluation of the intermaxillary space in the mandibular postural
position is revealing, for the correction utilizes vertical develop-
ment of the alveolar processes.
(b) Appliances. - When the problem is mediolateral maxillary
insufficiency, the appliance of choice is the palate splitting device
(see Chapter 18 for design). The Quad Helix appliance may be
used in milder cases but it is more difficult to avoid excessive
tooth tipping with it in severe cases. Figure 15-52 illustrates a
case of maxillary narrownes~ in which the patient was treated at
an early age with a palate splitting device. Figure 15-48 illustrates
a case of marked mandibular insufficiency treated with ~ conven-
tional activator because a Class 11 correction also was required.
The improved anteroposterior relationship aided the mediolateral
problem, and the vertical development of the alveolar processes
was guided and controlled by the appliance. A Bionator or Acti-
vator with a built-in expansion screw (see Chapter 18) is favored
by some. The primary goal, however, is usually not expansion of
the mandibular basal bone, which is impossible, but the utilization
of vertical alveolar development to widen the mandibular den-
toalveolar arch diameter and to curtail width increases in the maxilla.
FIG 15-52.
Rapid palatal expansion treatment in the early mixed dentition.
 398 Treatment
6. Class 11 (Distocclusion, Postnormal Occlusion)
The term "Class n"* is an unfortunate generalization which
groups together mal occlusions of widely varying morphologies
often having but one common trait, their abnormal molar rela-
tionship. Angle can be easily forgiven, for as-his classification
system was devised prior to the invention of cepljalometry and
detailed knowledge of growth of the craniofacial skeleton. The
Angle classification was a significant advance in orthodontics, but
its continual simplistic misuse is unfortunate, particularly after the
introduction of cephalometrics and the appreciation and delineation
of a wide variety of types within "Class n."
Class n is a common severe malocclusion. When combined
with serious space management problems, it becomes a most dif-
ficijlt malocclusion to treat well. In Class n, secondary features
of the malocclusion-that is, aspects other than the molar rela-
tionship and anteroposterior skeletal dysplasia-are important to
the treatment plan. Vertical skeletal dysplasia, muscle dysfunc-
tions, and space for alignment of teeth are frequent complicating
factors in Class n.
A vast literature on the diagnosis and treatment of Class II
malocclusion presents many strategies of treatment, numerous ap-
pliances, and quite differing opinions about this malocclusion. The
following pages constitute only a brief outline and are not intended
in any way to suggest that all Class n mal occlusions should be
treated routinely in general practice. However, as Class II is the
most common severe malocclusion, every dentist must have a
correct understanding and perspective of it whether the patients
are treated or referred.
a) Differential Diagnosis
1) Skeletal Morphology.-Because of the immense varia-
bility within Class n, it is illogical to treat all cases alike. Dif-
ferential diagnosis is the basis for differential treatment. Therefore,
diagnosis includes identification of the discriminating Class n fea-
tures of the individual case to be treated. A cephalometric analysis
is a necessity when diagnosing and planning treatment of Class II
malocclusions, and it should provide localization and identification
of the anatomic regions at fault to suggest individualized treatment
prescriptions. The cephalometric methods described in Chapter 12
help locate the site(s) which contribute to the total malocclusion
and aid in the classification of each case into a horizontal and
vertical type.
Typically, the variant skeletal characteristics are found in one
or more of the following:
* The term "Class 11" will be used here in only the most
general sense (see Chapter 10, Classification and Terminology of Mal-
occlusion). Unfortunately, there is as yet no standard method of identi-
fying and classifying the types of Class 11malocclusion except for
Angle's Divisions I and 2, which are inadequate. The types described
in Chapter 12 and later in Sections a, Differential Diagnosis, and e,
Planning Differential Early Treatment of Class 11Malocclusions, are
based on epidemiologic studies of a large sample of malocclusions des-
ignated by the orthodontists who treated them as "Class II." (See
Moyers, Riolo, and Guire, Suggested Readings.) Procedures for dis-
crimination of the several horizontal and vertical types in this class are
described in Chapter 12. Differential treatment procedures based on ty-
pal differences of older patients are given in Chapters 16 and 17.
a) Maxillomandibular relationship anteroposteriorly. The
profile is typically retrognathic or convex due to mandibular re-
trognathism, midface protrusion, or both;
b) The cranial base. Increased length in the anterior cranial
base contributes to midface protrusion, whereas increased obtusity
of the cranial base angle or lengthening of the posterior cranial
base will tend to position the temporomandibular articulation more
retrusively;
c) Vertical dysplasia. Anterior face height or critical portions
of anterior face height often may be disharmonious with analogous
posterior face heights. These disproportions may appear as ab-
normal positions of the palatal, occlusal, and mandibular lines.
2) Dental and Occlusal Malpositions.- The dental aspects
of Class n largely are adaptations to the skeletal and muscular
pattern, although they may exist alone sufficiently exaggerated to
produce Class n dental relationships in a balanced facial skeleton.
The dental features must be studied in the cephal~gram (see Chap-
ter 12), and the dental casts (see Chapter 11), as well as in the
patient. Occlusal line malrelationships and vertical dentoalveolar
abnormalities often are adaptations to the total skeletal dysplasia.
• Incisors.-The upper and/or lower incisors may be tipped
labially off their boney bases (see Fig 15-58). Labiover-
sion of incisors is particularly evident when the posterior
face height is less than the anterior face height, producing
a steep occlusal line. When the anterior and posterior verti-
cal heights are balanced and the midface is normal, the
maxillary incisors are more likely to be normally inclined.
Excessive overjet is a feature of some Class n types as is
excessive depth of bite. The gross deviations in incisor re-
lationships often result in the loss of functional incisal
stops, permitting the incisors to erupt past the functional
occlusal line.
• Molars.-Mesial displacement of maxillary molars is a
common finding in Class II (see Fig IS-56). Upper molars
tip, rotate, and translate during mesial drifting, which con-
tribute to an increase in the depth of bite. The more the
maxillary posterior teeth have drifted mesially, the easier it
may be to correct the overbite relationship by "derotat-
ing," distal tipping, and distal placement of the molars.
Study the lateral cephalogram and maxillary cast carefully
in order to identify the details of mesial positioning of
maxillary posterior teeth.
• Cuspids.-The angulation and position of cuspids is a re-
vealing feature of Class n diagnosis. Correlate the angula-
tion of the maxillary cuspid with possible mesial drifting of
the molars and the angulation of the cuspids in both arches
" .with the space analysis. "
• 'Occlusalline.-The Functiot}al Occlusal Lin~ is an impor-
tant reflection of the vertical skeletal features of the Class
n type. Anteriorly, the failure of the incisors to form oc-
clusal stops at the level of the Functional Occlusal Line
often betrays the role of the tongue and lip in aggravating
the incisal features of the malocclusion (see Fig IS-58).
3) Arch Form.-In Class n, the maxillary arch is more likely
 Early Treatment 399

to be narrow and elongated and thus disharmonious with the man-

dibular arch form (see Fig 15-56). Since coordination of the arches
is an early and important part of Class II treatment, identification
of arch form disharmonies is essential.

4) Neuromuscular ("Functional") Features.- The neu-

romuscular features seen at diagnosis often seem to be largely
adaptive to the skeleton and tooth positions typical of Class II
malocclusion (Fig 15-56). But one must not discount too quickly
the possible role of the neuromusculature itself in producing and
maintaining the malocclusion (recall Chapter 7). The establishment
of normal muscular function at the earliest possible time is a
primary goal of all early treatment. Lip positions imposed by the
fa~ial skeleton may cause increased labioversion of the maxillary
incisors and/or lingual tipping of the mandibular incisors. In other
instances, both upper and lower incisors are tipped off their bases.
Since the lips and tongue must effect an anterior seal during swal-
lowing and in the production of certain speech sounds, their efforts
to do so in the presence of a skeletal dysplasia often result in some
aggravation of the incisal relationships.
A functional mandibular retraction is a common feature of
Class II malocclusion in the primary and mixed dentitions. Though
seen less often in the completed permanent dentition, it'is a com- FIG 15-54.
mon finding in adolescent and adult patients with temporoman- Schematic drawing of response to functional jaw orthopedic treat-
dibular difficulties. Therefore, all patients with Class 11 ment. (Courtesy of Professor van der Linden.)
malocclusions must be examined especially carefully for tempo-
romandibular symptoms and dysfunction. Other common neuro- .
muscular factors which may accompany the Class 11 state are
b) General Strategies for Class Il Treatment
mouth-breathing and abnormal tongue activities. Carefully study
Strategy is planning: in this instance, planning how to cope
Chapter 5, Maturation of the Orofacial Musculature, and Chapter
with a Class 11 malocclusion. If one's perceptions of Class II are
10, Analysis of the Orofacial Musculature, to understand and iden-
incorrect or incomplete, it affects how one plans treatment. Also,
tify the neuromuscular features of Class 11.
if one has limited tactical resources and/or mastery of but one or
two appliances useful in Class II treatment, then one is handicapped
in planning therapy and able to treat only those malocclusions or
those aspects of a mal occlusion in which a particular appliance
does well. Since there are many complicated aspects to Class 11
malocclusion, a variety of clinical strategies have been developed.
through the years.
Some of the strategies listed are more appropriate for some
Class 11 types than others. The time at which Class 11 treatment
is begun is critical, and the strategies which can be employed
depend on the age of the patient.

1) DifferentiaI~estraint
,/
and Control of Skeletal Growth.-
The use of extra-oral traction to inhibit maxillary development is
a frequent method of treatment of some types of Class 11 maloc-
clusions (Fig 15-53).
, /
• 2) Differential Promotion of Skeletal Growth.-Some types
within Class 11are characterized by mandibular insufficiency. Cli-
nicians employ functional appliances to improve or promote man-
dibular growth, affecting the size and shape of the mandible (Fig
IS-54).

3) Guidance of Eruption and Alveolar Development.-

FIG 15-53. Malpositions of pennanent teeth may be the result of skeletal
Schematic drawing depicting response to treatment of Class 11mal- dysplasia, or the teeth may have been guided into malpositionsby
occlusion by extra-oral traction. (Courtesy of Professor van der Linden.) the abnormal functioning of lips and tongue. During eruptive de-
400 Treatment
velopment the alveolar process must adapt to the skeletal dysplasia
which characterizes Class H, often resulting in greater alveolar
height anteriorly than posteriorly, narrowed maxillary alveolar
arches, and other effects. The clinician may prevent excessive
alveolar maldevelopment by guiding the erupt~on of the teeth and
purposely controlling alveolar growth, and the permanent teeth
often can be guided to better positions during eruption than they
would have achieved untended.
4) Movement of Teeth and Alveolar Processes.-Lay per-
sons often equate orthodontics with tooth movements. Dentists
know that one does not move teeth through the bone, but that the
roots of the teeth provide handles by which one can control and
direct alveolar morphology (see Chapter 13). One of the most
common strategies of orthodontic treatment is that of moving teeth
to reshape the alveolar processes and provide better occlusion.
Such tooth movements and alveolar changes are also used to cam-
ouflage serious skeletal dysplasias, particularly when skeletal growth
is largely completed .
5) Translation of Parts During Growth.-lt is possible
during growth to change physically the relationship of skeletal
parts. A common procedure illustrates this point. Because a narrow
maxilla is frequently found in Class H malocclusions, it is possible
to use palate-widening devices which physically separate the mid-
palatal suture, moving the halves of the maxilla apart. The space
created at the midline of the maxilla fills in with bone, and max-
illary and mandibular growth then proceeds more normally than
it otherwise would have done (see Fig 15-52 and Chapter 18).
6) Training of Muscles.-Abnorrnal muscle function is a
frequent and important aspect of the Class H malocclusion and is
often a prominent etiologic factor in its development. One of the
primary purposes of functional appliances is to alter the reflex
activities of the facial and jaw muscles. Myotherapy is often em-
ployed, adjunctively, in Class H treatment.
7) Surgical Translation of Parts.-On occasion the skeletal
dysplasia is so severe that orthodontic treatmen! alone cannot cor-
rect the problem, and orthognathic surgery is then employed in
conjunction with orthodontic treatment. Such surgical procedures
are usually carried out in adulthood after growth is mostly com-
pleted (see Chapter 17).
Because control of unfavorable growth is a prominent feature
of Class Il strategy, it is obvious that the methods employed for
early treatment are different than those used during adolescence,
when skeletal growth is waning, and adulthood, when growth is
most over.
c) Tactics for Class II Therapy
Strategy is planning; tactics involve management and exe-
cution. In orthodontic treatment, tactics means the use of ortho-
dontic appliances, although this term also includes removal of
etiologic factors and myotherapy.
1) Functional Appliances (Functional Jaw Orthopedic Ap-
pliances).-Functional appliances an~ employed to alter the neu-
romuscular environment of the developing dentition aJjd masticatory
muscles. They are also used to disarticulate teeth, to promote
mandibular growth, guide the ,eruption of the permanent teeth,
control alveolar development, etc.
2) Orthopedic Devices.-In orthodontic usage the word
"orthopedic" conveys the idea of physically promoting changes
in shape or position of the craniofacial skeleton.
(a) Extra-oral Traction to the Dentition.-Extra-oral forces
may be applied to control the position of the maxillary dentition,
to restrain maxillary corpus growth forward, or to move the max-
illary teeth distally. Similar extra-oral traction appliances are some-
times employed to move mandibular teeth as well.
(b) Extra-oral Traction to the Chin.-Extra-oral forces
are applied vertically by means of a chin cup to diminish anterior
face height, a frequent feature of Class H malocclusion (vertical
type I).
.'
(c) Palatal Widening.-Palatal-widening appliances are used
to translate physically the maxillary halves in order to improve
their positions and thus affect subsequent growth.
3) Bracketed Appliances.-Banded and bracketed ortho-
dontic appliances are commonly used to improve the positions of
teeth and to reshape the alveolar processes.
4) Muscle Training.-Myotherapy is a common adjunctive
treatment tactic in Class 11 therapy. It should not be forgotten that
functional appliances are efficient providers of myotherapy.
5) Surgery.-Orthognathic surgery offers immediate trans-
lation of parts of the severely dysgnathic craniofacial skeleton.
Orthognathic surgical procedures have become highly developed
and are an important part of orthodontic treatment for severe skel-
etal Class 11 problems, but their use is primarily limited to adult-
hood (Chapter 17).
d) Rationale for Early Class II Treatment
1) Skeletal Morphology.- The primary goal of early Class
11 skeletal treatment is to achieve a m\'1re favorable skeletal mor-
phology prior to the complete eruption of the permanent dentition.
Therapy aims at restraint of midface growth, ,promotion of man-
dibular growth, widening of the maxilla, control of dentoalveolar:
adaptation, or planned combinations of these strategies. The ap-
proach should be based_.more on the particular details of the pa-
tient's own skeletal morPhology than the appliance. As a rule, the
more severe the skeletal dysplaSia, the more advantageous is early
treatment. The vertical skeletal aspects of Class H, difficult to
compensate for with tooth movements alone in adolescence, are
improved in earlier years by controlling the basal skeletal growth
and by differential management of the alveolar processes and oc-
clusal plane.
Since there are distinct sexual differences in the onset of the
pubescent growth spurt and in the cessation of craniofacial growth
(see Chapter 4), the rationale for skeletal Class H therapy varies

with the sex: that is, girls generally ought to be treated earlier, in
which case results are achieved sooner. Obversely, the tendency
for craniofacial growth in men to continue past the second decade
of life is a complicating factor irrespective of the time treatment
was begun. Logic and the clinical research evidence now available
support the use of early skeletal Class II treatment, since achieving
a balanced skeletal profile prior to the eruption of most permanent
teeth minimizes tooth movements, is less taxing to anchorage,
diminishes actual treatment time, and reduces some kinds of re-
lapse tendencies.
2) Dental and Occlusal Aspects.- The first of the dental
aims of early Class II treatment is to obtain normal molar and
incisal relationships and establish normal occlusal function prior
to the eruption of the cuspids, premolars, and second permanent
molars (see Fig 15-56). If these aims are achieved in concert with
skeletal correction, the arrival of the remaining teeth usually results
in good occlusal function and an occlusal plane better related to
the profile. Early reduction of excessive labioversion of incisors
not only creates functional incisal stops, helping to control the
occlusal plane, but also reduces the chances of their accidental
fracture and improves esthetics and lip function.
In Class II there often is disharmony between the upper and
lower arch forms. Accordingly, a second dental aim is widening
the maxillary arch form, thereby aiding incisal retraction, im-
proving occlusal function, and easing anteroposterior skeletal cor-
rection and improving occlusal relations.
Distinct sexual differences in the eruption of teeth and in the
amount of space available for alignment of teeth (see Chapter 6)
necessitate more critical early planning of treatment for girls.
Exact protocols for early treatment of the dental features of
Class II malocclusion vary greatly but include the following points
differentially according to skeletal typal features: (\) distal rota-
tion, tipping, and movement of the maxillary molars to correct the
Class 11 molar relationship, a procedure that may open the bite
and lengthen the maxillary arch perimeter; (2) restraint of the
maxillary dentition while the midface grows forward, thus chang-
ing the relative position of the maxillary dentition to its base; (3)
retraction and intrusion of maxillary incisors reducing the den-
toalveolar protrusion, producing normal incisor function, and im-
proving lip and tongue movements; and (4) control of the mandibular
arch perimeter and fitting of the mandibular incisors to the skeletal
profile, Functional Occlusal Plane, and maxillary incisors. Note
that protocols 1-3 involve quite different treatment tactics than
the midface orthopedics necessary for some skeletal Class 11types,
though these may be undertaken simultaneously.
3) Neuromuscular Features.-Early treatment of the neu-
romuscular aspects of Class 11 malo~clusion is undertaken to es-
tablish a normal neuromuscular environment that will aid function
and growth and neither aggravate nor distort the unfolding skeletal
pattern (see Fig 15-57). Such therapy often consists of control of
deleterious habits and treatment of the skeletal and dental features
in order that normal neuromuscular function can obtain. Some-
times, in the primary dentition, the neuromuscular pattern is the
dominant Class II theme, for example, nasorespiratory or airway
problems, faulty posture, or deleterious sucking habits. The aims
for treating the neuromuscular features ?f Class \I in the mixed
Early Treatment 401
dentition are similar; however, the permanent molars and incisors
must be corrected, as a Class II muscle pattern already controls
them (see Fig 15-57). In Class 11 malocclusions without severe
skeletal features, correction of the dental symptoms alone may
restore near-normal function of the muscles. In other cases, pri-
marily those with a severe skeletal pattern, it is much harder to
achieve adaptation and conditioning of the muscles, and myo-
therapy must be part of the mechanotherapy and continued through-
out the retention period. This point underlies the rationale for the
use of functional jaw orthopedic appliances in some cases, for
these appliances aid in skeletal, dental, and neuromuscular cor-
rection simultaneously.
The establishment of normal muscular function at the earliest
possible age is one of the most important steps in treatment of
Class II malocclusions.
.'
e) Plllnning Differential Early Treatment of Class Il
Most Class 11 mal occlusions are first seen by one's family
dentist, who may prefer not to get involved in extensive or com-
plicated Class 11treatment. This brief outline of Class II treatment
is provided to give a general background and an understanding of
the principles involved. It will aid in (I) the recognition and group-
ing of cases according to their significant differences, (2) referral
as soon as the problem is recognized, (3) explanations to the parents
and patients, and (4) cooperation with a colleague who might be
treating the case. It is also intended to be of benefit in the selection
of cases for treatment and in the recognition of the more difficult
problems which may be referred.
In the United States of America there has been an enthusiastic
interest in Class II treatment by general dentists in recent years,
a healthy development. Unfortunately, this new enthusiasm has
been prompted largely by the promotion of appliances often with-
out sufficient accompanying teaching of diagnosis and craniofacial
growth. Inadequate training in craniofacial growth and orthodontic
diagnosis in dental school leaves many at a disadvantage when
evaluating the claims and promises of zealots.
Orthodontists will appreciate the sketchiness of the discussion
which follows. It makes no pretense of depth or detail and is
intended only as a brief, but correct, orientation on standard clinical
practice for the correction of Class 11malocclusion. It is intended
primarily as an orderly introduction to the various concepts and
strategies employed in treatment of Class 11.
We define clinical Class \I types* for several reasons:
a) To group cases with similar needs for ease in planning .
. b) To locate the site(~).of skeletal imbalance.
'0 To estimate the effects of growth on the present imbalanced
form. (Growth alone does not correct Class II; it often exacerbates
the problem.)
cl) To determine the best treatment for the special needs of a
particular case. Many treatments may get by, but which is best?
*The cephalometric methods by which Class II types are
identified are presented in Chapter 12 and should be studied closely for
the understanding of this section.
402 Treatment

I
TOTAL SPACE AVAILABLE .'
Maxilla: Mandible:
Right Left

~ e~h
Right

e:
Arch
Lengths
~
Segments
Left

mm
mm
mm
Vd b
Arch Segments

Lengths,.
a' ------------11 .••
c

mm
h:
g:f'
Total:

~.
T:tat. ;. ~~~ ::

TOTAL SPACE REQUIRED

FIG 15-55. ('J.9
A-I, treatment of a Class 11type A malocclusion by extra-oral traction MAXILLA MANDIBLE
and space supervision. (Courtesy of Dr. William Northway.) Incisor widths
(measured) ____ mm. ~mm.

width of cuspids
and bicuspids
(predicted) ~ mm. ~mm.

needed to achieve
Class I occlusion so+ s: 0 ~mm.
of molars (estimated) + mm.

right left
Estimated possibilities of maxilla: s: 0 mm~O_mm
increasing space available mandible:~_mm ~. 0 mm
S9.S-III.Q; G.!. S'(~)
"

1) Treatment of Horizontal Type A.-In Horizontal Type

A malocclusion there is maxillary dental protraction with a normal
skeletal profile (Fig 15-55) .
(a) Basic Strategy.-The basic strategy in treatment is to
retract the maxillary dentition to a normal molar and incisal re-
lationship without altering the favorable skeletal relationship, dis-
placing the mandibular dental arch, or disturbing the vertical
dimensions.
(b) Suggested Tactics.-
• Rotate, tip, and translate the upper first permanent molars
without extrusion, using extra-oral traction to a face bow
fitted to first molar bands. The angulation of the outer bow
and direction of the pull are determined by the steepness of
the occlusal line.
• Retract (tip .and translate) the upper incisors, intruding as .I
necessary. Place brackets on permanent incisors only . •

/

• Fit the angulation and position of the maxillary incisors to
the skeletal profile.
• Establish compatible upper and lower arch forms.
• Retain with conventional Hawley retainers.
(c) Common Problems or Complieations.-Only mild Ver-
tical Type I or Type 2 features are ordinarily seen with horizontal
type A. More severe vertical features complicate the picture and
require different treatment.
Mandibular space management problems (se~ Section 4-a)
are treated on their own schedule.
2) Treatment of Horizontal Type F.-The characteristics
ofthis type are mild skeletal Class II features accompanying Class
II dental relationships (Fig 15-56).
(a) Basic Strategy.-Determine from the cephalometric anal-
ysis which of the four syndromal types (B, C, D, or E) the case
most nearly resembles. Every horizontal type F is a mild version
of either type B, C, D, or E. The vertical types are similar but
milder too. Treat according to the tactics of the type.
(b) Suggested Taeties.- There are no tactics special for Type
F; in fact, success may come with the use of any standard method
for correction of Class II malocclusions. The best results are ob-
tained when the tactics are those of the related syndromal type
(see below).
(c) Common Problems or Complieations.-Superposed space
management problems are the most common difficulties. A gross
space discrepancy greatly complicates matters requiring diphasic
treatment (i.e., bands and brackets at a later age though the skeleton
is corrected early).
(d) Variations.-The variations seen are those of the syn-
dromal types B, C, D, and E, but in milder form.
(e) Retention.-Retention is determined as "itis for the related
syndromal type.
3) Treatment of Horizontal Type B.-Type B character-
istics are maxillary prognathism and midface protrusion, accom-
panied by a normal mandible (Fig 15-57).
a) Basic strategies.-The basic strategies in treatment are:
• To reduce dento-alveolar protrusion, if present.
• To produce orthopedic midface changes altering the maxil-
la's position relative to the mandible and the anterior cra-
nial base.
b) Suggested Taeties.-Extra-oral traction to produce max-
illary skeletal change is indicated for Type B patients, but mere
distal movement of maxillary teeth is insufficient. Functional jaw
orthopedic appliances are contraindicated. If the incisors are well
placed, the Cetlin or Sved appliance may be used advantageously
Early Treatment 403
in conjunction witb extraoral traction. If the maxillary incisors are
flared and tipped labially, they should be retracted first. Often the
mandibular arch is normal and the occlusal plane is flat. Under
these circumstances little treatment may be necessary in the lower
arch.
(c) Common Problems or Complieations.-
• If the maxillary arch is narrowed, a preliminary phase of
treatment involving maxillary expansion is necessary prior
to the start of extra-oral traction·.
• If there is an enhanced Curve of Spee, the upper arch must
be leveled and the maxillary incisors placed in ideal posi-
tions (i .e., retracted and angulated properly prior to insti-
tuting extraoral traction). It is also necessary to band the
lower molars and place brackets on the lower incisors, lev-
eling and intruding the lower arch. These two steps control
the overbite and overjet.
• Like all other Class II malocclusions, those in Horizontal
type B may be complicated by difficult space management
problems. Space supervision in the lower arch may be car-"
ried out concomitantly with the Class II correction in the
maxilla. A gross discrepancy problem necessitates diphasic
treatment; that is, serial extractions may be undertaken
while extra-oral traction is correcting the mid face prognath-
ism. Later, all the teeth must be bracketed and space clo-
sure and detailed tooth positioning completed.
Type B constitutes a fairly common form of Class II and
requires specific treatment emphasizing midface orthopedics. Harm
can be done, especially in severe malocclusions, with improper
or misapplied treatment. In adolescence the need for differential
treatment is even more critical as there is less growth remaining
to be controlled (see Chapter 16).
(d) Variations.-Horizontal Type B malocclusion is most
frequently associated with Vertical Type 2, a skeletal deep bite
with flat and nearly parallel occlusal and mandibular lines. The
use of a maxillary extra-oral traction device with a flat bite plane
(like that of the Cetlin or Sved appliance) is advantageous. Some
employ <;ervical extra-oral traction assuming that the downward
pull of the neck strap will open the bite.
Vertical Types 4 and 5 are serious complications of horizontal
type B which should be identified at the very start since they are
quite complicated and difficult. Indeed, it is the author's opinion
that the relatively rare Class II Type B-4 malocclusion may be the
most difficult of all Class II problems.
(e) Retention.-In early treatment of Horizontal Type B,
"~etention" means contr.Qlling the midface growth at least until
theeompletion of the pe~manent dentition. Therefore, after the
molar relationship has become Class I and the incisor relationship
is normal, extra-oral traction may be continued and the case mon-
itored until the arrival of the second molars. Severe Class II Type
B cases, particularly in men and boys, may show persistent hor-
izontal midface growth to the end of the second decade of life.
Use of a traditional Hawley retainer under such circumstances may
be quite insufficient. It is sometimes necessary to continue noc-
turnal extra-oral traction until the cephalometric analysis gives
assurance that midface growth is over.
404 Treatment

FIG 15-56.
A-D, treatment of a Class 11type F malocclusion, (Continued.)

"
 Early Treatment 405

02
Horizontal MALE FEMALE
Measure -3 -2 -ISO. X ISO. 2 3 -3 -2 -ISO. X ISO. 2 3
Md.Pl/A-B 80 85
Pol PI./A-B

SE-FMN-A
SNA 70 90
I I

SE-N-A 70 90
--- 1

I
Ba-Se-B 65 801- 85
I I
~a-Se-Gn t60
SNB .JL
-------1 70

"

lIF.O.P.
l/Md PI

ES

03 CLASS II PLOT, HORIZONTAL

Skeletal Class O?

Nandiblll
IMlrognolhic .~

Mandibular 1116'"
ProcumlHtnl

MO.lillory",'h +1- +,-

P'OCumb,nl

5 0 , 1 0 0 5 5 8 1211 332227 6 " 28

F[F[FeFeFcFCFoFo AAA A

N'697
Unclassified' 12
Incomplete Data· 25

"

FIG 15-56 (cont.).

406 Treatment

N'G9?
Unclassified' 12 _. CA 10-1
Incomplele Dolo' 25"<'
FIG 15-57.
A-L, treatment of a Class 11type B malocclusion. (Courtesy of Or.
William Northway.)

4) Treatment of Horizontal Type D.~Horizontal type 0
malocclusion is characterized by mandibular insufficiency with
maxillary dental protraction (Fig 15-58).
-
(a) Basic Strategies.-The basic strategies in treatment are
intended to promote optimal mandibular growth, to reduce max-
illary dentoalveolar protrusion and align the maxillary teeth, and
to improve lip and facial muscle function.
(b) Suggested Tactics. - Type 0, the most frequent of the
four syndromal types, lends itself well to early treatment with
functional appliance therapy (Activator, Bionator, Frankel appli-
ans;e, etc.) since abnormal neuromuscular function is a charac-
teristic feature. The mandibular lip and mentalis muscle are
hyperactive-functioning beneath the maxillary incisors during the
swallow and thus maintaining the mandibular incisors in an upright
position. A properly constructed appliance restores normal lip and
tongue function quickly while positioning the mandible ventrally
to promote its growth, and, at the same time, improve maxillary
dental features. Differential control of alveolar development levels
the occlusal plane. Arch coordination is essential.
(c) Common Problems or Complications.-When the max-
illary arch is narrowed, it should be widened prior to the placement
of the functional jaw orthopedic appliance. When the narrowness
is not severe, a modified functional appliance with its own max- .
illary widening device is sometimes sufficient. In more severe
cases a Quad Helix or palate-splitting device is used in conjunction
with bands and brackets to achieve coordination of upper and lower
arch forms prior to the beginning of functional appliance therapy.
In Vertical Type I cases in which the mandibular line and
occlusal lines are steeper than normal, great care must be taken
to prevent eruption of the maxillary molars, since this aggravates
the vertical aspects of the case and interferes with the anteropos-
terior correction. Maintaining acrylic occlusal stops for the upper
teeth and selectively grinding away the plastic to permit controlled
eruption of the lower posterior teeth results io an improved and
flatter occlusal plane.
'd) Variations.-For Vertical Type 2· cases the construction
bite may be taken with more vertical opening than for types I and
3 in order to correct the skeletal deep bite by differential growth
of ramus and alveolar process.
In Vertical Type 3 the mandibular growth is treated as for
Vertical Type I, but it is necessary to free the appliance to permit
the extrusion and retraction of the maxillary incisors, for there is
a strong tendency to open bite. The characterizing feature of Ver-
tical Type 3 is inadequate anterior upper face height, so the open
bite becomes worse as the lower face grows downward and for-
ward. Functional appliances are usually insufficient to handle the
problem alone. When Vertical Type 3 is unrecognized early or
improperly handled, it will assuredly reveal itself later.
Space management problems are treated concomitantly ac-
cording to the development of the dentition. As in all gross dis-
crepancy cases, if extractions are undertaken, bracketed appliances
are necessary later for space closure, paralleling of roots, and final
detailed esthetic placement of the incisors and cuspids.
Early Treatment 407
(e) Retention.-Retention of Type 0 malocclusions, when
treated early, consists primarily of guaranteeing that the improved
mandibular growth persists; therefore, the functional appliance
itself makes an ideal retainer. It is necessary to monitor craniofacial
growth regularly at least until the completion of the permanent
dentition (exclusive of third molars) and often even longer in boys.
4) Treatment of Horizontal Type C.-Horizontal Type C
malocclusion is characterized by mandibular insufficiency, gen-
eralized small facial dimensions, and bimaxillary dental protrusion
(i.e., both the maxilla and mandible are small and the teeth in
both arches are off their bases). Horizontal Type C is more frequent
among girls than boys.
a) Basic Strategies.- Type C Class 11 malocclusions are de-
ceptively difficult to treat. Extra-oral traction seems contraindi-
cated because of the retrognathic maxilla. Functional jaw orthopedic
appliances are difficult to use because they may challenge the
integrity of the mandi~ular dentition, which is tipped off its base.
A high percentage of Type C Class 11 mal occlusions display in-
adequate space for all the permanent teeth. Because of the extreme
labioversion of the incisors in both arches, analysis of space re-
quirements must be done with great care, accounting for fitting of
the incisors to the skeletal profile, a step which reduces each arch
perimeter. Perhaps the most important strategy in early treatment
'of Type C is that of prompting optimal mandibular growth. When
the skeletal profile has been improved, one must then reanalyze
the space requirements. Unfortunately, one is not always able to
synchronize skeletal correction and serial extraction of teeth in
Type C as well as is possible in other malocclusions. Type C is
a most difficult form of Class 11, and treatment at any age is not
to be undertaken lightly, for there is so much that is abnormal,
and so many features to control and change.
(b) Suggested Tactics.-In the early mixed dentition a func-
tional jaw appliance may be used to improve the skeletal profile
and vertical dimension. If extractions are a foregone conclusion,
they may be undertaken serially according to the schedule of den-
titional development. In borderline extraction cases, the space
requirements must be reanalyzed as the skeletal profile and vertical
dimensions improve. Do not expect Type C cases to show re-
markable improvement in space requirements with skeletal treat-
ment. Do expect a high percentage to require extractions, and all
will require bracketed appliance therapy ~ubsequent to the func-
tional jaw therapy.
" Class 11 Type C 11Jl\locclusions require a panoply of sophis-
ticited orthodontic diagnostic and technical skills for their treat-
ment. Early maltreatment may' intensify the problem, making
correction even more difficult. These are difficult cases to conclude
satisfactorily, even for the most experienced clinician.
(c) Common Problems or Complications.- The most com-
mon complication in treatment of Type C Class 11 malocclusion
is that of difficult space 'management, even after extractions. Type
C cases are difficult to treat early and even more arduous to treat
during adol~scence (see Chapter 16).
408 Treatment

Horizontol MALE FEMALE

Measure -3 -2 -IS.o. X lSD 2 3 -3 -2 -ISH X lS.o. 2 3
I I
MdPI/A-B I1 j:l I I
eo 1 85 60 85
I
Pal PL/A-B 90 95
______ 1

SE-FMN-A 85
I
SNA
SE-N-A
I
I
Ba-Se-B --L
80 I 85
I
Ba-Se-Gn
SNB lI 60
70
----I
--- !

lIFOP
l/Md PI. 65 20

FIG 15-58.
A-C, treatment of a Class 11type 0 malocclusion. (Continued.)
 Early Treatment 409

CLASS n: PLOT, HORIZONTAL

A
Skeletal Class II.'"
1

Mid-face Prognathic? 1

Mandible 1

Retragnathic .? 1

I
Mandibular teeth 1

Procumbent 1

Maxillary teeth +,- +1-\ +,-

Procumbent 1

I
1

5 0 1 429402654275766119719194711 1 00 5 5 81211 3322276 1128

E (El B+ B C+ C 0+ 0 F F F F FE FE Fe Fe FC FC Fo Fo A A A A

N=697
Unclassified = 12 LH 9-10
Incomplete Data = 25

FIG 15-58 (cont.).

410 Treatment
(d) Variations.-Vertical Type 2 appears three times as fre-
quently as Type I in Horizontal Type C malocclusion. This is in
contrast to Types D and F, in which Vertical Types and I and 2
appear with about equal frequency (see Table 12-3).
(e) Retention.-The complicated details and variations of Class
II Type C retention are many. Functional appliances are sometimes
combined with precision bracketed therapy and the appliances are
subsequently continued as retainers.
6) Treatment of Horizontal Type E.-This type is char-
acterized by maxillary prognathism and bimaxillary dentoalveolar
protrusion.
(a) Basic Strategies.-Horizontal Type E malocclusion is
most closely related to Horizontal Type B and may be thought of
as bimaxillary dentoalveolar protrusion within a Type B skeletal
pattern. North American blacks, when they display Class 11 mal-
occlusions, are more apt to show this type than any other. The
needs of the skeletal profile should dominant the choice of strat-
egies in early treatment. Extra-oral traction to control midface
growth and retract the maxillary dentition is the basic strategy;
however, the space needs of the mandible and the labioversion of
mandibular incisors greatly complicate matters. Accordingly, one
is more apt to resort to extraction in both arches in TypeE than
in Type B.
(b) Suggested Tactics.-When Horizontal Type E is treated,
extra-oral force is applied to the maxillary dentition and the maxilla
as in type B and an attempt is made to position the mandibular
incisors correctly over basal bone. When there is insufficient room
for all the teeth, the skeletal correction may be combined with
serial extraction and the case treated as if it were a Type B gross
discrepancy problem.
(c) Common Problems or Complications.-The two most
common problems in Horizontal Type E are skeletal deep bite and
bimaxillary dentoalveolar protrusion. Early treatment provides a
better chance to combat the skeletal vertical dysplasia, but exten-
sive work after all the permanent teeth are erupted may still be
necessary to position the teeth properly. One should expect, when
beginning early treatment of Type E, to have a necessary period
of bracket therapy later, for early treatment, while greatly im-
proving the skeletal aspects, certainly is not total treatment. The
lip and facial musculature often present complications in treatment
planning.
(d) Variations.-Vertical Type 5, sometimes seen, is much
more difficult to handle than Type 2.
e) Retention.-Retention problems include monitoring the
skeletal Class 11 growth pattern, maintaining the final tooth po-
sitions, and preventing the reappearance of the vertical dysplasia.
Retention is particularly difficult if maxillary growth persists, as
it sometimes does in boys, who constitute the majority of patients
within this type.
7. Class III
(Mesioclusion, Pre-normal Occlusion) and
Pseudo Class III
Three rather distinct types of malocclusion may all appear to
be mesioclusions (Fig 15-59). True Angle Class Ill, or mesio-
clusion, is a skeletal dysplasia involving mandibular hypertrophy,
marked shortening of the midface, or a combination of these two.
The pseudo-, or apparent, Class III is a positional malrelationship;
a reflex functional mandibular protraction. A third condition, sim-
ple linguoversion of one or more maxillary anterior teeth, is an
abnormal axial inclination of maxillary incisors with no real Class
III features. It will be noted that the first condition is a problem
of skeletal morphology and osseous growth, the second an acquired
muscular reflex, and the third a problem in dental positioning. In
all three conditions, the maxillary anterior teeth are back of the
mandibular, but only the first two show the mandibular molars
ahead of their normal position. Linguoversion of maxillary anterior
teeth is a Class I (neutroclusion) malocFlusion discussed later in
this chapter (see Section 9, Anterior Crossbites, ~imple). The first
two are discussed together here for clarification of the differential
diagnosis .. ~
a) Differential Diagnosis
1) Patient Examination.- The differentiation of true and
pseudomesioclusion requires a precise examination of the patient
for the following items.
(a) Profile.-Study the profile carefully for evidence of the
effects of the skeletal dysplasia on the soft tissues and facial mus-
culature. The lip relationship during occlusion and mandibular
posture is particularly revealing, for the profile improves as the
mandible drops from occlusal contact relationship to the postural
position only for the pseudo-Class III patient. Skeletal Class III
cases are more likely to have an even anteroposterior pattern of
closure. Translation of the mandible forward in pseudomesioclu-
sion can be confirmed by gently placing the fingertips over the
temporomandibular joint during .opening and closure.
(b) Molar Relationship.-Note the relative positions of the
first molars both in occlusion and in the postural position.
• True mesioclusion.-A distinct Class III relationship per-
sists in both positions.
• Pseudomesioclusion.-There is apt to'be a shift from a
Class I to a Class III relationship as the mandible closes
, (see Fig l5-61) .• ~.
Manipulate the mandible posteriorly to ascertain if it is pos-
sible to assume a more normal relationship with the maxilla. One
also should use articulation paper to locate points of occlusal con-
tact and interference. Read carefully the section on crossbites, for
pure pseudomesioclusions are in reality anterior cross bites some-
times involving maxillary narrowness plus an occlusally prompted
forward positioning of the mandible. Mild cases of skeletal Class
III may have a functional element, particularly in young children;
therefore, the cephalometric analysis is critical.
 Early Treatment 411

FIG 15-59.
Three kinds of Class Ill. A, midface deficiency, 8, mandibular prog-
nathism, C, midface deficiency and mandibular prognathism. The
values shown are maxillary skeletal and dentoalveolar length and
mandibular skeletal and dentoalveolar length (see Chapter 12, Coun-
terpart and Profile Analyses). Numbers in parentheses are appro-
priate age and sex norms. Comparisons to these norms helps localize
the primary site of the disproportion. Note the difference in the three
types when compared to the norms.

5.5. 11-2'

"

G.M, 11-8
412 Treatment
2) Cephalometric Analysis.- The purposes of the cepha-'
lometric analysis (see Chapter 12) are (I) to separate pseudo from
true Class III malocclusions, (2) to identify the specific morpho-
logic features of any skeletal dysplasia, since discriminate char-
acteristics determine the specific strategies and tactics of treatment,
and (3) to ascertain the relative importance of skeletal and func-
tional features when they are combined. The cephalometric anal-
ysis, more than any other single diagnostic procedure, aids in
determining the timing of treatment and indicates the choice of
appliances. Obtain lateral cephalograms in the usual occlusal (in-
tercuspal) and postural positions, as well as the posteroanterior
view. The cephalometric analyses referred to in this section are
described in Chapter 12.
(a) Basic Morphologic Analysis. -This screening analysis
(see Chapter 12) helps one to localize the sites of skeletal dysplasia.
If the maxillo-mandibular relationship is near normal, and all other
measures are within one standard deviation of the mean, a severe
skeletal Class III is not present. Further analysis is required if any
single measure is over one stanclard deviation in the Class III
direction or if the combination of cranial base-maxilla and cranial
base-mandible measures together show anteroposterior dysplasia.
(b) Profile Analysis, Skeletal.-The Profile Analysis (see
Chapter 12) enables one to localize skeletal and dentoalveolar
contributions to the Class III profile. Tables of growth mejlsures
are provided at the end of Chapter 12 to support the profile analysis.
They also aid in assessing the effects of growth and treatment on
the correction.
(c) Vertical Analysis.-The Vertical Analysis is often critical
in skeletal Class III since it reveals dentoalveolar adaptations to
the basic skeletal pattern. By use of the tables of vertical growth
measures at the end of Chapter 12, help is provided in assessing
the response to therapy.
3) Pseudo Class I1I.- The pseudo Class III shows normal
values for the Basic Morphologic Analysis, when one has dis-
counted the functional mandibular translation, which may be done
by taking the lateral cephalogram with the mandible withheld to
the retruded contact position by a wax bite in situ. Mildly deficient
values for the maxillary dentoalveolar unit distance may be seen
in the profile analysis, and the maxillary incisors may be more
upright than normal. The vertical analysis will be uormaL
4) Skeletal Class I1I.- There are three basic categories of
skeletal class III malocclusion: midface deficiency, mandibular
,
prognathism, and a combination of the'two (Fig 15-59).
(a) Midface Deficiency.-In the Basic Morphologic Analysis,
patients with Class III midface deficiency display a Class III max-
illo-mandibular relationship, a diminished cranial base-maxilla
value, and normal cranial base-mandibular values. The profile
analysis usually shows shortened maxillary skeletal unit and max-
illary dentoalveolar unit distances. The mandibular skeletal, unit
distance is near normal, but the mandibular dentoalveolar unit
distance may be slightly above normal. The Vertical Analysis
usually shows a normal Mandibular Line and' a near normal Oc-
c1usal Line. Face height measures are more apt to be normal with
midface deficiency than with mandibular prognathism, although
anterior upper face height and anterior maxillary height sometimes
are often mildly deficient.
(b) Mandibular Prognathism.-Patients with mandibular
prognathism show a Class III maxillo-mandibular relationship, an
excessive cranial base-mandible dimension both horizontally and
vertically, and may show a diminished cranial base angle. The
Profile Analysis reveals unit distance ratios significantly less than
1.0, because both the mandibular skeletal unit distance and man-
dibular dentoalveolar unit distance are excessive. In severe cases,
the maxillary dentoalveolar unit distance may also be excessive
as the maxillary teeth tip labially to obtain function with the man-
dibular incisors which have been carried forward by the excessive
mandibular length. The Vertical Analysis is critical in mandibular
prognathism. Anterior face height is usually excessive when com-
pared with posterior face height, and lower face height is quite
abnormal anteriorly. Mandibular prognathism is sometimes seen
without excessive anterior face height (i.e., the mandibular border
is not steeply positioned).
(c) Midface Deficiency and Mandibular Prognathism.-Some
patients show a combination of mild midface deficiency and mild
mandibular prognathism, for which treatment differs from that
required by either the pure midface deficiency or mandibular prog-
, nathism. The prognosis usually is not as poor as for the serious
mandibular prognathism.
b) General Strategies for Early Treatment
Treatment strategies for the three types of Class III maloc-
clusion are quite clear and different. For pseudo-Class Ill, one's
aim is to obtain normal dental and occlusal relationships by prompt-
ing a normal neuromuscular environment for a normally devel-
oping craniofacial skeleton. Cases of skeletal Class HI with midface
deficiency require midface orthopedic traction to promote maxil-
lary growth forward to match a more normally placed mandible.
Patients with mandibular prognathism must have the excessive
mandibular growth restrained and/or redirected. Cases combining
the features of midface deficiency and mandibular prognathism
require combined strategies.
c) Rationale for Early Treatment
lhe te~ea.tch e\l\.d\O\\~\O
\.\!. ~\\\\~ ~\~~.\ \\Q\l\\ ~\\.Q\l\\\\~\\\.~\ \\ \~
possible to alter the growth of thecraniofacjal skeleton in early
Class III conditions (see Fig 15-62). These treatment procedures
require thorough knowledge of craniofacial growth and consid-
erable.skill in manipulatini'a variety of functional and orthopedic
appliances. Current treatments are more successful and satisfying
than those done previously, and the number of patients requiring
orthognathic surgery in adulthood has been greatly diminished.
d) Tactics for Early Treatment
1) Pseudo-Class I1I.-In the early dentition, the patient
sometimes can be treated by equilibration alone (see Chapter 18)
or by the placing of an acrylic inclined plane on the mandibular
/'
412 Treatment
2) Cephalometric Analysis.- The purposes of the cepha-
lometric analysis (see Chapter 12) are (I) to separate pseudo from
true Class III malocclusions. (2) to identify the specific morpho-
logic features of any skeletal dysplasia, since discriminate char-
acteristics determine the specific strategies and tactics of treatment,
and (3) to ascertain the relative importance of skeletal and func-
tional features when they are combined. The cephalometric anal-
ysis, more than any other single diagnostic procedure, aids in
determining the timing of treatment and indicates the choice of
appliances. Obtain lateral cephalograms in the usual occlusal (in-
tercuspal) and postural positions, as well as the posteroanterior
view. The cephalometric analyses referred to in this section are
described in Chapter 12.
(a) Basic Morphologic Analysis. -This screening analysis
(see Chapter 12) helps one to localize the sites of skeletal dysplasia.
If the maxillo-mandibular relationship is near normal, and all other
measures are within one standard deviation of the mean, a severe
skeletal Class III is not present. Further analysis is required if any
single measure is over one stanoard deviation in the Class III
direction or if the combination of cranial base-maxilla and cranial
base-mandible measures together show anteroposterior dysplasia.
(b) Profile Analysis, Skeletal.- The Profile Analysis (see
Chapter 12) enables one to localize skeletal and dentoalveolar
contributions to the Class III profile. Tables of growth me)lsures
are provided at the end of Chapter 12 to support the profile analysis.
They also aid in assessing the effects of growth and treatment on
the correction.
(c) Vertical Analysis.- The Vertical Analysis is often critical
in skeletal Class III since it reveals dentoalveolar adaptations to
the basic skeletal pattern. By use of the tables of vertical growth
measures at the end of Chapter 12, help is provided in assessing
the response to therapy.
3) Pseudo Class III.- The pseudo Class III shows normal
values for the Basic Morphologic Analysis, when one has dis-
counted the functional mandibular translation, which may be done
by taking the lateral cephalogram with the mandible withheld to
the retruded contact position by a wax bite in situ. Mildly deficient
values for the maxillary dentoalveolar unit distance may be seen
in the profile analysis, and the maxillary incisors may be more
upright than normal. The vertical analysis will be normal.
4) Skeletal Class III.- There are three basic categories of
skeletal class III malocclusion: midface deficiency, mandibular
prognathism, and a combination of the two (Fig 15-59).
(a) Midface Deficiency.-In the Basic Morphologic Analysis,
patients with Class III midface deficiency display a Class III max-
illo-mandibular relationship, a diminished cranial base-maxilla
value, and normal cranial base-mandibular values. The profile
analysis usually shows shortened maxillary skeletal unit and max-
illary dentoalveolar unit distances. The. mandibular skeletal. unit
distance is near normal, but the mandibular dentoalveolar unii
distance may be slightly above normal. The Vertical Analysis
usually shows a normal Mandibular Line and a near normal Oc-
clusal Line. Face height measures are more apt to be normal with
midface deficiency than with mandibular prognathism, although
anterior upper face height and anterior maxillary height sometimes
are often mildly deficient.
(b) Mandibular Prognathism.-Patients with mandibular
prognathism show a Class III maxillo-mandibular relationship, an
excessive cranial base-mandible dimension both horizontally and
vertically, and may show a diminished cranial base angle. The
Profile Analysis reveals unit distance ratios significantly less than
1.0, because both the mandibular skeletal unit distance and man-
dibular dentoalveolar unit distance are excessive. In severe cases,
the maxillary dentoalveolar unit distance may also be excessive
as the maxillary teeth tip labially to obtain function with the man-
dibular incisors which have been carried forward by the excessive
mandibular length. The Vertical Analysis is critical in mandibular
prognathism. Anterior face height is usually excessive when com-
pared with posterior face height, and lower face height is quite
abnormal anteriorly. Mandibular prognathism is sometimes seen
without excessive anterior face height (i.e., the mandibular border
is not steeply positioned).
(c) Midface Deficiency and Mandibular Prognathism.-Some
patients show a combination of mild midface deficiency and mild
mandibular prognathism, for which treatment differs from that
required by either the pure midface deficiency or mandibular prog-
nathism. The prognosis usually is not as poor as for the serious
mandibular prognathism.
b) General Strategies for Early Treatment
Treatment strategies for the three types of Class III maloc-
clusion are quite clear and different. For pseudo-Class Ill, one's
aim is to obtain normal dental and occlusal relationships by prompt-
ing a normal neuromuscular environment for a normally devel-
oping craniofacial skeleton. Cases of skeletal Class III with midface
deficiency require midface orthopedic traction to promote maxil-
lary growth forward to match a more normally placed mandible.
Patients with mandibular prognathism must have the excessive
mandibular growth restrained and/or redirected. Cases combining
the features of midface deficiency and mandibular prognathism
require combined strategies.
c) Rationale for Early Treatment
The research evidence is quit~ clear now, showing that it is
possible to alter the growth of the craniofacial skeleton in early
Class III conditions (see Fig 15-62). These treatment procedures
require thorough knowledge of craniofacial growth and consid-
erable. skill in manipulatinfa variety of functional and orthopedic
appliarices. Current treatments are more successful and satisfying
than those done previously, and the number of patients requiring
orthognathic surgery in adulthood has been greatly diminished.
d) Tactics for Early Treatment
1) Pseudo-Class I1I.-In the early dentition, the patient
sometimes can be treated by equilibration alone (see Chapter 18)
or by the placing of an acrylic inclined plane on the mandibular

incisors (see Fig 15-66). The inclined plane acts as an extension
of the lower incisal edges contacting the lingual surfaces of the
maxillary anterior teeth. On closing, the mandible is forced to be
retruded, and the maxillary anterior teeth, if they are tipped lin-
gually, will be moved labially. The bevel of the appliance should
be ground very carefully so that all teeth contact is even and the
load well distributed to avoid trauma. The appliance may be ce-
mented into position with a stiff mix of zinc oxide and eugenol
and removed by slicin& the acrylic with an abrasive disk. Do not
worry about the large posterior open bite when the appliance is
first inserted; it soon closes when the incisors are corrected. Pe-
riodic observations may show that occlusal grinding is necessary
to keep the load evenly distributed and to avoid the introduction
of unwanted new closure patterns. Prescribe a semisolid diet for
c E
'ts
FIG 15-60.
Neuromuscular type of Class III malocclusion. A, at age 8, treatment
was by occlusal equilibration alone. B, the harmonious result ob-
tained in a few days. C, the patient's postural position at the start of
treatment. 0, the patient's usual occlusal position, showing the func-
tional mandibular protraction. E, the improved occlusal position ob-
Earry Treatment 413
the short period of treatment (usually only about I week). If marked
improvement is not seen quickly, the case should be reassessed,
for the original diagnosis probably was erroneous. This appliance
is sometimes presented to the profession with too much enthusi-
asms. It has but limited use, but in a selected few cases it is
advantageous. In the mixed dentition, make doubly sure of the
diagnosis before proceeding.
A maxillary labial archwire may be used alone or in con-
junction with the mandibular inclined plane. Again, failure to
achieve quick improvement likely means a misdiagnoSis. Remem-
ber that the continual thrusting forward of the mandible and the
locking of the teeth in pseudomesioclusion can only result in even-
tual perversion of the growth pattern of the facial skeleton and the
eventual appearance of mild Class III skeletal features. Thus, the
15
tained after occlusal equilibration. F, 9 years after the occlusal
eql:Jilibration. No other orthodontic therapy was undertaken. Ob-
viously, this patient has a mild skeletal Class III problem, but the
occlusal equilibration at the right time prevented the problem from
becoming more complicated.
 414 Treatment
older the patient the more difficult and lengthy the treatment.
Steps in treatment
Fjrst locate and remove all tooth interferences. This may
involve grinding of primary teeth or moving interfering permanent
teeth. Do not grind permanent teeth in the mixed dentition period
for this purpose, since the areas removed may be needed later for
occlusal stability after the positions of the teeth have been altered
by growth.
Arch coordination' should be achieved as soon as possible,
lest the buccolingual malrelationships may inhibit and constrict
maxillary growth.
Treatment is more difficult in the mixed dentition than in the
primary, the prognosis is less favorable, and the results are not so
dramatic. Nonetheless, if the case is one of pure pseudo-mesio-
clusion, the results usually are satisfactory. Figure 15-60 illus-
trates a case of this kind treated successfully when the patient was
8 years of age.
2) Midface Deficiency.-When mild midface deficiency is
diagnosed in the primary or very early mixed dentition, I prefer
to use the Frankel Function Regulator-Ill (FR-Ill; see Fig 18-44).
In the mixed dentition the FR-Ill appliance may also be used
FIG 15-61.
A-K, treatment of Class I1 midface deficiency in the mixed dentition. (Courtesy of Dr. William Northway.)
for mild midface deficiency cases, however, for the more serious
problems the De Laire face mask is preferred (see Chapter 18).
Striking results may be obtained with this device-which translates
the maxilla forward, improving the skeletal profile, and seems to
have a mild restraining influence on mandibular growth (Fig 15-
61).
3) Mandibular Prognathism.-Patients with mandibular
prognathism require appliance therapy that is quite different from
that used for midface deficiency. While some advocate FR-Ill
therapy for these problems, Graber has reported that chin cup
treatment utilizing heavy extraoral tractions rotates the mandible
posteriorly, decreases the gonial angle, restricts vertical condylar
growth, and causes the corpus of the maxilla to rotate slightly
clockwise. The result is an improvement in the A-B relationship
of the skeletal profile, maintenance of the Mandibular Plane Angle,
and change in the articular angle and in the orientation of the ramus
to the cranial base (Fig 15-62). Woodside reports success with
the Activator-showing similar effects horizontally but transfer-
ring some of the expected mandibular horizontal growth in a more
vertical direction. With either chin cup or activator therapy the
dentoalveolar development is altered both vertically and horizon-
 Early Treatment 415

A
A
B c
__ UnloadedCondyles

•.• -0 10 ___ loaded Condy1es

.
o
09

08
07

06

\\~ 05
"o-- o!_:----~
~~
0'
6.~'" -"'1ft>
03
~""
" " ,
09, 02
"'0·,,····0 --"'~-~
_--. Untreated Class III Six Years *-. Untreated Class 111 . SIX Years
0'
o ..···.{)· Untreated Class 111 Nine Years 0---0 Treated Class III Nme Years ,
TIME IN ,""fEKS

SKELETAL CLASS ID SKELETAL CLASS ill

UNTREATED CHIN-CAP TREATMENT FIG 15-62.
(CHANGES BETWEEN (CHANGES BETWEEN A-C, responSe of mandibular prognathism to extra-oral chin cup
SIX AND NINE YEARS) SIX AND NINE YEARS) therapy. (From Graber LW: Chin cup therapy for mandibular prog-
SNB ANGLE INCREASES 1 SNB ANGLE DECREASES nathism. Am J Orthod 1977; 72:23-41. Reproduced by permission.)
ANB ANGLE DECREASES 2. ANB ANGLE INCREASES
MANDIBULAR PLANE 3 MANDIBULAR PLANE ANGLE
ANGLE DECREASES CONSTANT
4 ARTICULAR ANGLE 4. ARTICULAR ANGLE
DECREASES INCREASES
5 RAMUS HEIGHT INCREASES 5 RAMUS HEIGHT INCREASE
SUBSTANTIALLY SUBNORMAL

tally in order that alveolar process adaptations may help mask the prove the vertical morphology and aid in leveling the line of oc-
skeletal dysplasia (Fig 15-63). clusion (see section D).

4) Midface Deficiency and Mandibular Prognathism.- a) Diagnosis

Skeletal Class III patients showing both midface deficiency and
mandibular prognathism often are less difficult to treat than patients
with mandibular prognathism alone, since some improvement may
be obtained in the midface by face mask therapy, and some in the
mandible by either chin cup or functional appliance therapy. De-
vices which combine chin cup traction and midface protraction are
appropriate for these cases.
8. Labioversion of Maxillary Ineisors (Excessive Overjet)
With Class I Molar Relationship
This condition seems similar to a Class n Horizontal Type
A malocclusion, since the anterior teeth of the maxilla are in
labioversion; the maxillary posterior teeth, however, remain in
Class I. There is a good facial skeletal morphology or a Class n
molar relationship would have resulted. The cause may have been
a thumb- or finger-sucking habit so the condition may be accom-
panied by an open bite and maxillary narrowness. It also is found
with a deep overbite owing to overeruption of the mandibular
incisors. Though the overbite may not be as severe as is sometimes
seen in Class n, Division I, this is not a condition to be taken
lightly.
The following discussion focuses on cases without a marked
Curve of Spee. Cases with a marked Curve of Spee and an im-
pinging overbite are much more severe and must be treated by a
multibanded appliance to level the occlusal plane, intrude, torque,
and retract the incisors. Such tooth movements shorten the arch
perimeter, further complicating the case. Banded therapy may be
preceded or accompanied by use of a functional appliance to im-
This condition must be carefully differentiated from a skeletal
Class 11, Division I malocclusion in which the lower teeth may
have drifted forward, causing anterior crowding yet maintaining
a Class I molar relationship.
b) Treatment
If there is an active tongue-thrust, abnormal tongue posture,
or finger-sucking habit, the first step in treatment is correction of
the habit.
A Hawley retainer is most unsatisfactory for treatment of this
malocclusion, though it is often used. A primary problem is the
damage done to the palatal gingivae by the appliance and the lower
incisors when the plastic is cut away to permit maxillary incisal
retraction. f
Another appliance sometimes recommended is the oral shield,
though its range of utility is quite limited (Fig 15-64). Use of the
oral. shield helps correcC'abnormal lip and sucking habits while
utilizing lip force to move the maxillary anterior teeth lingually.
It provides no vertical control of the incisors. The oral shield is
not indicated for treatment of any kind of distoclusion.
A functional appliance, such as a Bionator, Activator, or
Function Regulator-I, are efficient for these cases during the tran-
sitional dentition since they control abnormal lip and tongue ac-
tivities while retracting the maxillary incisors and helping level
the occlusal curve as the permanent posterior teeth erupt.
Molar bands and bracketed incisors in each arch can effect
an efficient correction of these problems in the late mixed dentition.
416 Treatment

"

E
BEFORE --
AFTER _n_

FIG 15-63,
Treatment of Class III malocclusion. A and 8, before treatment.
and D, after treatment. This patient was treated with a Monobloc
(Activator) appliance. (Courtesy of Or. Ross O. Fisk, Department of
Orthodontics, Faculty of Dentistry, University of Toronto). E, ceph-
f
C alometric tracings of a Class III patient befor,e and after treatment.
Notice the dental adjustments made possible by the downward dis-
placement of the mandibular growth. (Note: the case in E is not the
saFP~ as shown in A-D. "'~.
 Early Treatment 417

.'

FIG 15-64.
Treatment of labioversion in a Class I malocclusion by means of an should have been remade so that traumatic occlusion was not intro-
oral shield. A, at the start of treatment. B, after 3 months. C, after 6 duced. The shield itself provided the trauma that produced the peri-
months. Note recession of the gingival tissue around the neck of the odontal lesion. D, a modification of the maxillary acrylic palate ap-
mandibular cuspid as the incisor relationship improved. The shield pliance, which also may be used for such problems.

"
418 Treatment
FIG 15-65.
Crossbite of a maxillary incisor before qeft) and after right) treatment.
In this instance, there was insufficient space for the lateral incisor
The archwires level and idealize the arch forms, while the max-
illary incisors are intruded and retracted.
9. Anterior Crossbites, Simple
Simple anterior crossbites are dental malocclusions resulting
from abnormal axial inclinations of maxillary anterior teeth. They
must be clearly differentiated from mesioclusions, which they may
seem to resemble4. 13.62.69 The simple anterior crossbite has many
other names (e.g., "in-locked" incisors and "scissors bite"). The
use of the word "simple" implies that some anterior crossbites
are more complicated, and indeed they are, particularly those which
accompany a Class III malocclusion or are part of a skeletal deep
bite (see Section D-7 and elsewhere in this chapter).
It is stretching the outline of this chapter a bit to discuss
anterior cross bite of several teeth in two places (Sections D-7 and
0-9), but there are good reasons for doing so. Primarily we want
to direct the reader to the importance of the differential diagnosis
and the correct treatment regardless of the original classification
or designation of the condition. All anterior crossbites are not
"simple" !
a) Dwgnosis
The molar relationship should be noted carefully in the pos-
FIG 15-66.
Acrylic inclined plane extension of incisal edges of the mandibular
incisors, sometimes used for treatment of lingual crossbites of an-
terior maxillary teeth.
and all teeth in the right lateral segment had to be moved posteriorly
until the crossbite could be corrected. (Courtesy of Dr. Aaron Posen.)
tural position·and in occlusion. If a Class 11or Class III relationship
is seen at either position, the problem is not a simple anterior
crossbite, for the latter is solely a matter of lingually tipped max-
illary anterior teeth without serious disruption of- the molar rela-
tionship. If there is any doubt, a cephalometric analysis is needed ..
Simple anterior crossbites may involve one or more teeth.47
b) Treatment
1) Single Tooth.-A single anterior tooth in crossbite may
be brought into alignment easily, provided there is space in the
arch for it. If there is-not, space must be created before tipping
the offending tooth labially (Fig 15-65). When there is sufficient
space, the tooth may be brought directly into line. An auxiliary
spring attached to a lingual archwire or maxillary acrylic plate
may be used, or the locked tooth may be brought to a light labial
archwire by means of ligatures.
An acrylic inclined plane, shown in Figure 15-66, also is
effective. It must be adjusted carefully and not \eft in place unduly
long. Figure 15-67 illustrates an anterior crossbite treated with an
inclined plane.
2) Several Teeth.- Treatment of several teeth in crossbite
requires the observance of the same fundamentals needed for a
single tooth. Lingual archwires with auxiliary springs are effective,
labial archwires and banded anterior teeth are also excellent, and
the inclined' plane appliance is sometimes recommended, though
we think it inefficient for this purpose. Figure 15-68 illustrates
successful treatment of such cases.
10. Bimaxillary Protrusions
a) Bimaxillary Progn.lfthism
" Bimaxillary prognatnism must be differentiated from bimax-
illary dental protrusion.
Bimaxillary prognathism is a skeletal problem in which both
maxilla and mandible have a relationship more forward than normal
with respect to the cranium and cranial base (Fig 15-69). In true
bimaxillary prognathism, both the maxilla and the mandible are
forward with respect to the anterior cranial base while the axial
inclinations of the teeth are nearer normal than in bimaxillary dental
protrusion. There are distinct ethnic variations in the normal po-
 Early Treatment 419

."

FIG 15-67.
Above, an anterior crossbite treated with mandibular inclined plane: Below, a skeletal Class III malocclusion on which a similar treatment
left, before therapy; right, after therapy (courtesy of Or. John Mortell). was attempted. Note the difference in the response to treatment.

FIG 15-68.
A, dental-type crossbite of several teeth before (left) and after (right) to treatment disproves that diagnosis. A and B, left is before treat-
treatment (courtesy of Or. Aaron Posen). B, this anterior crossbite ment; right is after treatment.
looked like a skeletal Class III malocclusion, but the ready response
420 Treatment
FIG 15-69.
Bimaxillary prognathism. The values are for the skeletal and dental
length measures of Enlow's Counterpart Analysis (see Chapter 12).
Norms for the appropriate age and sex, in this instance a female of
10 years, 2 months, are in parentheses. Note that there is bimaxillary
prognathism as well as bimaxillary dentoalveolar protrusion.
sition and size of both the maxilla and mandible. The North Amer-
ican black, (or example, has a normal maxillo-mandibular skeletal
relationship which, by North American white'standards, might be
termed "bimaxillary prognathism" (see Chapter 12).
The cephalometric analyses must first reveal bimaxillary
prognathism (Basic Morphologic Analysis plus above normalval-
ues in the Profile Analysis for both maxillary and mandibular
skeletal unit distances). Forward positions of the dentoalveolar
region only are shown by the maxillary and mandibular dental unit
distances and abnormal angulations of the incisors to the functional
occlusal line (Figs 15-69 and 15-70).
Because bimaxillary prognathism is a problem in the basic
morphology and growth pattern of the bony skeleton, interception
is not a very satisfactory strategy. A common mistake is made
when the basic skeletal morphology is not recognized and attempts
are made to impose too "flat" a dental profile in a facial skeleton
FIG 15-70.
Bimaxillary dental protrusion. The Counterpart Analysis (See Chapter
12) reveals both maxillary and mandibular lengths near the norms
for a boy of 7 years, 2 months, but the dental alveolar lengths are
about two standard deviations above the mean.
FIG 15-71.
Anterior open bite.
with both the maxilla and mandible abnormally forward. Lip and
soft tissue adaptation then is often not as pleasing -as anticipated.
b) Bimaxillary Dental Protrusion
Bimaxillary dental protrusion is procumbency of both den-
titions on the bOIJYbas.es (see Fig 15-70) and'must be discriminated
from bimaxillary prognathism. There may be familial tendencies,
as in bimaxillary prognathism, but bimaxillary dental protrusiqn
can also arise from mesial drifting of the teeth in both arches. The
.condition also is seen when larger than normal teeth are found in
conjunction with normal or smaller than normal osseous bases. In
our opinion, bimaxillary dental protrusion is not treated very sat-
isfactorily at an early age (see Chapter 16).
11. Open Bite
a) Definition
Open bite is the failure of a tooth or teeth to meet antagonists
in the opposite arch (Fig 15-71). During the normal course of
eruption, it is expected that the teeth and their supportive alveolar
bone will develop until occlusal antagonists are met. Any inter-
ference with the normal course of eruption and alveolar devel-
opment may result in an open bite. The causes of open bite generally
may be grouped under three headings (see Chapter 7): (I) dis-
turbances in the eruption of the teeth and .alveolar growth, for
example, ankylosed primary molars; (2) mechanical interference
with eruption and alveolar, growth, for example, a finger-sucking
habit; and (3) vertical skeletal dysplasia. The last, though less
frequently seen, is a quite different and much mote difficult problem.
Unfortunately, there are two current definitions of open bite
(Fig 15-72). Throughout thi~ book, the term "open bite" means
the latk of functional antagonistic teeth. This definition is not only
functionally correct, it is more pragmatic.
b) Diagnosis
The definition of open bite is, in a sense, the diagnosis, but
to plan treatment one needs to learn the etiology and to localize
precisely the extent of the inadequate vertical development. We
may divide open bites into (I) simple open bites, those confined
to the teeth and alveolar process; and (2) complex, those based
on primary vertical skeletal dysplasia-the so-called "skeletal open

FIG 15-72.
The definition of open bite. Left, normal incisal relationship. Center,
an open bite without vertical overlap of the incisors. Right, an open~n
bites" -which are more varied and much more difficult to treat.
When the vertical cephalometric analyses (see Chapter 12)
reveal no abnormal measures and the sole problem is the failure
of some teeth to meet the line of occlusion, the condition is termed
simple open bite.
When the vertical cephalometric analysis reveals disharmo-
nies in the skeleral components of anterior face height (e.g., very
short upper face height, or total anterior face height dispropor-
tionately small for the total posterior face height), dentoalveolar
vertical development sometimes cannot cope with the skeletal mor-
phology well enough to guarantee anterior functional occlusal stops:
the result is termed complex or skeletal open bite (see Fig 15-73).
In simple open bite alveolar adaptation cannot or does not take
place; in complex open bite alveolar adaptation does take place
but it cannot be sustained.
The use of Vertical Analysis 11 and the tables of vertical
growth measures presented in Chapter 12 provides localization of
the problem in the craniofacial skeleton and makes possible mon-
itoring of treatment during growth.
c) Treatment
1) Anterior Open Bite, Simple.-When studying anterior
open bites before treatmfnt, take care to'note the relationship of
the osseous bases to the dentition. Preoccupation with the den-
toalveolar aspects of the open bite may lead 6fie-tQ...overlook a
more basic skeletal problem. Always suspect a habit of some sort
when~an open bite is first seen, since the majority of simple anterior
open bites are caused by digital sucking habits or abnormal tongue
posture, If, 9uring eruption, the teeth repeatedly encounter a fingei~
thumb, of tongue, eruption is impeded and an open bite results.
In'young children treatment consists, first, of controlling the
habit which alone may be sufficient to permit the teeth to erupt
to normal position. Habit control is discussed in Chapter 18. Re-
tention, after treatment, of any malocclusion due to a sucking habit
is almost impossible unless the habit is overcome completely and
normal lip and tongue function are restored.
Often the best way to break the habit is to correct the open
bite itself. This is certainly true for a simple tongue-thrust that is
maintaining an open bite created by an earlier sucking habit. Brack-
Early Treatment 421
bite with vertical overlap of the incisors. This latter type of open bite
not diagnosed.
eted appliances may be used to move the incisors to correct overbite
and overjet relationships, and functional appliances (e.g., Acti-
vator, Bionator, or Frankel appliance), are especially indicated in
the early mixed dentition.
2) Posterior Open Bite, Simple.-Open bites in the posterior
region are rare in young children and usually result from a lack
of vertical alveolar development, either ankylosed primary molars
or "idiopathic failure to erupt." Lateral "tongue-thrusts" are largely
tongue postures adaptive to an open bite resulting from another
cause. A common example illustrates the point. Ankylosed primary
molars result in a localized cessation of alveolar development,
creating a posterior open bite. The tongue must spread laterally to
seal the open bite space during reflex swallowing, When the pri-
mary teeth are removed, the tongue's continued lateral swallowing
movements may impede the eruption of the bicuspids.
In early treatment the appliance of choice is either the Ac-
tivator or Bionator whose lingual flanges and palatal covering
prevent the tongue from entering the posterior open bite. Plastic
stops against the incisors permit more vertical posterior alveolar
growth as the ankylosed teeth are removed on a schedule deter-
mined by the development of their permanent successors. The
condition is much more difficult to treat later when the tongue
reflex has become more fixed, the open bite has increased, less
potential vertical growth remains, and the eruptive forces of the
teeth are diminished.
3) Complex or Skeletal Open Bite.-Complex or skeletal
open bite (Fig 15-73) is a symptom of a variety of serious skeletal
qysplasias including suSh varied morphologies as Class 11, vertical
type I (steep mandibular plane, or excessive anterior total face
height), mandibular prognathism, and several of the craniofacial
syndromes (e.g., Downs' syndrome). The most frequently en-
countered skeletal open bite is that seen in Vertical Type 3 (upward
tipped Palatal Line and inadequate development of anterior upper
face height; see Chapter 12). Skeletal contributions to open bite
are often overlooked in young children, which is unfortunate, since
the later they are discovered the more difficult the treatment. One
reason early or incipient skeletal open bite is unnoticed is the
insensitivity of many cephalometric analyses to any but the most
422 Treatment
FIG 15-73.
Gross skeletal dysplasia resulting in an open bite. Surgery was un-
dertaken early in the patient's life to correct a bifid nose, causing
gross vertical dysplasias. If a skeletal open bite is suspected, the
vertical analyses described in Chapter 12 provide methods of di-
agnosis, localization, prediction of future severity, and assessment
of the response to treatment. Some skeletal open bites in young
children involve abnormal maxillary development, in association
with nasorespiratory dysfunction (see Chapter 7).
It is impossible to. provide detailed rules for early treatment
of the many kinds of skeletal open bite, but a few guide lines and
principles are helpful.
a) The earliest possible diagnosis is essential because the
condition is not self-correcting and. usually worsens with time.
b) Removal of all possible etiologic factors a~ soon as di-
agnosed is important. Consultation with the pediatrician or oto-
laryngologist may be important. When referring the patient to the
physician, send along the cephalogram and a summary of your
cephalometric findings. Explain to your colleague the implications
of the condition to future craniofacial growth. When you document
the case well, understanding and cooperation is usually assured;
however, do not expect all pediatricians and otolaryngologists to
be experts in craniofacial growth.
c) Since these cases may be very difficult and require pro-
,.
further impedance to normal growth of the nasomaxillary complex.
A, note the upward slope of the palate. (Continued.)
long<;:dand varied appliance therapy, they challenge the experience
and skills of the best orthodontists. Early mistakes in treatment
can compound the problem.
12. Deep Bite (Excessive Overbite or Vertical Overlap)
a) Definition
A wide range of incisal overlap is seen 'with normal posterior
occlusal relations. Depth of bite (see Fig 15-74) becomes a defined
clinical problem when occJpsal or temporomandibular function is,
or ·inay become, impaired and when facial esthetics is harmed.
The depth of bite must be related to the health of the soft and
supporting structures, temporomandibular function, and the effects
of future skeletal growth on these factors. Incisors in labioversion
may seem to have normal overbite, but their correction by simple I..
tipping may produce a deeper bite. Therefore, deep bite as a clinical
problem is not defined in terms of miIIimeters seen today but in
the light of future changes on esthetics and function.
Closed bite (excessive overbite resulting from loss of posterior
teeth), only rarely seen in young children, must not be confused
with deep bite. Brief comments on treatment of closed bite in

FIG 15-73 (cont.).
B-O, the crossbite. E, the disharmony in the dimensions of the dental
arches. (Continued.)
children, however, appear later in this section (part c, Treatment.)
b) Diagnosis
The factors contributing to excessive overbite vary with the
type of occlusion. Their determination is the most important step
in diagnosis. Excessive overbite is not to be viewed as an isolated
entity: it must be seen as a part of the total malocclusion. In good
occlusions, the amount of overbite is determined largely by dental
factors, that is, crown length and tooth position. In Class I mal-
occlusion the depth of bite is controlled by dental factors, for
example, length of the crowns of the incisors, elevation of the
Early Treatment 423
.'
maxillary first molars, and the angle between the long axes of the
cen~ral incisors as well as' by skeletal features. However, in Class
H, the skeletal morphology dominates dental features. Diminished
anterior lower face height and shortened ramus height, in partic-
ular, dominate the dental factors mentioned above. Consequently,
depth of bite is usually more difficult to correct and retain in Class
H than in Class I malocclusion. Cast analysis alone or observations
based solely on the usual occlusal position are insufficient: a proper
cephalometric analysis and determination of the interocclusal free-
way space are necessary.
The amount of freeway space is a critical factor in prognosis
424 Treatment

..
G
St. S. 11-5 VERTICAL ANALYSIS

-3 -2 -IS.D. X IS.D. 2 3
Cranial 80S.
PM VertlFMN-SE MALES

Maxilla
PM Vert/Pol. Line MAlES

FEMALES

Occlusion
PM Vert/Occ!. Line MAlES
(not a constont In Cia •• Dl

FEMALES

~
PM Vert/Mond. Line MAlES

FIG 15-73 (cont.).

F, the cephalometric tracing of a patient with an open bite. G, the Z
scores for the vertical analysis reveqling three measures more than "
one standard deviation above the mean and indicating a skeletal
basis for the open bite. H, superposed before and after tracings
showing the treatment produced dentoalveolar adaptations to effect
a closure of the open bite.
 Early Treatment 425

-
-.-.-
.O«lusieJn
~
Occlusion 90
85
3.I16-1
, ---,
I Vert/Oee!.
(not 0 constant In Cia •• DJ Vert I
PM..L......:
-I--
-..
-2
85 -~-
I,-IS.D.
-_.90 --
..95
IS.D.
Vert/Mand.
Vert/Pal
Vert
FEMAlES
T.p.
T.p.
,X- .. ANALYSIS
290
-IS.o.
10-1
IS.O.
10eel.
Pal L1n. Line
L1n.
Lln.
0
MAlES
MAlES

FEMAlES \
I 90
--
VERTICAL
VERTICAL
I
~@
,@
B115 I

FIG 15-74.
Simple deep bite. A, cephalometric tracing prior to orthodontic treat- treatment. 0, the verticaL.aflalysis Z scores after therapy showing
ment. B, the vertical analysis. C, the cephalometric tracing after that'!."'ree measures were affected f!"vorably by therapy.
426 Treatment
(see Chapters 10 and 11). When there is a larger than normal
distance between the postural and the intercuspal (usual occlusal)
position, greater opportunities exist for correction by guiding ver-
tical alveolar development. Study the freeway space carefully.
Measure the interocclusal distance in the cepnalogram and the
direction of mandibular movement from posture to o~clusion. You
may have the patient wear a flat maxillary bite plan for a few days
to reduce the occlusal sensory input, then the interocclusal distance
can be measured more accurately.
A detailed vertical cephalometric analysis is required (see
Chapter 12), but many cephalometric analyses do not discriminate
vertical details well. Proper treatment planning depends on specific
localization of skeletal contributions to the deep bite.
c) Treatment
When an excessive overbite is seen in the primary.dentition,
it is likely to have a skeletal basis. Activator type appliance may
be used to direct differential alveolar growth, reduce the inter-
occlusal distance, and improve skeletal morphology.
If the overbite seems excessive in the mixed dentition when
there is a Class I molar relationship and normal sk~letal mor-
phology, it usually is due to one or more of the following related
factors:
a) Overdevelopment vertically of the incisal regions,
b) Inadequate elevation of the maxillary first molars (i.e.,
the anatomic crown of the molar has not erupted to its
full clinical crown height).
c) Failure to recognize a normal stage of development. The
overbite is greater just after eruption of the permanent
incisors and decreases with eruption of the posterior
teeth.
None of these factors requires heroic orthodontic treatment.
Eruption of the first molars can be aided by the use of a flat
maxillary bite plane or a monobloc and the incisors depressed with
utility archives. Such appliances may help, too, if the curve of
Spee is excessive. Tb.,efunctional jaw orthopedic appliances, (e.g.,
Activator) are ideally suited to direct vertical skeletal development
and to control adaptive alveolar growth in Class I deep bite as
well as Class II.
With a Class II molar relationship, treatment of overbite must
be directed to the total Class II problem. Understanding of the
different vertical types within Class II helps one in planning therapy
(see Section D-7 in this chapter and see Chapter 12). The choice
of appliances is largely determined by the type of Class II mal-
occlusion, but the functional appliances are especially advanta-
geous for early treatment of Vertical Type 2. The more severe the
skeletal aspects of the deep bite, the more there is to be gained
by early treatment.
13. Craniofacial Malformations
Although gross craniofacial deformities appear rarely, each
instance poses enormous problems in clinical management for the
surgeon and orthodontist. Babies with severe congenital malfor-
mations require immediate surgical, medical, and dental attention
of a very specialized nature. Troubled parents turn instinctively to
the family pediatrician and dentist for advice. Ordinarily, gross
craniofacial abnormalities are not the responsibility of the family
dentist, but the dentist has the obligation to steer the parent to a
craniofacial anomalies center (sometimes called a cleft palate team
or center), for the team approach is essential for these children.
Fortunately, such centers are well developed and widespread
throughout the world. They are made up of clinicians from many
fields sharing research and treatment responsibilities and indivi-
dualizing the therapy for each child. Surgeons, speech therapists,
pedodontists, orthodontists, psychologists, and prosthodontists are
all involved in planning the joint treatment. However, the speech
therapist and orthodontist will spend the most time in corrective
work and guiding the development of more difficult cases.
The most common of the serious congenital deformities is
that of cleft lip and/or palate (Fig 15-75), which occurs in ap-
proximately one in 700 North American white children. In recent
years important progress has been made in cleft lip and palate
treatment. The schedule of lip and palate surgery, varies according
to the nature and extent of the clefting, and there are frank dif-
ferences of opinion among the best surgeons about the exact timing
and surgical techniques for both lip and palate procedures. Gen-
erally, the lip is closed very early and the palate some months
later. Some now advise that some neonates have the maxillary
segments and premaxilla positioned by appliances and tension
bandages prior to lip surgery. The responsibility for these decisions
resides with the attending surgeon of the cleft palate team. Sub-
sequent orthodontic treatment attempts to normalize the growth of
the deformed maxilla and the effects of surgery on craniofacial
growth. Even the best surgery results in significant effects on
subsequent growth of the entire facial skeleton and occlusion.
It is the duty of every family dentist to be thoroughly ac-
quainted with a craniofacial anomaly or cleft palate team long
before the need for their services arises. In this way, when advice
is sought, the answer is prompt and authoritative.
14. Temporomandibular Dysfunction.
a) Definition
The current literature on temporomandibular dysfunction ap-
pears largely in journals dedicated to adult dental rehabilitation,
where the problem is primarily viewed as one of degenerative
geriatric disease and dysfunction. There is increasing evidence that
some of the signs and symptoms associated with temporomandib-
ular dysfunction in adults are first seen in young children (see
Suggested Readings) and that certain occl~sal disorders in child-
hood predispose to later temporomandibular dysfunction. Accord-
ingly, it is proper to consider temporomandibular dysfunction as
an.i~portant aspect of the development of malocclusion.
b) Diagnosis
Class n, deep bite, open bite, and asymmetry are the skeletal
morphologic variations most associated with temporomandibular
joint dysfunction in children. Functionally unstable mal occlusions
in childhood most associated with temporomandibular signs and
symptoms include functional crossbites and functional Class II and
Class III molar relationships. Of special concern are end-to-end
molar relationships which do not completely change to a Class I
occlusion during the late mixed dentition and pubescent periods.

FIG 15-75.
A, a unilateral cleft palate prior to orthodontic treatment. B, the Friel .
lingual archwire in place. C, the result of maxillary expansion with
the Friel lingual archwire. 0, after positioning of the teeth with a
Because end-to-end occlusion of the first permanent molars has
been described as normal (see Chapter 6 for a discussion of why
end-to-end is not necessarily normal), its potential for trouble is
often overlooked. An end-to-end molar relationship combined with
a mild Class 11 skeletal morphology and slight deep bite make a
collection of symptoms which should be carefully watched for
early signs of temporomandibular dysfunction and/or pain (see
Chapter 11). The most critical diagnostic features are those of
functional occlusal disorders, erratic mandibular movement on
opening and closure, atypical joint sounds, limited jaw opening,
and pain of the jaw musculature (see Chapter 10 and 11) ..
Trauma to the facial region has been shown to be a significant
etiologic factor in temporomandibular dysfunction in children ..
c) Treatment
Clinical studies of the value of early treatment of temporo-
mandibular dysfunction are just appearing in the literature. While
it is obvious that most problems of the temporomandibular joint
have their origins much earlier tha'n the time of their typical treat-
ment, the most appropriate age for the treatment of each problem
has not yet been determined. It is generally agreed, however, that
functional malocclusions in early childhood merit special attention,
particularly when associated with skeletal dysplasia. Correction of
functional malocclusions by occlusal equilibration, functional ap-
pliance therapy, or tooth movements (according to the circum-
stances) in such instances is surely indicated. The "treatment" of
every end-to-end molar relationship in the mixed dentition is not
indicated. However, any occlusion not in solid intercuspation and
Early Treatment 427
"
standard orthodontic appliance, the patient is now ready for a
prosthesis.
associated with temporomandibular pain, sounds, tendonitis, or
myalgia of the jaw muscles should be considered for treatment.
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Dent Assoc 1968; 76(4):778-784.
49. Popovich F, Thompson GW: Evaluation of preventive and
interceptive orthodontic treatment between three and eight-
een years of age, in Cook lR (ed): Transactions of the
Third International Orthodontic Congress. St Louis, CV
Mosby, 1975.
50. Posen AL: The effect of premature loss of deciduous mo-
lars on premolar eruption. Angle Orthod 1965; 35:249-252.
51. Pulver F: The etiology and prevalence of ectopic eruption
of the maxillary first permanent molar. J Dent Child 1968;
35:138-146.
52. Richardson ME: The relative effects ot; the extraction of
various teeth on the development of mandibular third mo-
lars. Trans Eur Orthod Soc 1975; 79-85.
53, ~igenberg Q: Seria!.extraction-Stop, look and be certain.
I1:mJ Orthod 1964; 50:327-336.
54. Salzmann lA: Effect on occl~sion of uncontrolled extraction
of first permanent molars: Prevention and treatment. J Am
Dent Assoc 1943; 30:1681-1690.
55. Savara BS, Steen lC: Timing and sequence of eruption of
permanent teeth in a longitudinal sample of children from
Oregon. J Am Dent Assoc 1978; 97:209.
56. Schroder U, Granath L: A new interceptive treatment of
cases with missing maxillary lateral incisors. Swed Dent J
1981; 5:155-158.
57. Schwanninger B, Shaye R: Management of cases with up-

per incisors missing. Am J Orthod 1977; 71:396-405.
58. Shapira Y: Transposition of canines. J Am Dent Assoc
1980; 100(5):710-712.
59.' Shapira Y, Kuftinec M: Treatment of impacted cuspids.
The hazard lasso. Angle Orthod 1981; 51 (3):203-207.
60. Shapira Y, Kuftinec MM: Orthodontic management of
mandibular canine-incisor transposition. AmJ Orthod 1983;
83:271-276.
61. Simon JF, Farrage JR, Misner LR: Regaining space in the
mixed dentition. Dent Clin North Am 1978; pp 669-684.
62. Sleichter CG: The influence of premature loss of deciduous
molars on premolar eruption. Angle Orthod 1963; 33:279-
283.
63. Swaine TJ, Wright GZ: Direct bonding applied to space
maintenance. J Dent Child 1976; 42:21-25.
64. Thilander B, Skagius S: Orthodontic sequelae of extraction
of permanent first molars. A longitudinal study. Trans Eur
Orthod Soc 1970; pp 429-442.
65. Trisovic D, Markovic M, Starcevic M: Observations of the
development of third mandibular molars. Trans Eur Orthod
Soc 1977; pp 147-157.
66. Tsamtsouris A, White GE: Space maintainers for the integ-
rity of the arch perimeter. Part I. The transpalatal arch ap-
pliance. J Pedodontics 1977; 1(2):91-98.
67. Tuversson DL: Orthodontic treatment using canines in place
of missing maxillary lateral incisors. Am J Orthod 1970;
58: 109-127.
68. Tweed CH: Treatment planning and therapy in the mixed
dentition. Am J Orthod 1963; 49:881-906.
69. Valentine F, Howitt JW: Implications of early anterior
crossbite correction. J Dent Child 1970; 37:420-427.
70. Vanarsdall RL, Corn H: Soft-tissue management of labially
positioned unerupted teeth. Am J Orthod 1977; 72(1 ):53-
64.
71. Von der Heydt K: The surgical uncovering and orthodontic
positioning of unerupted maxillary canines. Am J Orthod
1975; 68(3):256-276.
72. Way DC: Direct bonding and its application to minor tooth
movement. Dent Clin North Am 1978; pp 757-770.
73. Weber AD: A longitudinal analysis of premolar enuclea-
tion. Am J Orthod 1969; 56:394-402.
74. West E: Treatment objectives in the deciduous dentition.
Am J Orthod 1969; 55:617-632.
75. Wilson HE: Long-term observation of the extraction of sec-
ond molars. Trans Eur Orthod Soc 1974; pp 215-221.
76. Wright GZ, Kennedy DB: Space control in the primary and
mixed dentitions. Dent Clin North Am 1978; 22:579-601.
SUGGESTED READINGS
Sections A-C
A. Understanding Early Treatment
B. Defining Goals in Early Treatment
C. Clinical Problems and Procedures
Ackerman JL, Proffit WR: Preventive and interceptive ortho-
dontics: A strong theory proves weak in practice. Angle
Orthod 1980; 50:75-86.
Popovich F, Thompson GW: Evaluation of pre:ventive and inter-
ceptive orthodontic treatment between three and eighteen
years of age, in Cook JT (ed): Transactions of the Third
International Orthodontic Congress, St Louis, CV Mosby,
1975.
Early Treatment 429
D-I-a: Congemlally Missing Teeth
Graber LW: Congenital absence of teeth: Review with emphasis
on inheritance patterns. J Am Dent Assoc 1978; 96:266-
275.
McNeil RW, Joondeph DR: Congenitally absent maxillary lat-
eral incisors: Treatment planning considerations. Angle Or-
thod 1973; 43:24-29.
Schroder U, Granath L: A new interceptive treatment of cases
with missing maxillary lateral incisors. Swed Dent J 1981;
5:155-158.
Schwanninger B, Shaye R: Management of cases with upper in-
cisors missing. Am J Orthod 1977; 71:396-405.
Tuversson DL: Orthodontic treatment using canines in place of
missing maxillary lateral incisors. Am J Orthod 1970;
58: 109-127.
D-l-b: Loss of Permanent Teeth (Trauma, Caries, and Other
Causes)
Adamson K: The controversy concerning the first permanent
molar. Aust Dent J 1962; 7:191-201.
Holm U: Problems of compensative extraction in cases with loss
of first permanent molars. Trans Eur Orthod Soc 1970; pp
409-427.
Salzmann JA: Effect on occlusion of uncontrolled extraction of
first permanent molars: Prevention and treatment. J Am
Dent Assoc 1943; 30:1681-1690.
Thilander B, Skagius S: Orthodontic sequelae of extraction of
permanent first molars: A longitudinal study. Trans Eur
Orthod Soc 1970; pp 429-442.
D-3: Spacing of Teeth
Edwards JG: The diastema, the frenum, the frenectomy: Clinical
study. Am J Orthod 1977; 71:489-508.
Popovich F, Thompson GW, Main PA: Persisting maxillary
diastema: Differential diagnosis and treatment. J Can Dent
Assoc 1977; 43:330-333.
D-4-a: Space Management
Artun J, Marstrander PB: Clinical efficiency of two different
types of direct boned space maintainers. J Dent Child
1983; 50:197-204.
Fischer TJ, Psaltis GL: Serial guidance in the developing denti-
tion. Compendium Continuing Ed 1981; 2:163-171.
Hunter S: Application of analysis of crowding and spacing of
the teeth. Dent Clin North Am 1978; pp 563-578.
Kisling E, Hoffding J: Premature loss of primary teeth. Part V.
Treatment planning with due respect to the significance of
drifting patterns. J Dent Child 1979; 46:300-306.
Norton LA, Wickwire NA, Gellin ME: Space management in
the mixed dentition. J Dent Child 1975; 42:32-38.
Singer J: Effect of the passive lingual archwire on the lower
denture. Angle Orthod 1974; 44:146-155.
Wright GZ, Kennedy DB: Space control in the primary and
~- mixed dentitions. Dent Clifl; North Am 1978; 22:579-601.
D-4-a-3: Regaining Space
Bergersen EO: A cephalometric study of the clinical use of the
mandibular labial bumper. Am J Orthod 1972; 61:578-602.
Bjerregaard J, Bundgaard AM, Melson B: The effect of the
mandibular lip bumper and maxillary bite plate on tooth
movement, occlusion and space conditions in the lower
dental arch. Eur J Orthod 1980; 2:257-265.
Bundgaard M, Bjerregaard J, Melsen B, et al: An electromyo-
430 Treatment
graphical study of the effect of a mandibular lip bumper.
Eur J Orthod 1983; 5:149-156.
D-4-ac4: Space Supervision
Fanning EA: Effect of extraction of deciduous molars on the
formation and eruption of their successors~ Angle Orthod
1962; 32:44-53.
Norton A, Wickwire NA, Gellin ME: Space management in
mixed dentition. J Dent Child 1975; 42:112-118.
Savara BS, Steen JC: Timing and sequence of eruption of per-
manent teeth in a longitudinal sample of children from Or-
egon. J Am Dent Assoc 1978; 97:209-214.
D-4-a-5: Gross Discrepancy Problems
Joondeph OR: Second premolar serial extraction. Am J Orthod
1976; 69: 169-184.
Weber AD: A longitudinal analysis of premolar enucleation. Am
J Orthod 1969; 56:394-402.
D-4-b-2: Ectopic Eruption of Teeth
Bjerklin K, Kurol J: Ectopic eruption of the maxillary first per-
manent molar: Biologic factors. Am J Orthod 1983;
84:147-155.
Canut JA, Raga C: Morphological analysis of cases with ectopic
eruption of the maxillary first permanent molar. Eur J Or-
thod 1983; 5:249-253.
Pulver F: The etiology and prevalence of ectopic eruption of the
maxillary first permanent molar. J Dent Child 1968;
35: 138-146.
D-4-b-3: Transposition of Teeth
Laptook T, Silling G: Canine transposition-approaches to
treatment. J Am Dent Assoc 1983; 107:746-748.
Mader C, Knozelman JL: Transposition of teeth. J Am Dent As-
soc 1979; 98(4):412-413.
Shapira Y: Transposition of canines. J Am Dent Assoc 1980;
100(5):710-712.
Shapira Y, Kuftinec MM: Orthodontic management of mandibu-
lar canine-incisor transposition. Am J Orthod 1983;
83:271-276.
D-4-b-4: Impaction of Teeth
Boyd RL: Clinical assessment of injuries in orthodontic move-
ment of impacted teeth. Part I. Methods of attachment. AI!!
J Orthod 1982; 82:478-486.
Boyd RL: Clinical assessment of injuries in orthodontic move-
ment of impacted teeth. n. Surgical recommendations. Am
J Orthod 1984; 86:407-418.
Fournier A, Turcotte J, Bernard C: Orthodontic considerations
in the treatment of maxillary impacted canines. Am J Or-
thod 1982; 81:236-239.
Shapira Y, Kuftinec M: Treatment of impacted cuspids. The
hazard lasso. Angle Orthod 1981.; 51(3):203-207.
Vanarsdall RL, Corn H: Soft-tissue management of labially po-
sitioned unerupted teeth. Am J Orthod 1977; 72(1):53-64.
Von der Heydt K: The surgical uncovering and orthodontic po-
sitioning of unerupted maxillary canines. Am J Orthod
1975; 68(3):256-276.
Williams BH: Diagnosis and prevention of maxillary cuspid im-
paction. Angle Orthod 1981; 51:30-40.
Section D-5: Lateral Malrelationships of the Dental Arches
Frank SW, Engel GA: Effects of maxillary Quad-Helix appli-
ance expansion on cephalometric measurements in growing
patients. Am J Orthod 1982; 81:378-389.
Hultgren BW, Isaacson RJ, Erdman AG, et al: Growth contri-
butions to Class n corrections based on models of mandib-
ular morphology. Am J Orthod 1980; 78:310-320.
Kisling E: Occlusal interferences in the primary dentition. J
Dent Child 1981; 48:181-191.
Kutlin G, Harves RR: Posterior crossbites in the deciduous and
mixed dentitions. Am J Orthod 1969; 55:491-504.
Leighton BC: The early development of cross-bites. Dent Pract
1966; 17: 145-152.
Section 6: Class II (Distocclusion, Postnormal Occlusion)
Moyers RE, Riolo KE, Guire RL, et al: Differential diagnosis
of Class n malocclusions. Part I. Facial types associated
with Class II malocclusions. Am J Orthod 1980; 78:477-
494.
Section 7: Class III (Mesiocclusion, Prenormal Occlusion) and
Pseudo Class III
Graber LW: Chin cup therapy for mandibular prognathism. Am
J Orthod 1977; 72:23-41.
Jacobson A, Evans WG, Preston CB, et al: Mandibular prog-
nathism. Am J Orthod 1974; ,66:140-171.
Section 9: Anterior Crossbites, Simple
Clifford F: Crossbite corrections in the deciduous dentition:
Principles and procedures. Am J Orthod 1971; 59:343.
Payne RC, Mueller BH, Thomas HF: Anterior crossbites in the
primary dentition. J Pedodontics 1981; 5:281-294.
Section i3-a: Cleft Palate
Bishara SE, Krause CJ, Olin WH, et al: Facial and dental rela-
tionships of individuals with unoperated clefts of the lip
and/or palate. Cleft Palate J 1976; 13:238-252.
Cronin DG, Hunter WS: Craniofacial morphology in twins dis-
cordant for cleft lip and/or palate. Cleft Palate J 1980;
17: 116-126.
Dahl E; Craniofacial morphology in congenital clefts of the lip
and palate. Act Odontol Scand 28:(suppl 57), 1970.
Fraser FC: The genetics of cleft lip and cleft palate. Am J Hum
Genet 1970; 22:336-352.
Hunter WS: Review: The Michigan Cleft Twin Study. J Cranio-
facial Genet Develop Bioi 1981; 1:235-242.
Pashayan HM: What else to look for in a child born with a cleft
of the lip and/or palate. Cleft Palate J 1983; 20:54-82.
Robertson NRE: Oral Orthopaedics and Orthodontics for Cleft
Lip and Palate: A Structured Approach. London, Pitman
Medical Books, 1983.
Robertson NRE: Facial form of patients with cleft lip and pal-
ate: The long-term influence of presurgical oral orthopaed-
ics. Br Dent J 1983;J55:59-61.
Ross~RB, .Johnston MC'Cleft Lip and Palate. Baltimore, Wil-
llams & Wilkins, 1972.
Section 13-b: Other Craniofacial Malformations
Gorlin RJ, Pindborg 11, Cohen MM Jr: Syndromes of the Head
and Neck, 2nd Ed. New York, McGraw-Hill, 1976 ..
Pas hay an HM: What else to look for in a child born with a cleft
of the lip and/or palate. Cleft Palate J 1983; 20:54-82.
Smith DW: Recognizable Patterns of Human Malformations,
3rd Ed. Philadelphia, WB Saunders, 1982.

Section 14: Temporomandibular Dysfunction
Moyers RE, Nesbitt BA, Ten Have T: Adult temporomandibular
joints disorder symptomatology and its association with
childhood occlusal relations: A preliminary report, in De-
velopmental Aspects of Temporomandibular Joint Disor-
ders. monograph 16. Craniofacial Growth Series, Center
for Human Growth and Development, The llniversity of
Michigan, Ann Arbor, Michigan, 1985.
Early Treatment 431
Moyers RE, Nesbitt BA, Ten Have T: Childhood indicators of
adult temporomandibular dysfunction. In press.
Nesbitt BA, Moyers RE, Ten Have T: Adult temporomandibular
joint disorder symptomatology and its association with
childhood occlusal relations: A preliminary report.
Speck lE, Zarb GA: Temporomandibular pain-dysfunction: Sug-
gested classification and treatment. J Can Dent Assoc
1976; 42:305-310 .
.'
-.
-.
-,
CHAPTER 16

Adolescent Treatment

Robert E. Moyers, D.D.S., Ph.D .

.'
"Adolescence is the beginning of the end." -ST ANLEY M.
GARN

OUTLINE 6. Temporomandibular joints

D. Clinical Problems
A. Understanding Adolescent Treatment I. Number of teeth
1. General characteristics of adolescent malocclusion a) Congenitally missing teeth
2. Advantages of adolescent treatment I) Maxillary lateral incisors
3. Some difficulties in adolescent treatment a) Goals
B. Defining Goals in Adolescent Treatment b) Methods
I. Skeletal c) Problems
2. Dental 2) Mandibular second premolars
a) Axial inclinations 3) Multiple absence of teeth
b) Incisal relations a) Loss of permanent teeth (trauma,
c) Midlines caries, and other causes)
d) Arch form b) Supernumerary teeth
e) Spacing 2. Variations in size and shape of teeth
f) Curve of Spee-Occlusal Line a) "Large teeth"
3. Occlusal and functional b) Small teeth
4. Soft-tissue profile and esthetics c) Anomalies of tooth shape
5. Compromises 3. Spacing of teeth
C. Assessment of Results of Adolescent Treatment a) Localized spacing
1. Occlusion b) Generalized spacing
a) Occlusal plan 4. Problems singular to the young adult dentition
b) Molar relationships a) Crowding
c) Cuspid occlusion I) Simple crowding
d) Incisor position (a) Definition
e) Functional occlusal relations " .~. (b) Diagnosis
f) Root positions (c) ,Treatment
g) Alignment 2) Complex crowding
2. Soft tissues (a) Definition
a) Lips (b) Diagnosis
b) Tongue (c) Treatment
c) Swallow b) Delayed eruption
d) Gingivae 1) Impactions
3. Facial esthetics (a) Maxillary cuspids
4. Alveolar process and periodontium (b) Second molars
5. Root resorption (c) Third molars

432
 Adolescent Treatment 433

2) Ankylosed permanent teeth (a) Basic strategies

c) Juvenile periodontitis (b) Suggested tactics
5. Lateral malrelationships (c) Problems and complications
a) Background and definition of the problem (d) Retention
b) Diagnosis - 7. Class III (mesiocclusion, prenormal occlusion)
I) Skeletal a) Rationale for adolescent Class III therapy
2) Dentoalveolar b) Diagnosis
3) Neuromuscular c) General strategies
c) Treatment d) Tactics
I) Goals e) Differential treatment
2) Methods (1) Midface deficiency
(a) Skeletal (2) Mandibular prognathism
(b) Dentoalveolar correction (3) Midface deficiency and mandibular
(c) Neuromuscular prognathis.m
3) Specific problems f) Problems and complications
(a) Bilateral maxillary corpus g) Retention
deficiency 8. Localized incisal malrelationships
(b) Unilateral maxillary corpus a) Labioversion of maxillary incisors
asymmetry (1 ) Diagnosis
(c) Bilateral maxillary dentoalveolar (2) Treatment
contraction b) Simple anterior crossbite
(d) Unilateral maxillary dentoalveo- (1) Diagnosis
lar contraction (2) Treatment
(e) Unilateral or bilateral mandibular c) Simple deep bite
dentoalveolar contraction (1) Diagnosis
(f) Gross disharmony between the (2) Treatment
skeletal bases d) Simple open bite
6. Class 11 (Distocclusion, postnormal occlusion) (1 ) Diagnosis
a) Background (2) Treatment
I) Differential diagnosis e) Simple crowding (see D-4-a-l)
2) Strategies of treatment 9. Bimaxillary protrusions
3) Tactics a) Bimaxillary prognathism
b) Rationale for adolescent Class 11 therapy b) Bimaxillary dental protrusion
c) Differential treatment 10. Deep bite
I) Horizontal type A a) Simple deep bite (see 8-c)
(a) Basic strategy b) Complex (skeletal) deep bite
(b) Tactics 11. Open bite
(c) Problems and complications a) Simple open bite (see 8-d)
2) Horizontal type F b) Complex (skeletal) open bite
(a) Basic strategy 12. Temporomandibular dysfunction
(b) Tactics a) Background
(c) Problems and complications b) Treatment
3) Horizontal type B
(a) Basic strategy This chapter was written on the assumption that the reader is
(b) Tactics familiar with the outline and con'tents of Chapter 15. To obviate
(c) Problems and complications redundancies, each clinical problem is discussed primarily only in
(d) Retention either Chapter 15 or 16 according to the age of patients at which
4) HorizontaI" type D it",i~ most apt to be eneoimtered in practice. Treatment methods
(a) Basic strategies are described in both chapters when they differ because of devel-
(b) Suggested tactics opmental age.
(c) Problems and complications There are really very few proper clinical research reports on
(d) Retention the effects of adolescent orthodontic treatment as scientifically
5) Horizontal type C sound as modem clinical studies on, for example, the effects of
(a) Basic strategies certain drugs. Therefore, one cannot write with the scientific cer-
(b) Suggested tactics titude possible when describing skeletal growth or occlusal de-
(c) Problems and complications velopment: Accordingly, Chapters 15 and 16, and most other
(d) Retention clinical writing at this time, reveal more personal clinical expe-
6) Horizontal type E riences and perceptions tban is sometimes realized. Wherever pos-
434 Treatment
sible, sound clinical studies are noted and practices discounted by
good researc-h are mentioned. Well-designed clinical research stud-
ies on treatment effects of various appliances on differing occlu-
sions are beginning to appear (cf Baumrind et aI.2-4• ]4 and Bookstein
et al. 5) and will undoubtedly change ideas presented here. Sound
clinical research must take precedence over mere opinion, however
sincerely believed.
Some mal occlusions are best treated in adolescence and a few
are singular to this stage of development. No malocclusion can be
treated until it is first recognized by someone: patient, parent, or
dentist. More malocclusions are probably treated in adolescence
than any other period, not because it is always the best time for
therapy, but rather because this is the time at which patient and
parent often become aware of the problem. Furthermore, the treat-
ment of many malocclusions has been traditionally postponed until
the permanent teeth can be bracketed.
Within an outline similar to Chapter 15, the background of
each clinical problem will be provided first, followed by critical
aspects of the diagnosis. Finally treatment goals, methods, and
possible difficulties will be discussed. There are far too many
satisfactory procedures and appliances for all to be included in an
introductory text, and many are well presented elsewhere. Specific
technical details of treatment are not given when they are beyond
the scope of this book. This chapter deals primarily with the logic,
rationale, and principles of treatment, not with technical details.
Its purpose is to give a broad yet sound perspective on treatment
of malocclusion in adolescence-a perspective to provide the basis
for treatment, irrespective of the appliance or whether the patient
will be treated by general dentist, pedodontist, or orthodontist.
A. UNDERSTANDING ADOLESCENT
TREATMENT
1. General Characteristics of Adolescent MaloccIusion
a) Dentition and occlusal relationships are established.
b) Skeletal growth may be mostly over and decelerating.
c) Muscle function is matured.
d) Functional malocclusions are less frequent since they have
largely been accommodated by dentoalveolar, skeletal, and/or
mandibular joint adaptations.
e) Temporomandibular dysfunction is more frequent since
dental, skeletal,and joint adaptability have diminished.
f) Psychological aspects are more significant than at younger
ages.
2. Advantages of Adolescent Treatment
a) Control of all permanent teeth, except third molars, is now
possible.
b) It is beneficial to treat when bone turnover rates are still
high though adult dimensions are nearly achieved. Repair and
remodeling occur readily in response to orthodontic forces though
the basic craniofacial morphology is largely established.
c) Motivation for treatment is high, especially when facial
esthetics are affected.
d) Treatment-goals can be more surely defined, since one
does not have to counter, as much as earlier, the unpredictable
dynamics of growth.
e) Since treatment is less dictated by developmental events,
treatment options are lessened.
3. Some Difficulties in Adolescent Treatment
a) The best opportunities for control and manipulation of
severe skeletal dysplasia are past.
b) Sports and social activities, so important to adolescents,
often compete with plans for orthodontic treatment.
c) The time necessary for treatment may be longer for certain
malocclusions.
d) Tooth positioning is often more difficult when the occlu-
sion is fully established and root formation is complete than was
tooth guidance during eruption.
.'
B. DEFINING GOALS IN ADOLESCENT
TREATMENT
Since precise tooth poslttoning is the principal strategy in
adolescent treatment, cephalometric analysis for treatment plan-
ning is essential and many analyses have been designed solely to
determine the placement of teeth within particular skeletal mor-
phologic patterns. We may group treatment goals for discussion,
quantification, and planning as follows: (I) skeletal; (2) dental;
(3) occlusal and functional; (4) soft-tissue and facial esthetics; and
(5) compromises.
1. Skeletal
Improvement in the craniofacial skeleton by orthodontic treat-
ment is still possible in adolescence, although the greatest oppor-
tunities for so doing may be over by this age. A primary aim of
some clinicians is to predict the time of the adolescent growth
spurt to utilize it in the planned orthodontic correction. A number
of maturity indicators, particularly the hand-wrist radiograph, have
been used in such predictions. Despite their popularity, the evi-
dence is strong that predictions of peak facial growth velocity (or
more often Peak Height Velocity) based solely on carpal radio-
graphs are uncertain and of very limited practical value. However
most authorities see merit in studying several indexes of maturity,
especially for those instances where developmental events are ob-
viously abnormal. See Suggested Readings for modem references
on. this topic. When the 1J1~xillo-mandibular relationships are to be
alt~red, it is important to ascertain whether the maxilla, the man-
dible, or both are to be changed 'and to quantify the amount of
change sought in each jaw (see Chapters 12 and 14). Although
mandibular impedence or enhancement is more difficult after pu-
bescence, midface changes are possible with intensive orthopedic
forces. Vertical change is most apt to occur within the dentoal-
veolar process or by rotation of the mandible following dentoal-
veolar changes. Planned horizontal and vertical skeletal changes
should be quantified and monitored regularly by cephalometric
analysis.

2. Dental
a) Axmllnclinations
The roots of posterior teeth should be approximately parallel
to one another, especially those roots adjacent to extraction sites.
Artistic positioning of the crowns of anterior teeth usually results
in a slight divergence of the roots. The root angulation of the
anterior teeth is lingual and an interincisal angle 'of 130 degrees
may serve as a rough guide. However, the percentage of the 130
degrees contributed by upper incisors and lower incisors varies
greatly with the maxillo-mandibular relationship and the steepness
of the mandibular and occlusal lines (see Chapters 12 and 14).
b) Incisal Relations
Ideally the overbite should be approximately one-third of the
lower incisal crown. The overjet-which is determined by the
axial inclination of incisors, the skeletal relationship, the relation
of the widths of upper to lower teeth (Bolton Index, see Chapter
11) , and the labiolingual thickness of the crowns-should provide
incisal centric stops in the intercuspal (usual occlusal) position.
c) Midliness
The dental midlines should coincide with each other and with
the mid-sagittal plane of the craniofacial skeleton.
d) Arch Form
The arch forms should be symmetric and coordinated with
each other and should, as much as possible, be concordant with
the forms of their skeletal bases. The mandibular intercanine di-
ameter should rarely increase during adolescent treatment, since
such an increase has been shown repeatedly to be unstable irre-
spective of the appliance use 17.24.26
e) Spacing
Ideally, all teeth in both arches should have firm interproximal
contacts and there should be neither crowding nor rotations of the
teeth. However, the Bolton Index (see Chapter 11) may reveal that
such perfect results are impossible and that some spacing or crowd-
ing is inevitable.
1) Curve of Spee-Occlusal Line
Generally the occlusal line should be level and its final re-
lationship to the mandibular line determined prior to treatment,
according to the steepness of the mandibular line and the A-B
relationship (see Chapter 12). The desired angulation of the incisors
to the occlusal line is usefully decided prior to treatment.
3. Occlusal and Functional
The desired occlusal pattern .(group function or cuspid rise)
should be determined at the start and brackets placed accordingly.
The treated occlusion should display no deflective interferences
during mandibular occlusal movements or in the retruded contact
position (centric relation). There should be no balancing interfer-
ences and the posterior teeth should disclude during protrusive
movements.
4. Soft-Tissue Profile and Esthetics
It is harder to quantify esthetic goals of treatment and personal
Adolescent Treatment 435
tastes vary, yet there are some commonly accepted standards. The
incisor positions should not strain the lip musculature and the
incisal overlap should be harmonious with the lip line. Little dis-
play of the gingivae during smiling is desirable. The lips should
be without strain at rest and in function. Obversely, the incisors
should not be retracted excessively lest the lip drape at rest given
an aged or edentulous appearance to the soft-tissue profile. Ex-
cessive retraction of the incisors also robs the lips of proper par-
ticipation in facial expressions.
5. Compromises
When defining goals for adolescent treatment, one begins with
the ideals, listed above, accepting compromises only when the
conditions of the case force one to do so. In adult treatment, one
often is forced to begin with compromise (see Chapter 17). In
adolescent treatment every necessary compromi~e in the treatment
plan should be quantified in terms of the skeletal profile and tooth
positions, and all of the "trade-offs" and consequences of com-
promise should be noted and understood at the start. Often a
hastily, casually, or unwittingly accepted compromise at the be-
ginning has serious consequences later. Adolescent treatment should
aim for idealism.
C. ASSESSMENT OF RESULTS OF
ADOLESCENT TREATMENT
All of the goals previously described may be used as criteria
for assessing the results of adolescent treatment (Fig 16-1). Every
general practitioner must be able to evaluate the clinical results of
orthodontic colleagues in order that patients may be sent for the
best treatment available. But there is another good reason why
general practitioners must have a precise, clear picture of the
possibilities of good orthodontics: that is to set high standards for
the cases they choose to treat themselves. One must demand of
oneself the same high-grade results one insists on from the ortho-
dontist.
Evaluation of orthodontic treatments must be done precisely
and with caution for there are many variables which determine the
quality of a treated result. Unless one knows exactly the conditions
under which a case was treated, it is wise and professionally
prudent to be cautious in conclusion and discreet in comment;
nonetheless there are guiding principles to use in evaluating any
tn;a~ed case. "~.
• When adolescent treatment is progressing in an unsatisfactory
manner or an unsatisfactory result is observed at the "end" of
treatment there are no easy alternatives. Poor treatment does not
stabilize or improve with time. Retreatment to the standards to be
described is really the only satisfactory solution. For this reason
adolescent treatment must be accompanied not only by meticu-
lously designed original goals but also by persistent monitoring
throughout treatment. Should an unsatisfactory result necessitate
a consultation or referral to a colleague for advice andJ.or retreat-
ment, complete original diagnostic records are invaluable.
436 Treatment

A1bPI -3
------
-----
SE-FMN-A
Ba-Se-B
'lIFOP
I/Md
Measure
SNA
SNB
MdPL/A-B I/MdPI./A-B
Pol
SE-N-A
Ba-Se-Gn
I/A-Po
l/FOP PI
Horizontol FEMALE
-2 -ISO. X ISO. 2 3

JW /2-5

JW 12-5

A1c CLASS n PLOT, HORIZONTAL

Skeletol Closs II?

Mld-foce Prognothic?

Mondible
Retrognothic .;)
Mondibulor teeth
Procumbent
Moxillory teeth +,-
Procumbent

50'4294026542757661197191947'1100558121133222761128
E (El B+ B C+ C 0+ 0 F F F F FE FE Fe Fe 'C 'C Fo Fo A A A A

N=697
JW
Unclassified = 12
Incomplete Data = 25
FIG 16-1.
Records of well-treated adolescent cases. A, case of well-treated year-old girls; b, Class!hanalysis Z-score chart; c, horizontal ar-
Case 11type B-2 malocclusion. A-1·, before treatment: a, cephalo- borization. (Continued.)
metric tracing with profile analysis measurements and norms for 12-
 Adolescent Treatment 437

A29
J.W. VERTICAL ANALYSIS
• Before (12-5)
A After (15-7) -3 -2 - tS.D. X t S.D. 2 3
Cranial 8as~
PM Vert/FMN-SE MALES
90 85

90 I 85
Maxilla
PM Verl/Polline MALES
90 95
I
FEMALES A95
Occlusion
PM Verl/Oce!. line MALES
(not 0 constant in Closs DJ ~5
FEMALES
175 1051110

Mandib/~ I
I
PM Vert/Mond. Line MALES
i 95
I
125 130
I
115 120 125
I I I
FIG 16-1 (cont.).
A-2, after treatment. This patient was treated with hi-pull extra-oral tractiol"), and a full edgewise appliance. (Continued.)
 438 Treatment

FEMALES
-3 -2 -IS.O. l<' IS.o. 2 3
~
Bo-SE-fMN
11~~~~-
-Ll
~~ 14!.b I~~ I~. I~
Ba-S-No
I 120 ,~t ,..,! ...• ~.. j,~", ;l~$
I
Cronio/8Qstl-Noxi/lQ
l I

~.
$-N-A '"
, .0 las 190;
SE-FPolNA u' ..
11

CranlaIBou-Moll(/1b116(HJ I
Bo-SE-Me I ••

. Bo-SE -Pog . I 60 eo
CrolllOlBou-MOI7(/iblftfV) !
Bo-SE/Moncl. Line

PM VertlMond.Une
Moxillo-Mandlbltl
Mood. Une/A-a

F~.OcclLn./A-B
(nOlo""",.1OtrI1
~ I
,
fMN-A-B
''i45 150
,
1"
I

CK 12-0

FIG 16-1 (cont.). -.

B, case of well-treated Class III rT)alocclusion. B-1, pretreatment postlJeatment records. Note the improvement in the skeletal rela-
records: b, the cephalometric tracing with modified counterpart anal- tionsh'ip anteroposteriorly and the compensation in the dentoalveolar
ysis data indicate maxillary deficiency and a severe Class III A/B area, This patient was treated with face mask traction and a complete
relationship; c, the basic morphologic analysis Z-score chart, B-2, edgewise appliance,

1. Occlusion
The following is a checklist of occlusal features useful in
evaluating the results of orthodontic treatment. The classic article
by Andrews provides excellent reading on this topic. I
a) Occlusal Plan
Irrespective of the merits of various theories of occlusion, the
intended plan of occlusion should be readily obvious on any treated
case. If a cuspid rise occlusion was chosen, then the entire occlu-
sion should be consonant with that theory. If group function was
the plan, then the occlusion should be judged by the principles of
that approach.
b) Molar Relationships
Much orthodontic treatment focuses only on first molar oc-
clusion, but the occlusal relations of all molars and bicuspids
should be studied carefully and the lingual molar occlusion is
particularly revealing.
c) Cuspid Occlusion
While the cuspid occlusion is as important as the molars, it
is not always possible to have equally good molar and cuspid
relationships if there are tooth size disharmonies. More compro-
mises in cuspid occlusion and overbite and overjet are necessary
in men and boys because of the sexual dimorphism in maxillary
cuspid size.
d) Incisor Position
Incisors must be placed well over the basal bone in each arch
and well related to one another. Careful root positioning determines
incisal stability and esthetics. While lay persons may judge an
orthodontic case by incisal alignment alone, the dentist must ask
how the incisors have been fitted to the skeletal profile and how
they participate in all occlusal functions.
e) Functional Occlusal Relations
The occlusion must be studied in the retruded contact position
(centric relation) and in the intercuspal position (centric occlusion).
Gnathologically oriented orthodontists often attempt to achieve a
point centric in the retruded contact position; others will devise
an occlusal plan which permits a "long centric." Under either
scheme, they must obtain a complete AP occlusal correction at
the end of treatment and the cusp-fossa relationships must be
meticulously correct. There should be no occlusal interferences in
the retruded contact position nor any between the retruded contact
and intercuspal positions. It is especially important that there be
no balancing interferences (more apt to appear at the conclusion
of extraction treatment). In protrusive occlusion the incisors should
contact symmetrically and there must be complete posterior dis-
clusion (see Chapter 15, Section D 14, Temporomandibular
Dysfunction) .
fJ Root Positions
In extraction cases, it is important that the roots be parallel
and directly beneath. the crowns to avoid loss of interproximal
contact. In treated crossbite cases, root positions must agree with
crown correction.
Adolescent Treatment 439
g) Alignment
It is naive to consider alignment of the crowns the most critical
feature of a treated orthodontic case. Crown size disharmonies
may still be present at the end of treatment when there is a Bolton
discrepancy. Disharmonies of tooth size and the adaptation of
occlusal function to continuing growth may deny perfect alignment
in some cases.
2. Soft Tissues
Facial and tongue musculature play an important role in sta-
bilizing orthodontically treated ~ases, and the facial soft tissues
determine, to a great extent, esthetic results. The time of treatment
and the time of the evaluation are important since there are sig-
nificant soft-tissue growth changes during childhood and adoles-
cence28 One must also decide whether or not any adaptive functions
which accompanied the mal occlusion are still present after treatment.
a) Lips
The lips should be studied at rest as well as in action. With
the patient at rest, relate the lip line to the maxillary incisors. Note
the action of the lips in speech and breathing as well as facial
expression. In all functions they should be relaxed, well adapted
to the skeletal profile and the incisors, at no time strained, and
revealing minimal gingivae except during a full smile.
b) Tongue
At rest the tongue should lie mostly within the mandible with
the dorsum visible and the tip below the mandibular incisal edges.
If the tongue tip lies atop the lower incisors at rest, one may expect
a residual open bite when the teeth are in occlusion.
c) Swallow
The unconscious swallow is probably the single most im-
portant occlusal stabilizing feature (Chapter 10 gives details for
evaluation of the swallow). Test whether or not the teeth are in
occlusion during the unconscious swallow, observe the position
of the tongue during the swallow, and note any abnormal tongue
activities.
d) Gingivae
Gingival health after orthodontic treatment reflects not only
oral hygiene but also the positions of the teeth achieved at the end
of orthodontic therapy. 29 Especially vulnerable is the gingival height
of mandibular incisors" and the gingival relationship to maxillary
molar and bicuspid roots after palatal expansion. 10
.,
3. Facial Esthetics
Because each face is unique, it is impossible to produce iden-
tical results for all patients; rather, orthodontic treatment should
enhance the patient's individual esthetic features. Especial care
must be taken in evaluating the child patient for there is a tendency
to apply adult standards of facial esthetics. Serial studies of the
variability and change in soft-tissue and integumental growth are
rare28 The nose shows continued growth into adulthood, which
alters facial esthetics. Faces which seemed to be rather full in the
440 Treatment
dentoalveolar region in adolescence may look much better after
adult nasal growth is completed.
The two most common problems in facial esthetics involve
extraction. In some cases choosing not to extract strains the limits
of the alveolar process to achieve alignment, yet time, growth,
occlusal function, etc., may improve the eventual facial esthetics.
In other instances, unfortunately, the same factors produce crowd-
ing and mal alignment. Extractions which produce adult faces in
young adolescents are to be deplored, for those same faces a few
years later may look almost edentulous. No formulas are infallible
when planning treatment and it is always easier to second-guess
treatments after the fact. Criticism comes easier than craftsman-
ship. Facial esthetics is a matter of personal judgment, so one's
owl} opinions about esthetics should be imposed with caution on
colleagues who saw the patient at another time.
4, Alveolar Process and Periodontium
The height of the interseptal tip, the contours, and the general
health of the alveolar bone and thickness of the periodontal liga-
ment space may be studied in the periapical radiographs.
5. Root Resorption
There is no question that root resorption occurs in some or-
thodontic patients more frequently than in others and is often
associated with the necessity to translate and intrude incisors over
a considerable distance. 15. 16 Minor root blunting may be considered
a sort of "scar" of treatment. On the other hand, excessive root
resorption, particularly where roots were short originally, is an
occasional tragedy of orthodontic treatment. Unless the dentist
judging treatment after the fact has the original radiographs and
can prove (not an easy thing to do) that the orthodontic treatment
was the sole cause of the root resorption, critical comments should
be carefully phrased and professionally presented to the patient.
Idiopathic root resorption is a fact of life. I have seen cases with
normal roots at the end of orthodontic treatment that several years
!lIter showed root resorption. I have also seen cases in which the
orthodontist apprised the patient of the presence of active root
resorption at the start of treatment and they were willing to take
the calculated risk of a bit more resorption. See Chapter 13 for a
discussion of root resorption.
6. Temporomandibular Joints
Orthodontic treatment has been blamed for some difficulties
in the etiology of temporomandibular joint disorders, but there is
good evidence that temporomandibular abnormalities are an in-
tegral part of many skeletal dyplasijis32 and that orthodontic treat-
ment diminishes rather than exacerbates temporomandibular
symptoms.30
If treatment was completed before eruption of second molars,
their emergence may produce occlusal interferences which exac-
erbate temporomandibular symptoms in susceptible patients. In a
similar way, the eruption of the mandibular third molar may elevate
the distal marginal ridges of the mandibular second molar, creating
occlusal interferences.
The well-treated orthodontic case achieves an occlusal ho-
meostasis and thereby adapts to such features as tooth drift, oc-
clusal and interproximal wear, alveolar remodeling, and normal
craniofacial growth. If the occlusion was not equilibrated well at
the end of active treatment, adaptive homeostasis is less easy and
some relapse may be seen irrespective of how long retainers are
worn. Furthermore new restorations may upset the orthodontist's
occlusal result. All of these events may seem minor, but in the
patient susceptible to temporomandibular disturbance-and that
includes many of the more severe skeletal malocclusions-minor
occlusal disturbances can be disruptive. The diminution of tem-
poromandibular joint symptoms and the maintenance of tempo-
romandibular health and function are primary goals of all orthodontic
treatment, and therefore, assessment of temporomandibular joint
function is an integral part of the evaluation of any orthodontic
case.
D. CLINICAL PROBLEMS*
,.
1. Number of Teeth
a) Congenitally Missing Teeth
• Definition of the problem and background: See Chapter 15.
• Diagnosis: See Chapter 15.
• Treatment: See Chapter 15.
1. Maxillary Lateral Incisors.-
(a) Goals.-If a bridge or bridges are to be placed, the goals
of treatment must include attentive detail to the positioning of the
central incisors and cuspids which may be abutment teeth. When
the cuspid and all other maxillary posterior teeth are to be moved
mesially, obviating the need for a bridge, then the principal new
goal is the meticulous placement of the cuspid root to parallel the
central incisor. The first bicuspid and all posterior teeth are moved
forward into a Class 11 relationship.
(b) Methods.-A precision bracketed appliance is necessary,
usually in both arches. As the cuspid is moved mesially and turns
the corner of the arch, its crown is gradually reshaped to simulate
a lateral incisor (Fig 16-2). The labial surface must be flattened,
the incisal edge squared, and the lingual surface reduced consid-
erably to achieve an esthetic overbite and overjet. The opposite
lateral incisor which is present is usually smaller
• than normal size
(see Chapters 6, 7, and 15) and therefore should be placed to
accept additive composite build-up for esthetics and stability. Care-
fuL.and somewhat difficl\!t· mechanics are required to position all
of th~ maxillary teeth correctly, b~t the results in most cases are
well worth the effort."
(c) Problems.-Moving the first bicuspid forward into the
cuspid region usually creates balancing interferences; therefore,
its lingual cusp must be reduced gradually during its mesial move-
* All of the cases shown in this chapter were treated by the author
unless another clinician is credited. In a book of this size and scope,
examples of every problem discussed cannot be shown; therefore, only
some representative cases appear.

FIG 16-2.
Moving the maxillary cuspid mesially to serve as a lateral incisor. A,
panoramic radiographs after previous orthodontic treatment by a
colleague. Note the excellent result obtained. There was a maxillary
retainer with a lateral incisor pontic in place. The adjacent central
ment. If a cuspid rise occlusion is desired, the bracket height on
the first bicllspid must be placed atypically to guarantee its extru-
sion. (When using cuspids to replace lateral incisors I have gen-
erally found group function occlusion to be more satisfactory).
Particular attention must be paid to the positioning of the molars
and they must be equilibrated by occlusal grinding to secure the
occlusal result.
2) Mandibular Second Premolars.- The goals of treatment
are to obviate the need for a bridge, secure a more correct inter-
cuspation, and guarantee the height and health of the alveolar bone
on the mesial aspect of the mesial root of the first molar. If a
primary second molar is retained unduly, this usually results in an
undesirable relationship of the alveolar septum between the second
primary molar's root and the first permanent molar (see Fig 17-
22).
Treatment of congenitally missing mandibular second bicus-
Adolescent Treatment 441
incisor had a serious crown fracture replacement. The patient's mother
is a dental hygienist, and the patient is a dental student. Despite the
splendid orthodontic result obtained, they asked me to treat the case
again to obviate the need for a bridge. Band C, results after treatment.
pids by mesial movement of all posterior teeth is not a difficult
technical problem for anyone skilled in precision bracketed ap-
pliance therapy. While the problem is best treated earlier (see
Chapter 15), it can still be treated well in adolescence with brack-
eted appliances. Its treatment with removable appliances is not
recommended since ultimate parallelism of the roots is essential
f?r a stable result. .,~'
~..The method illustrated in ~ig 15-5 was developed by Pro-
fessor van der Linden and has advantages over simply extracting
the primary molar and moving the permanent molar forward.
3) Multiple Absence of Teeth.-See Chapter 17.
a) Loss of Permanent Teeth (Trauma, Caries, and Other
Causes)
• Definition of the problem and background: see Chapter 15.
• Treatment: see Chapter 15. While the general principles
442 Treatment
outlined in Chapter IS for treatment of lost permanent teeth
at an early age apply in adolescence as well, there are two
significant differences. First, one can not take such ready
advantage of the natural forces of eruption and mesial drift-
ing. Second, precision bracketed appliances-can now be
used more easily.
When one or more first molars are lost, the same difficult
problems are encountered as at an earlier age except that the shape
and size of crowns of the third molars are seen more clearly and
one can take better advantage of their eruption.
b) Supernumerary Teeth
See Chapter IS. It is a rare event when supernumerary teeth
are encountered in the completed adult dentition. The major prob-
lem at this late date is not the supernumerary tooth itself, but the
basic malocclusion, on which the treatment planning should be
focused.
2. Variations in Size and Shape of Teeth
• Definition of the problem and background: see Chapter IS.
• Diagnosis: see Chapters IS, 8, and 11.
• Treatment:
a) "Large Teeth"
This problem is really that of simple crowding (see Section
4, Problems Singular to the Young Adult Dentition).
b) Small Teeth
See Chapter 15. Esthetics are more critical at this age than
during childhood and "permanent" treatment combining ortho-
dontics and restorative dentistry can be quite sucessful. The in-
troduction of composites, laminates, and porcelain veneered crowns
offers esthetic and functional success previously not possible.
c) Anomalies of Tooth Shape
See Chapter 15. A more permanent treatment of crown anom-
alies is possible when started in adolescence. Moreover, problems
handled earlier often may be treated again, advantageously, to an
esthetic result not possible earlier. Anomalies in root length and
morphology are more obvious in adolescence and often play an
important role in treatment planning (e.g., deciding whether to
remove first or second bicuspids in extraction cases).
3. Spacing of Teeth
a) Localized Spacing
See Chapter 15. Diagnosis of localized spacing is easier when
the permanent dentition is complete and treatment to a more es-
thetic finished result is possible.
b) Generalized Spacing
See Chapter 15. After growth is largely over one may adopt
a different approach to the problem of generalized spacing. Usually
the solution requires combining prosthetic or surgical skills with
orthodontics, so cooperative treatment planning is essential. Oc-
casionally prosthetics alone is sufficient. More typically, consol-
idation of the teeth within the arch is done by orthodontics prior
to placing bridges with pontics representing accessory bicuspids
or molars in the spaces created orthodontically. I prefer to avoid
surgery except in the most gross instances of macroglossia. Modem
restorative procedures make possible results of the highest quality
'with infrequent resort to surgery.
4. Problems Singular to the Young Adult Dentition
a. Crowding
Dealing with crowding in the young adult dentition is different
than managing space in the mixed dentition. Crowding is a result
to be treated after the fact. Space management is controlling
development.
1) Simple crowding.-
(a) Definition.-Simple crowding is defined as disharmony.
between the size of the teeth and the space available for them. It
is crowding uncomplicated by skeletal, muscular, or occlusal func-
tional features. Simple crowding is most frequently associated with
a Class I molar relationship, although it may be found with Class
II horizontal type A (maxillary dental protraction and the normal
facial skeleton).
(b) Diagnosis.-First, complete a diagnosis setup without
advancing the lower incisors or expanding the bicanine, or bimolar
alveolar arch diameters (see Chapter 11) unless the lower posterior
teeth are obviously tipped lingually. The diagnostic setup under
these constraints answers the question of whether or not alignment,
simple uprighting, and rotation alone will solve the problem. The
diagnostic setup, a cephalometric analysis, and judgment of facial
esthetics and the lip musculature are critical in defining a simple
crowding case and planning its treatment.
There are no infallible cephalometric rules providing easy
determination of quantifiable amounts of arch perimeter increase
for measurable changes of incisor position or angulation. Nor are
there specific and reliable rules for combining lip, teeth, and bony
measurements from the cephalogram to provide simple answers
about extractions: all have built-in subjective factors of judgment.
One may advance and reposition the incisors in the cephalometric
tracing to visualize two-dimensionally and statically how such
repositioning encroaches on the lip muscles. In the end, however,
one is forced to make a clinical judgment, which at best integrates
three semiquantified factors, namely the a~ount of new space
which would be made by incisor repositioning, the amount of space
whi~h might be created t;>y. changing arch form and dimensions,
and tne amount of such dental ch,anges the lips might tolerate.
Schemes for including the third molar region in a "total arch
analysis" have been presented and are useful provided one un-
derstands (1) the importance of experience in making judgments
about esthetics, and (2) the large Standard Error in methods thus
far suggested for predicting third molar eruption.
Several well-designed studies of posttreatment changes in-
dicate that widening the mandibular cuspid diameter, irrespective
of the appliance used, is not well maintained. 17,24,26 Those who
claim otherwise for their favorite appliance have the obligation to

present patient results, as others have done, many years after active
therapy.
(c) Treatment.-
• Non-extraction.- Treatment planning is Simply choosing
the appliance to achieve the results displayed in the diag-
nostic setup. Precision bracketed appliances are particularly
advantageous in these cases, while lip bumpers are useful
adjuncts since they increase the arch length and condition
the lip musculature (see Fig 15-23). Small amounts of
space often may be created in either arch by their use dur-
ing alignment and positioning. Larger amounts than possi-
ble with lip bumpers can be garnered with extra-oral
traction but such increases are difficult to maintain in the
lower jaw.
• Extraction.- Treatment planning is primarily concerned
with the choice of teeth to be extracted and the tooth
movements necessary for positioning and closure of any re-
sidual spaces after alignment.
First bicuspids: In cases of anterior crowding, first bicuspids
are closest to the problem; thus, their extraction simplifies align-
ment, is the least apt to upset the molar occlusion, and is the best
alternative for maintaining vertical dimensions. The disadvantages
of first bicuspid extractions have been greatly exaggerated by some
in recent years. When the facial esthetics are good at the start,
despite severe incisal crowding, removal of first bicuspids can
harm appearance only if the appliance mechanics are mishandled ..
It is essential to maintain parallelism of the cuspid and second
bicuspid roots after space closure.
Second bicuspids: Second bicuspids are sometimes chosen for
extraction when there is a lesser space discrepancy making space
closure and vertical control easier after anterior alignment. They
may be the choice when one wishes to maintain the soft-tissue
profile and esthetics. It may be disadvantageous to take out second
bicuspids where the crowding is extensive and solely in the incisor
region since anchorage control is more difficult. Second bicuspids
show more variability in development and morphology and thus
are sometimes chosen for extractions irrespective of the site or
amount of crowding.
Second molars: In recent years there has been a revival of
the advocacy of second molar extractions (see Chapter 15). They
are rarely the teeth of choice in simple crowding, except in hor-
izontal type A or horizontal type B (see D6, Class 1I) where the
removal of maxillary second molars may aid dorsal movement of
the maxillary dentition when the third molars are normal in size
and shape. Often the removal of second molars provides too much
space in the wrong place for simple crowding. Further, the man-
dibular third molar's development and eruption may be compli-
cated and an additional later period of orthodontic treatment made
necessary by second molar extractions (see Section 4-a-2, Complex
Crowding, and Suggested Readings).
Other alternatives: Differences in crown size, location of car-
ious or restored teeth, and occlusal factors revealed in the diag-
nostic setup sometimes suggest the extraction of first bicuspids in
one arch and seconds in the other. The extraction of a first bicuspid
in one quadrant and the second on the opposite side of the same
arch is rarely indicated due to differences in crown size. It may
be necessary, however, due to asymmetry, caries, or to avoid
Adolescent Treatment 443
extraction of a sound tooth. The therapeutic extraction of first
permanent molars in simple crowding is almost always contrain-
dicated. If one or more first molars have already been lost (see
Chapter 15) the extraction of other first molars may be considered,
but the treatment planning is complicated, as noted in Chapter 15,
and the necessary tooth movements are extensive and difficult.
2) Complex Crowding.-
(a) Definition.-Complex crowding is crowding caused and
complicated by skeletal imbalance, abnormal lip and tongue func-
tioning, and/or occlusal disfunction as well as disharmony between
the sizes of the teeth and the available space.
(b)Diagnosis.- The diagnosis of complex crowding itself is
secondary to the diagnosis of any skeletal dysplasia. Tooth re-
positioning necessary to camouflage skeletal dysplasia usually ag-
gravates complex crowding; therefore, first estimate the effects of
treatment of the skeletal dysplasia on the crowding. Expected
growth may affect additionally the crowding. The use of a Visual
Treatment Objective is very helpful for the diagnosis and treatment
planning of complex crowding (see Chapter 12 and appropriate
sections later in this chapter).
(c) Treatment.- The choice of which teeth to extract for the
correction of complex crowding is critical. Review carefully the
considerations discussed above for extractions in Simple Crowd-
ing. Often one bicuspid in each quadrant will be found to be the
most logical solution, but the choice is seldom simple. Complex
crowding cannot be understood by study of the casts alone for it
is more than a tooth size-available space problem, and can be
made worse by ill-conceived "treatment." Failure to appreciate
the importance of skeletal morphology in the etiology and treatment
is a common mistake. Some typical severe mal occlusions suggest
particular extraction procedures; for example, in Class II horizontal
type B, when the crowding is all in the lower arch, it may be
advantageous to extract upper second molars and two lower bi-
cuspids. Under no circumstances should second molars be ex-
tracted unless the third molars are normal in size and development.
Lower second molars may be considered for extraction only when
they are severely malplaced and inadequate alveolar development
denies their complete eruption. Never be casual about the extrac-
tion of lower second molars. Though at first it may seem the most
logical choice to relieve the crowding, even apparently well-po-
sitioned third molars may not erupt into satisfactory positions after
second molar extractions (see Figs 15-31 and 16-3). Therefore,
a subsequent period of active treatment is necessary. Far too often
th~ .removal of lower second molars has been a cheap, quick fix
which leaves the unwitting patiel)t with another problem and an-
other treatment years later 27 (see Suggested Readings). In my opin-
ion, there is far too much overenthusiastic advocacy of the extraction
of second molars in the absence of well-documented study of
consecutively treated cases. Upper third molars are surprisingly
cooperative after second molar extractions, often erupting nicely
into position, but lower third molars respond quite differently and
their behavior after second molar extractions is, at present, only
crudely predictable (Fig 16-3).
Whatever the extraction choice, it must be followed by
444 Treatment

FIG 16-3.
Two examples of second molar extractions in orthodontic treatment.
A, an excellent result. Note that in one quadrant a first molar was
extracted. Observe too that neither of the lower third molars, even
in this splendid result, is positioned correctly and that the patient
might benefit from a bit of further treatment even at this late date.
B, a less satisfactory result. Note in the lower arch the differing
positions of the erupting second molars. After complete and suc-
cessful orthodontic treatment the third molars in the lower arch were
not able to position themselves adequately. Note too, the difference
in the size of the two upper third molars as they erupt. This difference
is not as noticeable in the earlier radiograph. (Courtesy of Dr. George
A. Eastman.)

precisely controlled tooth movements to close the spaces, parallel
the roots, fit the incisors to the profile, and define a secure oc-
clusion. Whoever makes the decision about extractions is ethically
reponsible for their sequelae.
b) Delayed eruption
1) Impactions
(a) Maxillary cuspids.-Background: When impacted max-
illary cuspids are first discovered in adolescence, root formation
is apt to be already completed. Thus the chance for utilization of
the natural eruptive forces is likely past. The teeth are truly im-
pacted, but they mayor may not be in ectopia.
Diagnosis: Diagnostic factors of interest include the position
of ,both crown and apex, the space available to accommodate the
cuspid in the arch, and the position and health of adjacent
teeth-especially the roots of the lateral incisor, the intactness of
the labial cortical plate of bone, the willingness of the patient to
undergo prolonged orthodontic treatment, and the relationship of
the condition to other orthodontic treatment needed. All require a
meticulous radiographic perspective. The size of an impacted cus-
pid may be determined by measuring the antimere. If both cuspids
are impacted, measure the crown width of the maxillary first and
second premolars and estimate the size of the cuspid crown by
referring to appropriate tooth size charts (Chapter It). Do not
forget that sexual dimorphism in crown size is more obvious in
A
FIG 16-4.
Treatment of bilateral palatally impacted maxillary cuspids.
Adolescent Treatment 445
the maxillary cuspid than any other tooth. Measurement of crown
size of impacted cuspids in the radiograph is flawed by distortion
due to the angulation and the curvature of the film. Study carefully,
in the radiograph, the health and morphology of the cuspid's root
as well as its position.
Treatment: Two treatment procedures are possible in adoles-
cence: (I) surgical exposure followed by orthodontic movement
and (2) autogenous transplantation.
Surgical exposure and orthodontic movement: Surgical ex-
posure and orthodontic movement of the tooth into position are
favored in most instances because, though more prolonged, the
treatment is less hazardous. If the primary cuspid is still in position
and the unerupted ·permanent cuspid is ideally located, surgical
exposure may be made after the initial stages of orthodontic bracket
engagement and leveling elsewhere in the arch. At the time of
surgical exposure a cuspid bracket is positioned on the crown of
the tooth. Following subsequent healing, traction may be applied
by an elastomeric chain and later direct tying to the archwire. In
the past, stainless steel lariats were passed around the neck of the
tooth or threaded pins were inserted into holes drilled into the
crown to apply traction. The development of direct bonding tech-
niques obviates the need for such drastic procedures and a healthier
gingival attachment results.31
If a bracket may not be advantageously positioned, a lingual
button or cleat may be bonded in place and tied tightly with a
••
.•
/
446 Treatment
twisted stainless steel ligature, which is passed through the sur-
gically incised mucosa and secured to the archwire, or placed
passively around adjacent brackets. When healing is complete, this
ligature may be tied directly to the archwire, whose tension aids
the tooth's eruption. When the crown becomes more fully exposed,
the attachment may be replaced with a bracket. OI1hodontic po-
sitioning of impacted cuspids is tedious since the forces must be
gentle and continuous and the distance is great. Because of the
surgical uncovering, the ultimate gingival contour may not be
perfect. When the crown is in position, paralleling of the root is
necessary to satisfy occlusal needs, develop the cuspid eminence,
and guarantee stability of the result. Figure 16-4 illustrates a
treated maxillary cuspid impaction.
More extreme malpositions necessitate other tactics. When
the apex is reasonably placed but the crown is not, the surgeon
may carefully remove bone around the crown and gently reposition
it without altering the apex. The crown is then held in place with
surgical cement during healing and prior to instituting traction.
Autogenous transplantation: Autogenous transplantation may
be indicated in older patients or those unwilling to tolerate pro-
longed orthodontic treatment. It is also useful in cases of trans-
position, extreme malposition of the impacted tooth, and dilac-
eration. It is usually a one-stage surgical procedure-the root is
not filled. 18The impacted tooth is carefully removed and placed
beneath the mucosal flap while an artificial alveolus is cut in the
bone. Then the cuspid is carefully placed and splinted during
healing. Professor James P. Moss of Great Britain, more than
anyone else, has studied and perfected the details of the procedure
and has reported large numbers of consecutively treated cases
followed years after treatment with surprisingly good results.]8
Although transplantation is sometimes done as a single form
of treatment without orthodontics, better results are obtained when
combined with orthodontics. It may be advantageous to have a
period of preliminary orthodontic therapy before the surgery. The
surgeon mayor may not choose to use the orthodontic appliance
as the splint. After surgery it is important that the transplanted
cuspid have a period of secure passive splinting prior to any con-
tinuing tooth movements, but the transplanted tooth must not be
in traumatic occlusion. Orthodontic treatment after transplantation
should be minimal and not be started until the alveolar process
has reformed around the transplanted tooth, and the tooth's vitality
is assured. Autogenous transplantation is quicker and allows suc-
FIG 16-5.
Treatment of "locked" (semi-impacted) mandibular second perma-
nent molars. This is the same case as shown in Fig 15-40. A, a
method for preliminary uprighting. A lingual button is bonded to the
occlusal surface of the second molar, and an elastomeric chain is
cessful treatment of some cases which could not be handled by
simple surgical exposure and orthodontic movements alone. It
requires skillful surgery and an appreciation by the surgeon of the
orthodontic problem, just as the orthodontist must be aware of the
surgical difficulties
(b) Second Molars.-Second molars may be impeded in their
eruption when they become locked under the distal bulge of the
first permanent molars. The locking may be relieved by the use
of "disimpaction springs" which separate the second molar from
the cervix of the first and free it to continue its eruption. In more
severe cases of semi-impaction, or after second molar root length
is completed, a compression loop spring may be fashioned and
fitted into a buccal tube on the first molar and formed to contact
a bracket or button attached by composite resin to the exposed
crown of the second molar (Fig 16-5). (See also the earlier com-
ments about second molar extractions in complex crowding, and
the discussion of third molars which follows) .. '
(c) Third molars.- The extraction of obviously impacted
third molars has been advocated early in adolescence when their
removal is easier and is less apt to damage adjacent teeth. In severe
instances this logic is sound, but it must be remembered that there
is. as yet, no thoroughly dependable method for predicting which
third molars will erupt successfully, which will impact totally, and
which partially. Some of our best clinicians have worked on this
problem, producing ingenious predictive formulae, but none has
yet been found reliably unerring in a practical percentage of all
instances. Nor can one yet estimate well the effects of orthodontics
on third molar position or development. 23 There seems to be too
much exuberant advocacy of early removal of third molars, an
advocacy unsupported by sound clinical research. There is little
logic in their prophylactic removal for their alleged role in man-
dibular incisal crowding is unsubstantiated9. 23; however, their util-
ity in combined orthodontic-restorative rehabilitation later is well
known (Chapter 17). Retained third molars are often very useful
in cases where orthodontics is combined with adult full-mouth
rehabilitation.
(2) Ankylosed Permanent Teeth.-First molars, maxillary
cuspids, and maxillary incisors are the permanent teeth most apt
to be ankylosed. The etiology is generally unclear, though a history
attached to the button and joined to a wire inserted in a tube on the
first molar. e, later, conventional orthodontic appliances complete
the eruption. In this instance a compressed coil spring is used. C,
the result with the patient some years out of retention.

FIG 16-6.
Ankylosis of a mandibular first permanent molar. A, in the initial
stages of ankylosis, age 9 years. B, after successive attempts to
of trauma is associated with incisor ankylosis.
The goal of treatment in adolescence is to establish, if pos-
sible, proper occlusion: three methods are used: surgical, ortho-
dontic, and restorative. The tooth should first be surgically exposed,
carefully luxated, and splinted into an improved position. Sub-
sequent orthodontic movements to an ideal position should then.
be attempted, though ankylosis usually reappears. I have had less
success with orthodontic movement after luxation than some re-
porting in the literature. If ankylosis recurs and the tooth is to be
retained consider building it up to occlusion with composite until
growth is apparently over and a permanent restoration can be
placed. There is a danger in retaining ankylosed teeth, namely
localized cessation of alveolar growth which may bare the roots
of adjacent teeth and predisposes to periodontal difficulties (see
Figs 16-6 and 17-22). One must look past the occlusion and the
present condition. Extracting an ankylosed permanent tooth may
indeed be the conservative answer and leaving it a troublesome
radical "solution." If an ankylosed molar must be extracted, do
not overlook the possibility of orthodontic closure of the edentulous
space (see Chapter 17 and Fig 17-17).
c) Juvenile Periodontitis
Juvenile periodontitis is a rapidly progressive, apparently bac-
terial disease appearing about the time of pubescence and char-
acterized by bony lesions in the incisor and first molar regions.
Adolescent Treatment 447
."
loosen and replace the tooth occlusally, age 11 years. (Courtesy of
Dr. Michael Riolo.)
Extensive bony pathosis can result in tooth loss in severe cases.
Juvenile periodontitis requires the immediate attention of a
periodontist, and orthodontics should not be started until the peri-
odontist approves. Furthermore, careful monitoring by the peri-
odontist should continue throughout orthodontic treatment (see
Suggested Readings).
5) Lateral Malrelationships
a) Background and Definition of the Problem
As noted in Chapter 15, it is important to attempt to recon-
struct the developmental history of all l~teral malrelationships.
Functional crossbites, so frequent earlier, are only rarely seen in
adolescents since the musculature has imposed itself during growth
ev,el)tually producing asyfnmetric adaptive changes in the skeleton,
alveolar arch, and/or tooth positions. Inherent skeletal asymmetry
is far more difficult to counter at this age than the less obvious
and milder dental and alveolar adaptations seen in an earlier simple
functional crossbite.
b) Diagnosis
1) Skeletal.-Posteroanterior cephalograms in the postural
and occlusal positions are necessary for one to identify and dif-
ferentiate both mediolateral and vertical skeletal asymmetry (see
Chapter 12). Mandibular landmarks which change between the
448 Treatment
two vertical positions are evidence of residual neuromuscular oc-
clusal dysfunction. The temporomandibular joint region should be
searched for evidence of condylar or fossa asymmetry of either
shape or position. Posteroanterior, lateral, and oblique cephalo-
grams and panoramic or special radiographic .projections of the
temporomandibular joint may be necessary. Asymmetries within
the joint or condylar neck region are proof of long-standing ad-
aptations to asymmetric dysfunction.
(2) Dentoalveolar.-Asymmetry of tooth positions and al-
veolar development, both buccolingually and vertically, may be
diagnosed from the PA cephalogram (see Chapter 12). Cast anal-
ysis of asymmetry (see Chapter 11) provides better visualization
buccolingually, but vertical asymmetries are often obscured on the
cast owing to the usual method of trimming the bases. Therefore,
the Posteroanterior cephalometric analysis is critical to the diag-
nosis (see Chapter 12). It is important to determine the site and
extent of dentoalveolar adaptation. When the asymmetry is con-
fined to the alveolar process and teeth in the maxilla, the prognosis
is the most favorable. Correction of mandibular alveolar asym-
metry is usually limited to uprighting the teeth, idealizing the
archform, and leveling the plane of occlusion. Frank skeletal asym-
metry outside the alveolar region is much more difficult to foil,
camouflage, or nullify at this age by orthodontics alone.
(3) Neuromuscular.-Simple functional crossbites are rare
at this age, but a neuromuscular component may persist and play
an important role in temporomandibular dysfunction and associated
symptoms. Therefore, be prepared to do a thorough analysis of
the neuromusculature and temporomandibular joint in all adoles-
cents with lateral malrelationships (see Chapter 10 and Section D-
12 later in this chapter).
c) Treatment
(1) Goals.- The primary goal of all treatment is to provide
coordinated arch forms and balanced occlusal and temporoman-
dibular joint function. Esthetic tooth positioning is secondary, but
is usually easy to obtain when functional relationships have been
normalized. If there is skeletal asymmetry it must be accomodated .
functionall y, though one may attempt to provide camouflage es-
thetics by tooth positioning. I
(2) Methods.-
(a) Skeletal.-Skeletal methods include the following:
• Maxillary corpus symmetry is restored by rapid palatal ex-
pansion, or by gradual palatal ex.pansion with a Quad-Helix
appliance.
• Some vertical mandibular skeletal morphologic shape and
size change may be still possible (not corpus width) by the
use of functional jaw orthopedic appliances, although the
best time for their use is past.
• If orthognathic surgery is necessary it usually is done later,
although preliminary orthodontic treatment might be com-
pleted at this time.
(b) Dentoalveolar Correction.-The most common therapy
may be to camouflage or counter skeletal asymmetry, or to correct
alveolar asymmetries. Methods include:
• Correction of maxillary alveolar process asymmetry by ex-
pansion with a Quad-Helix appliance and vertical develop-
ment with an Activator or Bionator. The rapid palatal
expansion method so efficient for maxillary corpus under-
development is less efficient when the asymmetry is con-
fined to the alveolar process. In fact, its bilateral action
and rigidity temporarily impede vertical asymmetric devel-
opment and correction.
• Idealizing maxillary tooth positions and archform. This is
done with bracketed appliances after a period of maxillary
alveolar process correction.
• Idealizing mandibular dental and alveolar archform. This is
done with bracketed appliances and may be begun after pe-
riods of maxillary expansion and/or functional jaw or-
thopedic appliance therapy directed at the mandible.
• Control of the occlusal plane height-a most important fea-
ture of treatment.
(c) Neuromusculizr.- The dentoalveolar correction outlined
in (b) should diminish occlusal dysfunction and establish normal
temporomandibular function, a primary neuromuscular goal. Func-
tional jaw orthopedic methods enable one to position the mandible
more favorably mediolaterally and vertically and to guide alveolar
development buccally (in the maxilla) and vertically. Changes in
mandibular form, muscle attachments, and improved symmetry of
mandibular closure movements should also result.
(3) Specific Problems.-Each clinical problem discussed is
assumed to be the primary malocclusion. When they are combined
with an AP skeletal problem, or a vertical dysplasia, the difficulties
of treatment planning and execution are greatly enhanced: one
must take care in assigning the primary name for the malocclusion.
It is impossible to describe all of the combinations and permuta-
tions which may be seen, yet the clinician treating the problem
must integrate the various diagnostic features into an individualized
treatment plan, a far more difficult task at this age than earlier.
(a) Bilizteral Maxi/lizry Corpus Deficiency.-Bilateral me-
diolateral maxillary skeletal deficiency is often associated with AP
deficiency as well resulting in a skeletal Class III mal occlusion
(see D-7. Class Ill, later in this chapter). Rapid palatal expansion
is usually necessarry to secure correct buccolingual dental and
alveolar relationships. A period of bracketed appliance therapy of
both upper and lower teeth is usually necessary (see Fig 16-7).
If the rapid palatal expansion does not secure sufficient widening,
latir:orthognathic surgery should ~e considered.
(b) Unilizteral Maxi/lizry Corpus Asymmetry.-Asymmetric
maxillary corpus asymmetry is far less frequent than bilateral de-
ficiency and must be verified before beginning treatment. Although
the Quad- Helix appliance can be adjusted for unilateral expansion,
I prefer to treat unilateral maxillary corpus asymmetry in the same
way as bilateral corpus deficiency. The result will be an overex-
pans ion of the dentoalveolar process on the more favorable side,
but that is not a problem, for occlusal function and the bracketed

FIG 16-7.
Rapid palatal expansion treatment for bilateral maxillary corpus de-
ficiency. A, periapical radiograph at the start of treatment. Note the
two supernumerary teeth. B, intra:oral photograph at the start of
treatment. Note the bilateral cross bite and the malposed cuspids. C,
a rapid palatal expansion appliance in place in the arch. D, radiograph
obtained a short time after palatal widening had been achieved. E,
photograph taken at the same time. F, the rapid palatal expansion
Adolescent Treatment 449
device is left in place, but inactive, as the median palatine suture fills
wilh. bone and the maxillary central incisors drift toward the midline.
G, radiographs of the midline at tt)e end of treatment and after the
removal of the supernumerary teeth. H and I, studies obtained after
the removal of the complete banded appliance and after the retention
period. (Courtesy of Dr. Robert Aldrich.)
450 Treatment
appliances soon achieve alveolar arch coordination.
(c) Bilateral Maxillary Dentoalveolar Contraction.- The
Quad-Helix appliance is the choice for an initial period of treat-
ment, followed by upper and lower bracketed appliances to com-
plete arch coordination and individual tooth positioning.
(d) Unilateral Maxillary Dentoalveolar Contraction.- The
Quad-Helix appliance may be adjusted for unilateral expansion of
the teeth and alveolar process, although some bilateral expansion
invariably occurs. Bracketed appliances may be inserted as soon
as the maxillary expansion is under way; thus, alignment, arch
coordination, and securing occusal relationships are all synchro-
nized. Vertical occlusal asymmetries may be difficult at the end
of treatment.
(e) Unilateral or Bilateral Mandibular Dentoalveolar Con-
traction.- The Quad-Helix appliance is useful for uprighting man-
dibular teeth only when there is mandibular dentoalveolar
contraction. As soon as this phase has begun, bracketed appliances
may be placed in the mandible to aid in alignment and individual
tooth positioning. Placement of maxillary bracketed appliances is
also necessary for arch coordination, which may be difficult, es-
pecially initially.
(f) Gross Disharmony Between the Skeletal Bases.-It is
indeed unfortunate when gross mediolateral disharmony between
the maxilla and mandible is not diagnosed until adolescence, for
this serious skeletal dysplasia can be treated far more advanta-
geously at younger ages (see Chapter 15). Irrespective of whether
there is bilateral or unilateral crossbite, the problem is usually
primary skeletal dysplasia in the maxilla or the mandible with
secondary dentoalveolar adaptation in the other. When there is
bilateral maxillary corpus deficiency resulting in a bilateral max-
illary lingual crossbite [see (a)], the treatment is fairly direct. It
is usually successful, though difficult at this age, if there is not
an associated skeletal Class III malocclusion. When the problem
is primarily that of maxillary skeletal hyperplasia and the man-
dibular teeth all are in total bilateral lingual crossbite-the so-
called "Brodie syndrome"-the problem is much more severe and
exceedingly difficult to correct at this late age. Gross mandibular
corpus expansion mediolaterally is impossible since there is no
patent midline suture. Heroic and very skillful use of fixed pre-
cision bracketed appliances to contract the maxillary dentoalveolar
processes and expand the mandibular (in conjunction with use of
a mandibular Quad-Helix appliance) is required to avoid surgery.
The cant of the occlusal and mandibular planes and the amount
of vertical freeway space are critical diagnostic features.
6. Class IT (Distocclusion, Postnormal Occlusion)
a) Background
Class 11is the most frequently occurring severe malocclusion.
Furthermore, treatment of severe types is made more difficult with
time and the cessation of development. Elaborate details of me-
chanotherapy cannot be presented; however, the principles of treat-
ment, critical diagnostic differentiations, and certain complications
and problems are appropriate here. A clear understanding of the
principal goals and strategies of treatment is necessary as a basis
for further study and development of skills in Class 11.
1) Differential Diagnosis.- The differential diagnosis for the
different types of Class 11 malocclusion is discussed in chapters
12 and 15; general strategies and tactics for Class II therapy are
discussed in Chapter 1521 The differences in both strategies and
tactics of Class 11treatment at different ages are important, though
differential treatment planning ba~ed on development often is not
presented in the literature.
2) Strategies of Treatment.-Of the general strategies for
Class II treatment discussed in Chapter 15, those related to guid-
ance of eruption and alveolar development, differential promotion
of skeletal growth, translation of parts during growth, and differ-
ential restraint and control of skeletal growth are of greatly di-
minished use by adolescence. The primary strategy remaining in
adolescents is movement of teeth and alveolar processes, plus
controlling or promoting such residual growth as may remain.
Posttreatment muscle conditioning. is still available as a retention
strategy but the use of muscle forces to promote mandibular growth
is largely past. Surgical considerations may assume more strategic
importance in severe cases. The primary strategy is no longer
manipulation of development but camouflage of skeletal dysplasia
by tooth positioning. This principal new strategy means important
changes in tactics.
3) Tactics.-Bracketed appliances, the chief tactic, assume
a far more important role at this age, though palatal-widening
devices and extra-oral midface traction are useful. Functional ap-
pliances may still be used to advantage in a few late skeletal
developers (usually boys).
b) Rationale for Adolescent Class II Therapy
Although some forms of Class 11malocclusion may be more
advantageously treated at a younger age, the opportunity for early
treatment sometimes never occurs because the patient is not seen
until adolescence. Treatment in adolescence may be the second
phase of diphasic treatment, the skeletal aspects having been treated
earlier and the tooth positioning and occlusal niceties postponed
until the arrival of most permanent teeth. Pragmatic reasons for
treating at this age include postponing treatment to allow social
maturity. This is done to provide an intense shorter period of
treatment, or to make certain that the family and patient have fully
accepted the responsibilities and consequences of orthodontic ther-
apy. Finally, some cases are just .as easy (even easier) to treat in
adolescence as earlier (e.g., horizontal types A and F).
c) Differential Treatment
" .8}gnificant differenc;~ in severity of the several types of Class
11are often not appreciated by the inexperienced2! In this chapter
it is presumed that the reader has a thorough command of the
diagnostic discrimination of Class 11 types (see Chapter 12) and
an understanding of the basic treatment strategies for each type
(see Chapter 15). The diminished growth potential and the arrival
of the permanent teeth significantly change the tactics of Class 11
treatment from those used.earlier (see Chapter 15).
1) Horizontal Type A.-Maxillary dental protraction with
a normal skeletal profile is characteristic of this type.
 Adolescent Treatment 451

MM
--12-1
---16-2

MM
--12-1 MM
---16-2 --12-1
---16-2

" G
'- '-/---

FIG 16-8.
Class 11,type F malocclusion. A, records before treatment. S, after treatment. This type resembles a mild type B.

(a) Basic Strategy.-One attempts to retract the maxillary parallel occlusal and mandibular lines) may be seen with
dentition to normal occlusal relationships without altering the cra- horizontal type A. Severe vertical types are not found with
niofacial skeleton, displacing the mandible, or disturbing the ver- horizontal type A.
tical dimension.

(b) Tactics.-All maxillary teeth are bracketed and/or banded,
and extra-oral traction is used to move the maxillary dentition
dorsally en masse to a Class I occlusion. The direction of the extra-
oral traction force is determined by the steepness of the occlusal
line. Unless the lower dental arch is perfect in shape, position,
and individual tooth alignments (rarely the case), it is advantageous
to bracket all mandibular teeth to position them ideally during the
maxillary retraction.
(c) Problems and Complications.-
• Simple crowding (see section D-4)
• Mild vertical type I (steeper than normal occlusal and
mandibular lines) or vertical type 2 (skeletal deep bite with
2) Horizontal Type F.-Mild skeletal Class II features with
Class II dental relationships is characteristic of this type.
., /a) Basic Strategy;-.2..Since every horizontal type F maloc-
clusion is a milder form of one of the four syndromal types (B,
C, D, or E) the strategies are the same as for the more severe
syndromal forms, but the execution is easier (Fig 16-8).
(b) Tactics.- There are no specific tactics for treating type
F, since the symptoms are so mild that almost any standard Class
II treatment may achieve success. However, the best tactic is
always that most appropriate for the syndromal type which a par-
ticular type F most resembles.

I
452 Treatment
o patient cooperation. In older adolescents whose growth has
JW
--12-5
-- -15-7
FIG 16-9.
Superposed tracings of a horizontal type B malocclusion. This is the
same case shown in Fig 16-1,A.
(c) Problems and Complications.-
• Simple crowding (see section 04)
• Complex corwding (see section 04). Treatment requires
not only alignment but also positioning of the teeth to fit
the vertical dysplasia and the skeletal profile.
3) Horizontal Type B.-Maxillary prognathism (midface
protrusion) associated with a normal mandible is characteristc of
this type.
(a) Basic Strategy.-One attempts to reduce the midface
prognathism and associated dentoalveolar protrusion, if present,
without alterating the favorable mandibular relationship.
(b) Tactics.-Intense, heavy orthopedic forces to the com-
pletely bracketed maxillary dentition are necessary. The direction
of the force is determined by the steepness of the occlusal and
mandibular lines, but vertical type I is a rarity with horizontal
type B. Although the mandible may be normal, it is necessary to
bracket all the mandibular teeth to achieve ideal positions and arch
coordination. Functional jaw orthopedic appliances are contrain-
dicated in horizontal type B. Figure 16-9 illustrates a treated Class
11, horizontal type B. (See also Fig l6-I,A.)
(c) Problems and Complications.-
• Simple crowding.
• Complex crowding necessitating extractions draws attention
to the selection of teeth to be extracted. Combinations to
be considered are a bicuspid in each quadrant, or maxillary
second molars and mandibular bicuspids. The choice of
which bicuspid in the lower arch to extract is dependent on
restorations present and the site of the principal crowding.
When there is no crowding in the maxilla, the extraction of
maxillary second molars may be considered, for this
greatly aids the dorsal movement of the maxillary dentition
(see section 0-4-a. Crowding). Absence of crowding in the
mandible may permit the consideration of extraction of
maxillary first bicuspids, where there is maxillary crowd-
ing, or second molars, when there is none.
• Inadequate response may lead one to consider the extrac-
tion of maxillary second molars, but that is not a useful
solution if the inadequate response is the result of lack of
definitely diminished, the extraction of maxillary bicuspids
may work out well, particularly if the case has marked
maxillary dental protraction such as in type A.
• In cases of narrow maxillary arch, a preliminary period of
expansion to achieve buccolingual arch coordination is nec-
essary in some instances.
• Vertical dysplasia is a characteristic feature of horizontal
type B. Standard therapy will accommodate most vertical
type 2 problems, but types 4 and 5 are serious complica-
tions requiring sophisticated control of vertical forces. Ver-
tical type 4, only found with horizontal type B, is one of
the most difficult of all Class II malocclusions to treat (see
Chapter 12).
(d) Retention.-A flat bite plane on the maxillary retainer is
often advantageous.
4) Horizontal Type D.-Mandibular insufficiency combined
with maxillary dental protraction is characteristic of this type.
(a) Basic Strategies.- The basic strategies are the same as
those used in childhood (i.e., to promote mandibular growth, to
reduce the maxillary dentoalveolar protrusion, and to improve lip
and facial muscle function); but the chances for achieving easy
skeletal improvement are much less at this age.
(b) Suggested Tactics.- The choice of tactics is primarily
dependent upon two factors: the developmental age of the patient,
(i.e., the potential for further mandibular growth) and the severity
of the mandibular skeletal deficiency. Boys who have not com-
pleted their pubescent growth spurt have the greatest chances for
success. The most difficult to treat without compromise are girls
who have a severe mandibular deficiency and have completed
pubescence. Assessment of the growth potential is critical in the
determination of tactics.
One may begin with an intensive period of functional jaw
orthopedics, perhaps combined with banded therapy for arch co-
ordination, alignment, and retraction of maxillary anterior teeth.
The Bionator, open-face Activator, and Frankel appliance can all
be used in conjunction with bracketed appliances (the Frankel with
more difficulty). For vel).' severe cases I prefer to use the Herbst
appliance alone after achieving arch coordination. Six months of
aggressive treatment and a rediagrtosis to assess treatment response
is sufficient to provide data for designing continuing treatment
tactics.
Possibilities, depending on severity and response of initial
facial treatment, include extra-oral traction to retract the upper
dental arch, Class 11 intermaxillary elastics, continuing the initial
treatment, or extraction of teeth to provide space for necessary
occlusal correction. Hi-pull extra-oral traction is more apt to be
useful in vertical type I cases, and continuing functional jaw or-
thopedic treatment may be more useful with skeletal deep bite

(vertical type 2) problems.
(c) Problems and Complications.-It must be remembered
that the primary skeletal problem in horizontal ~pe D is the man-
dible, not the maxilla; therefore, extra-oral orthopedic traction is
not the recommended primary treatment method. It may be used
secondarily and adjunctively, particulary in the severe vertical type
I cases, where control of the vertical dimension is essential.
To fail to appreciate the advantages of controlling lip and
tongue function may lead to problems. The initial period of func-
tional jaw orthopedics helps promote and test the potential for
mandibular growth, and also provides immediately improved lip
and tongue function so critical to success.
, Complex crowding may be a complication. If there is a doubt,
do not extract until after the initial period of functional jaw or-
thopedic therapy. In more severe cases, even with minimal crowd-
ing, extractions may be necessary to provide space for occlusal
correction.
(d) Retention.- These problems are often advantageously
retained with the removable functional appliance used in the initial
phase of treatment.
5) Horizontal Type C.-Mandibular insufficiency, bimax-
illary dental protrusion, and generalized small facial dimensions
are characteristic of this type.
(a) Basic Strategies.-Horizontal type C malocclusions are
difficult to treat at any age and a good argument can be made for
deferring their treatment until adolescence. They are more frequent
in girls who possess, at this age, diminished probabilities for uti-
lizing skeletal growth. Complex crowding is routinely present and
may be so severe that the extraction of four premolars still leaves
problems in alignment and occlusal correction. In adolescence,
treatment of horizontal type C is a strategy of compromises selected
to overcome and camouflage the individual features of a particular
malocclusion.
(b) Suggested Tactics.-An initial period of functional jaw
orthopedic therapy may be tried even when the chances for success
are not high simply because the least improvement of the mandible
is such a useful contribution to the profile. The functional jaw
orthopedic therapy should be under way before extractions are
made, if they are needed.
Extra-oral traction is contraindicated except for vertical con-
trol of maxillary molars or the obvious retraction of the maxillary
dentition on its base. Horizontal midface orthopedic forces would
only aggravate an already complex problem.
(c) Problems and Complications.-Severe vertical type I
requires intensive hi-pull extra-oral orthopedic forces to restrain
posterior vertical maxillary development.
The severe deep bite which accompanies some vertical type
2 cases may be aggravated if the extractions are ill timed or rigorous
control of arch coordination and tooth positions is not maintained
at all times. Often it is advantageous, in the severe deep bite case,
Adolescent Treatment 453
for the patient to wear a functional appliance adjunctively through-
out much of the treatment.
The most serious problem with type 2 cases is failure to
appreciate their complications and difficulties. Often these are
deceptive in appearance, and casual diagnosis and sloppy treatment
planning traps one rather quickly. Do not start the treatment of
these patients without a meticulous diagnosis and treatment plan;
even then they are difficult cases. One should not expect results
of type C treatment to be as esthetic and stable as those achieved
for other forms of Class n. (See Fig 16-10.)
(d) Retention.-Retention is difficult, not because of con-
tinuing growth, but because the tooth positions which provide the
best facial esthetics and lip function sometimes are difficult to
achieve and stabilize in treated type C. Prolonged monitoring dur-
ing the retention period is suggested.
(6) Horizontal Type E.-Maxillary prognathism plus bi-
maxillary dentoalveolar protrusion are characteristic of this type.
Horizontal type E looks like a severe bimaxillary dentoalveolar
protrusion superposed on a Horizontal type B. Though far less
prone to Class n than whites, North American blacks with Class
n usually display type E.
(a) Basic Strategies.-Treatment strategies are largely de-
termined by the needs of the skeletal profile and the facial soft
tissues. Orthopedic reduction of midface protrusion and retraction
of dentoalveolar prominence are routines of treatment.
(b) Suggested Tactics.- The tactics are quite similar to those
used to treat horizontal type B, but there is a more frequent need
for extractions in both arches. Another way to define the tactics
is to think of these as severe horizontal type B cases with complex
crowding in both arches. Of course, there may not be actual crowd-
ing, but one extracts for the same reasons, namely, to improve
the profile and the esthetic positions of the teeth.
Extra-oral traction to both arches is usually necessary and is
continued throughout active treatment. The maxillary protrusion
must be reduced to the extent that profile esthetics and occlusal
correction can then be accommodated within the extraction spaces.
(c) Problems and Complications.-Extremely severe cases
may require the extraction of maxillary second molars in addition
to the removal of four bicuspids.""
When a severe deep bite is primarily a skeletal feature, as in
vertical type 5, its control is difficult when absorbing the extraction
. sites.
'.
(d) Retention.-Well-treated horizontal type E cases ordi-
narily do not present retention problems except for the vertical
correction in severe cases. In such instances a bite plane on the
maxillary retainer is suggested.
7. Class III (Mesiocclusion, Prenormal Occlusion)
By adolescence two types of malocclusion which may be
designated Class III in childhood are rarely seen: the pseudo- (or
functional) Class nI malocclusion and and the anterior crossbite.
 FIG 16-10.
Class 11,type C-2 malocclusion. A, before treatment. B, after treat-
ment. This case was complicated by disproportionately large max-
illary central incisors. An initial period of Activator therapy was followed
by full edgewise treatment. No extractions were made. Note the labial .'
angulation of lower incisors before and after treatment. (Continued.)

Cl
C.D. 9-0 CLASS n PLOT, HORIZONTAL

+.- A
Slreletal Class II."

MId-face Prognathic?

Mandible
Retragnathic?

Maxillary teeth + - + - + - + - +:.. + - + - + - : +,-

Procumbent
M;;:;~~o:e:~eth~ ~ ~ ~., ~ ~ ~ ~ I
j.~.
1

I
50142940265427576611971919471; 1005581211 33222761128
E (El 8+ B C+@O+ 0 F F F F FE FE Fe Fe FC Fc Fe Fe A A A A

N=697
Unclassified = 12

Incomplete Data = 25
454
 Adolescent Treatment 455

C4
C.D.
C.D. ---9-0
C.D.
---9-0 ---9-0 --t4-6
--t4-6 --14-6

Cs
C.D .
• Before (10-3)
• After (14-6)
HOfllonlal 8~ ~
-3
23
90
-15.0
-2
;90-IS.o
IS.o 3xISO
X MALE 2 60
8~ FEMALE
-2 '6~
('. I
70 7-"? .
1,1"., I
eo Measure
1 8 , -3! I""
9~ I. i6'~" I' 1 7))i~ ~ ,

MdPL/A-B 60
PaL PI-/A-B c.:w
90
_______ 1

,
SE-FMN-A
SNA 90 ,'
.1,1",,-1I 7~
70
9~
'70 I 7~
:• I -CLASSO
I ., I
8~ ,60 ,6~ e~
, ,
Bo-Se-Gn 60 80
SNB --'--'-I
70 I
I/Md PI. 110 I

lIA-Po
~o

3~,
..u,
20

FIG 16-10·(cont.). before "and after treatment. Note in O. the extensive mandibular size
C, the Class 11arborization and superposed cephalometric tracings and shape response to treatment.
456 Treatment
The latter is never a Class m, even when it looks like it. The
malfunction of the pseudo-Class m, with its malfunction, will
have imposed itself on the facial skeleton and will likely have
produced a very mild skeletal Class m malocclusion by this age.
Cephalometric differentiation within Cla~ m is not as well
developed as that for Class Il but is equally important, for treatment
strategies and tactics depend solely on the site or sites of the skeletal
dysplasia (see Chapter 12). It will be useful when planning treat-
ment for a Class III malocclusion in adolescence to refresh one's
memory about the treatment of Class m in childhood (see Chapter
15), since knowledge of the developmental features of the different
Class m types sharpens ones treatment-planning strategies for
adolescent Class m.
a) Rationale for Adolescent Class III Therapy
The primary reason for treating Class m mal occlusion in
adolescence is simply that, if postponed, the probabilities of need-
ing orthognathic surgery combined with orthodontic therapy are
greatly increased. As noted in Chapter 15, some Class III mal-
occlusions can be treated quite successfully in early childhood.
Unfortunately, some apparently brought under control in childhood
revert dramatically during the exuberance of male adolescent growth.
There is a limit to how many times a mandibular prognathism can
be "treated" orthodontically before one resigns oneself to the
necessity of surgery. Obversely, those clinicians who dismiss the
opportunities for Class m orthodontic treatment in adolescence
will have unnecessarily burdened a number of patients with later
surgical correction.
One can rationalize the treatment of'Class m in girls during
adolescence easier than that of boys, because treatment in girls is
less apt to be thwarted by pubescent growth spurting and they are
nearer adult dimensions than boys at each chronologic age.
b) Diagnosis
Diagnosis at this age has two aspects (I) definition and lo-
calization of morphologic abnormality, and (2) estimation of any
remaining growth potential. In Chapter 12 cephalometric methods
useful in Class III diagnosis were described and attention was
drawn to the problems of predicting growth. Despite much well-
intentioned, enthusiastic writing on the subject, there is no reliable
method of predicting precisely the onset, acceleration rate, dura-
tion, or cessation of the pubescent growth spurt. Predictive math-
ematical models for the sigmoid curve of the pubescent growth
spurt simply do not exist in a form applicable to orthodontic prac-
tice. Yet one must still make estimates, however crude, of the
possible duration of continuing mandibular growth. The carpal
radiograph and a study of the patient's parents and siblings are
useful if care is exercised.] ]-13 Most important is study of the
individual patient-and it is a great help when one has two or
more serial cephalograms prior to starting orthodontic treatment.
c) General Strategies
The strategies of Class III treatment in adolescence include
the following: (1) ventral displacement of the midface6.25 (2) in-
hibition of mandibular growth7.8 (3) redirection of mandibular
growth34 and (4) dental and alveolar process repositioning.
The choice of strategies, of course, is dependent on the facial
morphology and estimates of the duration of continuing mandibular
growth. Only rarely will one be able to utilize functional reposi-
tioning of the mandible during adolescent treatment. Although one
searches diligently for functional aspects of the malocclusion, they
are rarely a significant factor.
d) Tactics
Cases of midface deficiency are best treated with face mask
orthopedics combined with fully bracketed arches in both jaws.
Mandibular prognathism alone may be treated with chin cup ther-
apy to inhibit mandibular growth. Woodside's34 method of com-
bining chin cup and mandibular block therapy to achieve mandibular
alignment is also useful when the mandibular line is not unduly
steep. Class m elastics and extractions sometimes permit mild
mandibular prognathisms to be camouflaged by tooth movements
and alveolar process repositioning.
Some cases combine midface deficiency with mandibular
prognathism, and both face mask and chin cup therapy may be
used succesively.
e) Differential Treatment
1) Midface Deficiency.-DeLaire6 has suggested the use of
the face mask for the treatment of midface deficiency. Intensive
orthopedic traction is applied to the fully banded maxillary dental
arch in an attempt to produce ventral midface displacement. 25 The
direction of the force is determined by the steepness of the occlusal
and mandibular planes. During orthopedic traction, arch coordi-
nation and individual tooth positioning are obtained. The prognosis
is good provided the diagnosis has been"'sound. Figure 16-11
illustrates a case of Class m midface deficiency.
2) Mandibular Prognathism.-Mandibular prognathism is
a more severe problem in adolescence than midface deficiency,
particularly when the mandible is already hyperplastic prior to the
adolescent growth spurt. The vertical aspects of the morphology
are critical-for when the freeway space is large and the mandib-
ular plane is not steep, there may be opportunities for camouflage
of the mandibular prognathism by redirecting mandibular growth,
dental alveolar repositioning, and even face mask therapy. Lip
length and function are important considerations in redirecting
mandibular growth vertically to mask mandibular prognathism.
The needs of the case define the tactics, and careful monitoring
of growth during treatment is essential. Figure 16-12 shows a
treated Class m mandibular prognathism. (See also Fig 17-5.)
Lee Graber7. 8 has shown the responsf to chin cup treatment
in younger children (see Chapter 15), and this tactic sometimes
can still be used in milder cases of mandibular prognathism during
a4~lescence. Combining:-Function Regulator-m or Activator ther-
apy with fully bracketed applian~es in both arches is useful only
in mild cases of mandibular prognathism at this age because of
the length of treatment time.
One must be prepared to accept defeat in some cases of
mandibular prognathism, particularly in boys, whose dramatic
growth during treatment may be a problem (Fig 16-13). In such
instances, secure cephalometric and cast records, remove the ap-
pliances, place retainers to maintain the arch and tooth positioning
improvements, and monitor the case cephalometrically until such
time as orthognathic surgery is indicated.
 Adolescent Treatment 457

FIG 16-11.
Class Ill, midface deficiency. A, cephalometric analysis (modified
Counterpart Analysis). Figures in parenthesis are the norms for 17-
year-old males. B, this boy decided against orthodontic treatment.

"
458 Treatment

.'

CK 12-0

As
MALES FEMALES
-3 -2 -15.0 X 15.0.2 3 -3 -2 -15.0.X 15.0.2 3
Cranial Sas. I I
I ..u
Bo-SE-FMN

Bo-S-No
1
155, 'i'I~5' , !~,'~e i4J(j' I~~" 'I~.' 'I~
115"
I T ' 'liJ' , 'I~ "I~.2' ~js" ),.:0"';'I~e
CraniaI8as.-Maxilla
S-N-A 7Et
I I I I I J i
1
901
SE-FMNA
11
CraniaI8aH-Mandlblt1(H)
Bo-SE-Me •
Ba-SE-Pog 80
CraniaI8ase-MandibltJ(V)
Ba-SE/Mond. Line

PM Vert/Mond. Line
Maxilla-MandibltJ
Mond. Line/A-B

Fl.rct.OccI.Ln./A-B
(not 0 constant)
Sk.,tJfal Prafll.
FMN-A-B lea 155
,I4e
I I I -.
-.•....

FIG 16-12.
Orthodontic treatment of a skeletal Class III malocclusion, mandibular
prognathism. A, records at time of transfer to my office. (Continued.)
 459

FIG 16-12 (cont.).

B, after 2 years of occlusal guidance chin cup and face mask therapy.
C, after 2 more years of intensive chin cup and face mask treatment.
Note the increasing mandibular prognathism. (See Figure 17-5 for
the continuing treatment of this case.)

(56)

(61)

(60)
(59)
460 Treatment

(53)
(55.5)

(52)
(50)

(54.5)
(58)
FIG 16-13.
Mandibular prognathism. A, pretreatment records at time of transfer
(536)
to my office; patient was age 9 years 0 months. S, at the start of
(51)
orthodontic treatment with edgewise appliances plus extra-oral chin
cup traction; patient was age 11 years 2 months. (Continued.)
 Adolescent Treatment 461

o E
F s.s.
9-0--
11-2--
16-2 .....
18-0--

(59)
(634)
(61.21
(6651
(60)
(57.6)

5.5. 16-2 Jfr. 71

73
(61.4)
(64.21
SS 18-0

FIG 16-13 (cont.).

C, progress records at 12 years 9 months. D, cephalometric record marked effects of the adolescent spurt on both the amount and
at 16 years 2 months, active orthodontic therapy having been aban- direction of mandibular growth. Observe too how the maxilla lags
doned 1 year earlier. E, cephalogram at 18 years 0 months. F, com- behind the mean values in later years while the mandible exceeds
posite cephalometric comparisons from age 9 to 18 years. Note the the mean more each time.

"
-
•....
462 Treatment
FIG 16-14.
Mandibular prognathism plus midface deficiency. A, pretreatment records, patient was age 11 years 8 months. (Continued.)
(3) Midface Deficiency and Mandibular Prognathism.-
Those cases revealing skeletal contributions in both maxilla and
mandible are often advap.tageously treated in adolescence even
though the total AP skeletal discrepancy is quite severe. They may
not respond as well, however, if the· tactics are focused on one
region only. Combining face mask therapy for the midface defi-
ciency plus the necessary mandibular tactics often provides sur-
prisingly satisfactory results (Fig 16-14).
f) Problems and Complications
The problems and complications are usually of two kinds: (1)
continuing growth, and (2) unreasonable or naive enthusiasm dur-
ing treatment planning. Skeletal Class III problems in adolescence
are at best difficult. Thorough differential diagnosis and treatment
planning are essential if success is to be achieved, they are even
more necessary if one must resort to a second period of orthodontic
treatment combined with orthognathic surgery. The records of the
ca~e at the start and the te~ponse to orthodontic treatment are very
us~ftil during the planning of any ~ubsequent orthodontic-surgical
treatment (see Chapter 17). -
g) Retention
Retention of midface deficiency problems may utilize a Func-
tion Regulator-Ill or a conventional maxillary Hawley appliance
with labial pads as those in the Function Regulator-Ill. Retention
for mandibular prognathism cases may utilize conventional Hawley

FIG 16-14 (cont.).
B, posttreatment records, patient was age 17 years 10 months, 18
retainers. In either event the retention period is more prolonged
than for other typical malocclusions.
8. Localized Incisal Malrelationships
The problems discussed in this section are unrelated to the
skeletal morphology and result from localized dentoalveolar or
neuromuscular variations. Most were present at an earlier age and
are treated more advantageously prior to adolescence (see Chapter
15).
a) Labioversion of Maxillary Incisors
(1) Diagnosis.-Labioversion of the maxillary incisors in the
absence of a skeletal Class 11malocclusion may result from digital
sucking, atypical lip or tongue behavior, or an abnormal Bolton
Index. In extreme cases there is an enhanced Curve of Spee,
Adolescent Treatment 463
months out of retention. Treatment consisted of fully banded edge-
wise appliances plus face mask orthopedic traction.
absence of centric incisal stops, and a simple deep bite (see Section
8-C, Simple Deep Bite). The angulation of the incisors to their
bases, to the occlusal plane, and to each other must be noted and
the normality of the skeletal profile guaranteed.
(2) Treatment.- The most efficient treatment results from
using fully bracketed appliances in both arches to position the
anterior teeth while mainfaining the normal posterior occlusion.
Arch 'coordination and leveling are critical for stability of results
and assuring adequate space for precise incisor positioning.
If the diagnosis is correct, there should be no complications.
If residual abnormal lip function persists, labial pads similar to
those of the Frankel appliance may be added to the Hawley retainer.
b) Simple Anterior Crossbite
(1) Diagnosis.-It is unfortunate when simple anterior cross-
464 Treatment
FIG 16-15.
Deep bite (excessive vertical incisal overlap). A, simple deep bite.
All vertical analysis measures are normal. Note the enhanced man-
dibular occlusal curve and the excessive vertical height of the man-
dibular incisor but the normal position of the maxillary incisor (see
also Fig 15-74 for more details of this case). B, complex deep bite.
bites persist into adolescence for they are more advantageously
treated earlier. First, make certain that the patient's skeletal profile
is normal and that the molar relationship is a firm Class 1. If both
are normal and the lower arch is sound, then simple displacement
of maxillary teeth or a severe tooth size disharmony is a likely
cause.
(2) Treatment.-Bracket all the maxillary teeth idealizing
the arch form and leveling the occlusion as the incisors are po-
sitioned labially. Pay particular attention to root parallelism and
the interincisal angle. Band the lower arch in order to level the
occlusal line and establish secure anterior centric stops. If the
maxillary teeth are disproportionately small (e.g., when the simple
anterior cross bite is associated with peg lateral incisors) then po-
sitioning of the teeth to permit esthetic buildup of the smaller
crowns with composite is critical to retention. In other instances,
use of a simple Hawley retainer suffices.
c) Simple Deep Bite
(1) Diagnosis.-A simple deep bite is localized to the teeth
and alveolar processes in the anterior region (see Vertical Ceph-
alometric Analyses in Chapter 12). The upper and/or lower incisors
have extruded past the occlusal line in the cephalometric tracing
(Fig 16-15). The result may be labial version of the upper incisors
and impingement of the lowers into the palatal mucosa. The denial
of a skeletal contribution to the condition is critical to the diagnosis.
These patients frequently show temporomandibular dysfunction
and a limited range of functional occlusal movements (see Chap-
ters 10 and 11). The extent of the intermaxillary distance (" freeway
The functional occlusal line posterior maxillary vertical angle is 1 SD
less than the mean, and the mandibular line angle is more than 3
SDs below the mean. Note the slight improvement when the mandible
is in its postural position.
space") is an important factor in treatment planning. When the
freeway space is minimal or even absent the problem is more
severe.
(2) Treatment.-In the presence of a normal or greater than
normal freeway space, treatment consists of banding or bracketing
all teeth in both arches, establishing coordinated arch forms, and
intensive arch-leveling mechanics. Rigorous intrusion of the in-
cisor teeth is necessary as an assurance of success and stability of
result. I prefer to retain theses cases with a Bionator or Activator
which opens the bite slightly in the posterior region. As the pos-
terior teeth develop vertically and settle into occlusion, some oc-
clusal equilibration is necessary.
When there is minimal intermaxillary occlusal space in the
postural position, and yet no obvious skeLetal deep bite morphol-
ogy, an initial cautious period of functional jaw orthopedic therapy
is useful. The construction bite must be taken by opening the
n;truded contact positiQI't minimally. Begin by inserting an Acti-
vator or Bionator which covers tl)e posterior occlusal surfaces, but
do no grinding of the plastic. If the muscles can accommodate to
this within a few weeks then grind the posterior plastic away
according to which posterior teeth must be brought to the occlusal
line. Leave the anterior teeth solidly imbedded in the plastic. It
may be necessary to take another construction bite later to open
the bite a bit more or to construct an entirely new appliance. When
the response is favorable, banding and bracketing in both arches
provides finishing details, as when the freeway space is normal.
The initial treatment phase is required in order to provide muscle

adaptation more certainly. Retain with the same functional appli-'
ance used in the first phase of treatment.
d) Simple Open Bite
(1) Diagnosis.-When the basal skeleton is-normal and the
open bite is confined to the teeth and alveolar processes the con-
dition is called a simple open bite. Complex open bite (see Section
D-IO-b later in this Chapter) results from skeletal dysplasia so
severe the alveolar processes cannot cope sufficiently to maintain
occlusal stops (Fig 16-16). The vertical cephalometric analyses
are essential to the differential diagnosis (see Chapter 12).
Anterior simple open bite usually results from digital sucking
or abnormal tongue behavior (see Chapters 7 and IQ). It is more
comIIlon in children than adolescents, for by adolescence many
simple tongue thrusts are lost. By adolescence, too, some vertical
effects on the facial skeleton may have occurred and what was an
earlier simple anterior open bite becomes more complex (see Sec-
tion D-IQ-b).
Posterior simple open bite (discussed here for understanding
rather than integrity of the chapter's outline) is rarer than simple
anterior open bite and frequently is the result of a lateral spreading
of the tongue at rest. The abnormal tongue posture usually begins
when it is necessary to secure a posterior seal during the swallow
because ankylosed primary molars are present or their early loss
creates a vertical open space. The persistence of the spreading
tongue posture impedes eruption and full vertical development of
succedaneous permanent teeth. This condition is sometimes con-
fused with "idiopathic failure to erupt." Maxillary apical base
insufficiency also may necessitate an abnormal posterior spreading
of the tongue.
(2) Treatment.- The treatment of simple open bite in ad-
olescence consists of identifying and controlling localized etiologic
factors first, then bracketing teeth and coordinating arch forms.
In a few cases, these steps alone may be sufficient. More typically,
vertical elastic traction is necessary to acquire full centric stops
on all teeth. Check the occlusion carefully with articulation paper
to determine that each tooth has been seated fully into occlusion.
Allow the patient to wear the banded appliances for the initial
period of retention, but do not remove them until normal swal-
lowing and lip function obtain at all times. Persistent hyperactive
mentalis muscle activity may be treated with a modified vestibular
shield (see Chapter 18). An activator with full posterior occlusal
coverage but no posterior grinding, with selected anterior teeth
relieved from plastic contact, may be worn at night to help in the
control of persisting tongue or digital sucking problems. For pos-
terior simple open bite, a Hawley retainer with extended lingual
flanges vertically is useful to control the tongue during retention.
e) Simple Crowding
For a discussion of simple crowding, see Section D-4-a.
9. Bimaxillary Protrusions
Our nomenclature does not always clearly differentiate be-
tween skeletal and dental protrusions. Bimaxillary prognathism is
a skeletal dysplasia characterized by ventral positioning of both
the maxilla and mandible with respect to the profile and anterior
Adolescent Treatment 465
cranial base (Fig 16-17). Bimaxillary dental protrusion is pro-
cumbency of both dentitions and their alveolar processes on their
bony bases (see Fig 16-17). In this section, an assumption of a
Class I occlusion and the absence of skeletal Class II or Class III
features is made.
a) Bimaxillary Prognathism
Ethnic variations in the normal positions of the maxilla and
mandible may obfuscate the diagnosis. Most cephalometric anal-
yses are based on Europeans or North European whites, whose
standflTds are quite inappropriate for analyzing North American
blacks, Japanese, North American Indians, Mexicans, and many
other groups. For these reasons, the diagnosis for bimaxillary
_prognathism may be more subjective than that for other skeletal
dY8plasias. The diagnosis must also account for the lips and facial
muscles. Treatment may be in response to concerns over facial
esthetics. Bimaxillary prognathism may exist alone, in conjunction
with Class II (horizontal type E), or combined with maxillary
dental protrusion. The Basic Morphologic Analysis and the Profile
Analysis are usefully discriminating (Chapter 12).
Treatment planning involves three steps, all concerned with
esthetic judgments. First, diagnostic setups utilizing the extraction
of different teeth helps to estimate improvements in anterior dental
esthetics. Second, cephalometric tracing of the presumed new in-
cisal positions after extractions permits estimates of the reduction
of the A and B points on the skeletal profile. Third, using the soft-
tissue tracing of the lateral cephalogram plus photographs, esti-
mates of the effects of extraction on static soft-tissue drape (i.e.,
in lips, facial muscles, etc.) are revealing. Improved facial expres-
sion may be the most important consequence of treatment, but it
is almost impossible to imagine prior to therapy.
Treatment consists of symm6tric extraction (usually first bi-
cuspids) in each quadrant and the retraction of anterior teeth to
camouflage the skeletal dysplasia. In moderate cases, orthodontic
treatment alone may be successful. In severe cases, the esthetic
improvement from orthodontics sometimes is inadequate though
the occlusion is fine. More severe cases may be treated by com-
bined orthodontics and orthognathic surgery (Fig 16-18). The
orthodontist and surgeon will judge the success of the case by the
improved occlusion, dental esthetics, and skeletal balance. The
patient invariably judges success by the soft-tissue change and
improved facial expressions.
b) Bimaxillary Dental Protrusion
Bimaxillary dental protrusion may be seen alone or combined
with bimaxillary prognathism. It is also found in Class Il, hori-
zontal type C (see Fig 16-10). The diagnosis is made by the Profile
Analysis and by measurin~.the angle of the upper and lower in-
cisors~o the functional occlusal line. Examine the swallow and
do a careful functional occlusal an;lysis, for bimaxillary dental
protrusion may be associated with a complex tongue-thrust (tooth-
apart swallow) or abnormal tongue posture.
The first step in treatment planning is to do diagnostic trial
setups to test the advantages of different patterns of extraction.
Trace the presumed new incisal positions on the lateral cephalo-
gram to estimate improved profile esthetics. When the occlusal
line and/or the mandibular line is steep, the upper and lower incisor
angulations must be adjusted accordingly (see Chapter 12).
 466 Treatment

A2
VERTICAL ANALYSIS

-3 -2 -IS.o. X tS.o. 2 3
Cranial 80S.
PM Vert/FMN-SE MALES

PM Vert/Mond. Une 115

Moxi/lo
PM V~rt 10cel MAlES
Line 110 I 90 95
1I
1 16-2
(not 0 constant in Clou D) I 75
175
FEMALES
line I I I II I
~OcclClsion FEMALES

82
(82)
S <PM Vert/Pal.
A.S.
FEMALES I 95
MAlE ,:.~5., ,Itl~.
100 105 110. t 115 120 125
t~I~.I,I~ 1L:L:J30 T...

VERTICAL ANALYSIS

-3 -2 - tS.o. X IS.D. 2 3
Cranial 80S.
PM Vert/FMN-SE MALES

75 (nol
PM" in Cion C)
a constant Lin.
Vert/Mond
MoxillO ...L....
170 MAlES 95
III
1

175 115
I~
I
1

170
FEMALES
FEMALES PM
~ Vert /Ocel
Occlusion Line PM Vert/PotI Line I
<..u I I II I
MAlES ,:.~5." \Ol~, ,11 ,~I, .I:~ 1L:L:J30
FEMALES 195 100 105 ttO.1 115 120 125

FIG 16-16.
A, simple open bite, cephalometric tracing: A •• simple open bite, cephalometric tracing. B2, complex open bite, vertical analysis. Note
vertical analysis of the same case. B" complex or skeletal open bite, the contribution of the tipped Palatal Line .

,
.

FIG 16-17.
Bimaxillary prognathism. Note in this instance there is also bimaxillary
dental alveolar protrusion. This patient is a beautiful young lady of
Incan ancestry. In 8, the dotted lines represent "ideal" positions as
FIG 16-18.
Bimaxillary dental alveolar protrusion, before and after treatment.
Adolescent Treatment 467
determined by a popular cephalometric analysis based on North
American, white, subjective values.
These procedures are treatment of cause and not camouflage;
therefore, the results are generally more satisfactory than the treat-
ment of bimaxillary prognathism The retention is usually routine
and uneventful when lip and tongue function are normal.
10. Deep Bite
a) Simple Deep Bite
For a discussion of simple deep bite, see section D-8-c.
b) Complex (Skeletal) Deep Bite
Complex deep bite is a deep bite associated with basic skeletal
features with which the alveolar processes cannot cope. The oc-
clusal, mandibular, and palatal lines appearqJarallel and the gonial
angle is less than normal; in fact, it may near orthogonality. Total
anterior face height approximately equals posterior total face height
(see fig 16-15). Complei deep bite is frequently associated with
ClassII (vertical types 2, 4, and-'5) and occasionally with Class
III (see Section D-7). Both Vertical Analyses are required for a
definitive diagnosis.
Early childhood is the best time to treat complex deep bite,
for functional jaw orthopedic appliances can then guide the erup-
tion of the permanent dentition and help control vertical skeletal
growth. Mild cases in adolescence are treated with full-banded or
bracketed appliances. In moderate cases a flat maxillary bite plane
or functional jaw orthopedic appliance is used in conjunction with
full-banded therapy. Adolescent treatment of moderately severe
468 Treatment
cases is usually more successful in boys than girls since boys
normally have more remaining growth to utilize in treatment. Se-
vere cases of complex deep bite may require orthognathic surgery
later. Even in the most severe problems, I prefer to attempt treat-
ment in adolescence and force the decision toward surgery by the
inadequate response to conservative therapy. On occasion I have
been pleasantly surprised by the response to ske"letal deep bite
treatment in adolescence. Patients and parents are delighted to
avoid surgery if possible. However, complex deep bite can be one
of the most difficult malocclusions to treat orthodontically: it cer-
tainly is so when combined with severe AP skeletal dysplasia.
11. Open Bite
Basic concepts of open bite are discussed in Chapter 15. Open
bite may be associated with Class 11or Class III malocclusion (see
Sections D-6 and D-7), but in this section it is assumed that there
is no anteroposterior skeletal dysplasia.
a) Simple Open Bite
For a discussion of simple open bite, see Section D-8-d.
b) Complex (Skeletal) Open Bite
Complex or skeletal open bite is the result of a vertical dys-
plasia so severe that compensatory alveolar growth cannot cope
(see Fig 16-16). The abnormal lip and tongue functioning observed
with a complex open bite is usually adaptive in coping with the
skeletal dysplasia, though the condition is held by many to be
associated with "mouthbreathing" and chronic nasorespiratory
dysfunction (see Chapters 7 and 10). Both Vertical Analyses are
a necessary part of the cephalometric diagnosis. In complex open
bite these analyses often show the palatal plane tipped upward,
the mandibular plane steeper than normal, and anterior face height
excessive relative to posterior face height. The skeletal dysplasia
may be confined to anterior lower face height. The gonial angle
may be obtuse and the ramus angled posteriorly. The mandibular.
alveolar process height may be excessive anteriorly, and the oc-
clusal and mandibular lines divergent. The maxillary arch is often
narrow and there may be excessive height to the alveolar process,
producing unfortunate gingival display. Complex open bite is fre-
quently associated with Class 11(vertical type 1) and skeletal Class
III malocclusions, particularly mandibular prognathism. In this
section it is assumed that the skeleton is normal anteroposteriorly.
In addition to the skeletal dysplasia, two neuromuscular fea-
tures characterize the more severe cases, that is, those cases in
which orthognathic surgery must be considered: (1) a strained high
maxillary lip line exposing much gingivae and, (2) little or no
freeway space. Upper posterior face height measures are critical
in this instance. When the posterio'r upper face height is excessive
the palatal plane is tipped upward, but not because of the more
frequent short anterior upper face height. Tooth positioning alone
cannot cope with the resultant maxillary vertical hyperplasia.
Complex open bite typically is difficult to treat orthodonti-
cally. In moderate cases, one attempts to achieve some esthetic
cover-up of the skeletal dysplasia by alveolar process compensa-
tion. Extractions may be necessary, even when simple crowding
is absent, to provide space for tooth positioning and alveolar re-
modeling. If initial orthodontic treatment does not succeed in more
severe cases, surgery at a later age may be indicated. Growth tends
to aggravate, not obscure, all cases of complex open bite.
12. Temporomandibular Joint Dysfunction
a) Background
Temporomandibular dysfunction and associated signs and
symptoms are more frequently seen in adolescence than in child-
hood. Reread Chapter 15, Section D-14, for a discussion of the
developmental aspects of temporomandibular dysfunction in child-
hood. The origins are important to an understanding of the clinical
problem in adolescence. A history of facial trauma or temporo-
mandibular joint trauma is often found. Temporomandibular joint
dysfunction may be seen with a variety of malocclusions in ado-
lescence, although it is most frequently associated with Class 11,
deep bite, open bite, and skeletal asymmetry. Of particular im-
portance are those cases with occlusal dysfunction-such as an
abnormal distance between the retruded contact and intercuspal
positions and markedly deviant or erratic paths of mandibular
closure. A meticulous examination of the joints and associated
musculature is essential for every adolescent malocclusion (see
Chapters 10 and 11). Many adolescents are unaware of myalgia
or pain in tendons and the joint region because the condition has
appeared so gradually that they have accommodated through time.
Precise palpation may elicit points of tenderness of diagnostic
significance (see Chapter 10).
b) Treatment
Treatment 'consists of correcting the mal occlusion to the finest
and most precise functional occlusal results, giving particular at-
tention to the joints. Detailed attention to tooth positioning, oc-
clusal equilibration, and precise occlusal coordination are essential.
Intermaxillary elastic traction during treatment is contraindicated
in patients with TMJ symptoms. Retention should not be started
until perfect occlusal coordination is seen, but occlusal equilibra-
tion may be begun while the bracketed appliances are still in place
(see Chapter 18).
References have been made in the literature implicating ad-
olescent orthodontic treatment as a causative factor in adult tem-
poromandibular dysfunction, but sound long-term clinical studies
clearly show orthodontic treatment is not a significant etiologic
factor on a population basis.30 Any poor occlusal treatment at any
age can contribute to temporomandibular ;ain or joint derange-
ment. Temporomandibular dysfunction is often construed as pri-
marily a problem in geriatric dentistry, for most treatment is now
do.n~ on older patients .•Recent research indicates there may be
impOrtant occlusal developmental ~tiologic factors which have been
overlooked. 20.22.32Definitive studies have established two impor-
tant points: (I) tempor~mandibular dysfunction is an integral part
of thl'f development of some malocclusions,32 and thus is present
before orthodontic treatment begins, and (2) orthodontically treated
patients have no more temporomandibular dysfunction than is seen
in the random population.30 Therefore, orthodontic treatment sig-
nificantly reduces the prevalence of temporomandibular joint dis-
orders in adolescents, for the condition is more prevalent in
mal occlusions before their treatment.

REFERENCES
I. Andrews LF: The six keys to normal occlusion. Am J Or-
thod 1972; 63:296.
2. Baumrind S, Franz R: The reliability of head film measure-
ments. 1. Landmark identification. Am J-Orthod 1971;
60: 111-127; 2. Conventional angular and linear measure-
ments. 1971; 60:505-517.
3. Baumrind S, Korn EL, Isaacson RJ, et al: Superimposi-
tional assessment of treatment associated changes in the
temporomandibular joint and the mandibular symphysis. Am
J Orthod 1983; 84:443-465.
4. Baumrind S, Korn EL, Isaacson RJ, et al: Quantative anal-
ysis of the orthodontic and orthopedic effects of maxillary
traction. Am J Orthod 1983; 84:443-465.
? Bookstein FL, McNamara JA Jr, Shaughnessy TG: Skeletal
and dental adaptations following functional regulator ther-
apy on Class 11 patients. Am J Orthod 1985; 88:91-110.
6. DeLaire J: L'articulation fronto-maxillaire, bases theoriques
et principles genereaux d'application de forces extra-orales
postero-anterieures sur masque orthopedique. Rev Stomat
(Paris) 1976; 77:921-930.
7. Graber LW: Chin cup therapy for mandibular prognathism.
Am J Orthod 1977; 72:23-41.
8. Graber LW: The alterability of mandibular growth, in
McNamara JA Jr (ed), Determinants of Mandibular Form
and Growth, monograph 4. Craniofacial Growth Series,
Ann Arbor, Mich, Center for Human Growth and Develop-
ment, University of Michigan, 1975.
9. Graber TM, Kaineg TF: The mandibular third molar: Its
predicative status and role in lower incisor crowding. Proc
Finn Den Soc 198i; 77:37-44.
10. Greenbaum KR, Zachrisson BU: The effect of palatal ex-
pansion therapy on the periodontal supporting tissues. Am J
Orthod 1982; 81:12-21.
11. Hagg U, Taranger J: Maturation indicators and the pubes-
cent growth spurt. Am J Orthod 1982; 82:299-309.
12. Houston W: Relationships between skeletal maturity esti-
mated from hand-wrist radiographs and the timing of the
adolescent growth spurt. Eur J Orthod 1980; 2:81-93.
13. Houston WJB, Miller JC, Tanner JM: Prediction of timing
of adolescent growth spurt from ossification events in hand-
wrist films. BrJ Orthod 1979; 6:145-152.
14. Johnston LE Jr: A comparative analysis of Class 11 treat-
ments, in Vig PS, Ribbens KA (eds), Science and Clinical
Judgment, monograph 19, Craniofacial Growth Series, Ann
Arbor, Mich, Center for Human Growth and Development,
University of Michigan, 1986.
15. Langford SR: Root resorption extremes resulting from clini-
cal RME. Am J Orthod 1982; 81:371-7.
16. Linge BO, Linge L: Apical root resorption in the upper
front teeth during orthodontic treatment: a longitudinal-radi-
ographic study of incisor root lengths, in McNamara JA Jr,
Ribbens KA (eds), Malocclusion and the Periodontium,
monograph 15, Craniofacial Growth Series, Ann Arbor,
Mich, Center for Human Growth and Development, Uni-
versity of Michigan, 1984.
17. Little RM, Wallen TR, Riedel RA: Stability and relapse of
mandibular anterior alignment-first premolar extraction
cases treated by traditional edgewise orthodontics. Am J
Orthod 1981; 80:349-365.
18. Moss JP: The indications for the transplantation of maxil-
lary canines in the light of 100 cases, Br J Oral Surg 1975;
12:268-274.
Adolescent Treatment 469
19. Moyers RE': Studies of orthodontic relapse. Paper presented
to the 60th Congress of the European Orthodontic Society,
Florence, Italy, 1984.
20. Moyers RE, Ten Have T: Childhood indicators of adult
temporomandibular disorders. Presented at the European
Orthodontic Society, Helsinki, 1985.
21. Moyers RE, Riolo ML, Guire KE, et al: Differential diag-
nosis of Class 11 malocclusions, Part I. Facial types associ-
ated with Class 11 malocclusions. Am J Orthod 1980;
78:477-494.
22. Nesbitt BA, Moyers RE, Ten Have T: Adult temporoman-
dibular joint disorder symptomatology and its association
with childhood occlusal relations: A preliminary report, in
Carlson DS, McNamara JA Jr, Ribbens KA (eds), Develop-
ment Aspects of Temporomandibular Joint Disorders, mon-
ograph 16, Craniofacial Growth Series. Ann Arbor Mich,
Center for Human Growth and Development, University of
Michigan, 1985.
23. NIH Consensus Development Conference for Removal of
Third Molars. J Oral Surg 1980; 3:235-236.
24. Pancherz H: Long-term effects of activator (Andersen appli-
ance) treatment. Odontol Revg 1976; 27(suppl 35):11-42.
25. Petit H: Adaptation following accelerated facial mask ther-
apy, in McNamara JA Jr, Ribbens KA, Howe RP (eds),
Clinical Alteration of the Growing Face, monograph 14.
Craniofacial Growth Series, Ann Arbor, Mich, Center for
Human Growth and Development, University of Michigan,
1983.
26. Riedel RA: Post-pubertal occlusal changes, in McNamara
JA Jr (ed), The Biology of Occlusal Development, mono-
graph 7, Craniofacial Growth Series, Ann Arbor, Mich,
Center for Human Growth and Development, University of
Michigan, 1977.
27. Rindler A: Effects on lower third molars after extraction of
second molars. Angle Or.thod 1977; 47:55-58.
28. Riolo ML, Ten Have T: The effect of different kinds of ap-
pliance therapy on the soft tissue profile, in Vig PS, Rib-
bens KA (eds), Science and Clinical Judgment in
Orthodontics, monograph 19. Craniofacial Growth Series,
Ann Arbor, Mich, Center for Human Growth and Develop-
ment, University of Michigan, 1986.
29. Sadowsky C: Long-term effects of orthodontic treatment on
the periodontium during adolescence, in McNamara JA Jr,
Ribbens KA (eds), Malocclusion and the Periodontium,
monograph 15, Craniofacial Growth Series, Ann Arbor,
Mich, Center for Human Growth and Development, Uni-
versity of Michigan, 1984.
30. Sadowsky C, BeGole EA: Long-term status of temporo-
mandibular joint function and functional occlusion after or-
thodontic treatment. Am J Orthod 1980; 78:201-212.
31. Shapira Y, Kuftinec M: Treatment of impacted cuspids.
The hazard lasso. Angle Orthod 1981; 51 :203-207.
3:Z.. Thilander B: TempOtomandibular joint problems in chil-
-dren, in Carlson DS, McNamara JA Jr, Ribbens KA (eds),
Developmental Aspects of Temporomandibular Joint Disor-
ders, monograph 16, Craniofacial Growth Series, Ann Ar-
bor, Mich, Center for Human Growth and Development,
University of Michigan, 1985.
33. Tuversson DL: Orthodontic treatment using canines in place
of missing maxillary lateral incisors. Am J Orthod 1970;
58:109-127.
34. Woodside DG, Reed RT, Doucet JD, et al: Some effects of
activator treatment on the growth rate of the mandible and
position of the midface, London, Transactions of the Third
470 Treatment
International Orthodontic Congress, London, 1975, pp 459-
480.
35. Zachrisson BU: Periodontal changes during orthodontic
treatment, in McNamara JA Jr, Ribbens KA (eds), Maloc-
clusion and the Periodontium, monograpb 15, Craniofacial
Growth Series, Ann Arbor, Mich, Center for Human
Growth and Development, University of Michigan, 1984.
SUGGESTED READINGS
A. Understanding Adolescent Treatment
Bjork A: Prediction of mandibular growth rotation. Am ] Or-
thod 1969; 55:585-599.
Bowden BD: Epiphyseal changes in the hand/wrist area as indi-
cators of adolescent. Aust Orthod ] 1976; 4:87-104.
Carlson DS, Ribbens KA (eds), Craniofacial Growth During
Adolescence, monograph 19, Craniofacial Growth Series,
Ann Arbor, Mich, Center for Human Growth and Develop-
ment, University of Michigan, 1987.
Grave KC, Brown T: Carpal radiographs in orthodontic treat-
ment. Am] Orthod 1979; 75:27-45.
Hagg U, Taranger J: Maturation indicators and the pubescent
growth spurt. Am ] Orthod 1982; 82:299-309.
Hagg U, Taranger J: Dental development assessed by tooth
counts and its correlation to somatic development during
puberty. Eur] Orthod 1984; 6:55-64.
Houston WJB, Miller JC, Tanner JM: Prediction of the timing
of the adolescent growth spurt from ossification events in
hand-wrist films. Br] Orthod 1979; 6:145-152.
Houston WJB: Relationships between skeletal maturity esti-
mated from hand-wrist radiographs and the timing of the
adolescent growth spurt. Eur] Orthod 1980; 2:81-93.
Lewis AB, Roche A, Wagner B: Growth of the mandible during
pubescence. Angle Orthod 1982; 52:325-342.
Pileski RC, Woodside DG, lames GA: Relationship of the ulnar
sesamoid bone and maximum mandibular growth velocity.
Angle Orthod 1973; 43:162-170.
Singer J: Physiologic timing of orthodontic treatment. Angle Or-,
thod 1980; 50:322-333.
B. Defining Goals in Adolescent Treatment
C. Assessment of Results of Adolescent Treatment
Andrews LF: The six keys to normal occlusion. Am] Orthod
1975; 63:296.
D-l-a: Number of Teeth
Graber LW: Congenital absence of teeth: Review with emphasis
on inheritance patterns. ] Am Dent Assoc 1978; 96:266-
275.
McNeil RW, Joondeph DR: Congenitally absent maxillary lat-
eral incisors: treatment planning considerations. Angle Or-
thod 1973; 43:24-29 ....
Schwanninger B, Shaye R: Management of cases with upper in-
cisors missing. Am] Orthod 1977; 71:396-405.
Tuversson DL: Orthodontic treatment using canines in place of
missing maxillary lateral incisors. Am] Orthod 1970;
58:109-127.
D-l-b: Loss of Permanent Teeth (Trauma, Caries, and Other
Causes)
Holm U: Problems of compensative extraction in cases with loss
of first permanent molars. Trans Eur Orthod Soc 1970; pp
409-427.
Thilander B, Skagius S: Orthodontic sequelae of extraction of
permanent first molars: a longitudinal study. Trans Eur Or-
thqd Soc 1970; pp 429-442.
D-4-a: Crowding
Dale lG: Guidance of occlusion: serial extraction. in Graber
TM, Swain BF (eds), Orthodontics, Current Principles and
Techniques, St Louis, CV Mosby, 1985.
Huggins DG, McBride LJ: Eruption of lower third molars fol-
lowing loss of lower second molars: longitudinal cephalo-
metric study. Br] Orthod 1978; 5:13-20.
Richardson ME: The etiology and prediction of mandibular third
molar impactions. Angle Orthod 1977; 44:165-172.
Rindler A: Effects on lower third molars after extraction of sec-
ond molars. Angle Orthod 1977; 47:55-58.
Schulhof FR: Third molars and orthodontic diagnosis. ] Clin
Orthod 1976; 10:272-281.
D-4-b( 1): lmpactions, Cuspids
Boyd RL: Clinical assessment of injuries in orthodontic move-
ment of impacted teeth. Am] Orthod 1982; 82:478-486.
Boyd RL: Clinical assessment of injuries in orthodontic move-
ment of impacted teeth. n. Surgical recommendations. Am
] Orthod 1984; 86:407-418.
Fournier A, Turcotte J, Bernard C: Orthodontic considerations
in the treatment of maxillary impacted canines. Am] Or-
thod 1982; 81:236-239.
Moss JP: The indications for the transplantation of maxillary
canines in the light of 100 cases. Br] Oral Surg 1975;
12:268-274.
Shapira Y, Kuftinec M: Treatment of impacted cuspids. The
hazard lasso. Angle Orthod 1981; 51(3):203-207.
Vanarsdall RL, Corn H: Soft-tissue management of labially po-
sitioned unerupted teeth. Am] Orthod 1977; 72(1):53-64.
Von der Heydt K: The surgical uncovering and orthodontic po-
sitioning of unerupted maxillary canines. Am] Orthod
1975; 68(3):256-276.
Williams BH: Diagnosis and prevention of maxillary cuspid im-
paction. Angle Orthod 1981; 51:30-40.
4-b-( 1): lmpactions, Molars
Bishara SE, et al. Third molars, a review. Am] Orthod 1983;
83:131-137.
Cryer BS: Orthodontic considerations in predicting and prevent-
ing third molar impactions: A review. ] Soc Med 1981;
74:909-910.
Kaplan RG: Some factors related to mandibular third molar im-
paction. Angle Orthod 1975; 45: 153-158.
Richardson ME: The etiology and prediction of mandibular third
molar impaction. Angle Orthod 1977;47:165-172.
Richardson ME: The development of third molar impaction and
•. its prevention. Intl,{. Oral Surg 1981; 10:122-130.
4-b'(2): Ankylosed Permanent Teeth
Biederman W: The problem of the ankylosed tooth. Dent Clin
North Am 1968; pp 409-424.
Konstat MM, White G: Ankylosed teeth: A review of the litera-
ture. ] Mass Dent Soc 1975; 24:74-78.
Skolnick IM: Ankylosis of maxillary permanent first molar. ]
Am Dent Assn 1980; 100:558-560.
D-4-c: Juvenile Periodontitis
McLain JB, Proffit WR, Davenport RH: Adjunctive orthodontic
therapy in the treatment of juvenile periodontics: report of

a case and review of the literature. Am J Orthod 1983;
83:290-298.
D-6: Class 11 Malocclusion
It is impossible to contrive a list of a few good articles on
treatment of Class Il malocclusion in adolescence, as there are so
many. This article listed here describes the differential diagnosis
of Class II types, an important aspect of Class n therapy often
omitted in the many articles which emphasize biomechanics.
Moyers RE, Riolo ML, Guire KE, et al: Differential diagnosis
of Class II malocclusions. Part 1. Facial types associated
with Class II malocclusions. Am J Orthod 1980; 78:477-
494.
DJ: Class III Malocclusions
Graber LW: Chin cup therapy for mandibular prognathism. Am
J Orthod 1977; 72:23-41.
Jacobson A, Evans WG, Preston CB, et al: Mandibular prog-
nathism. Am J Orthod 1974; 66:140-171.
Adolescent Treatment 471
D-lO: Open Bite'
D-l/: Deep Bite
The clinical problem of the skeletal aspects of open and deep
bite is primarily a matter of cephalometric analysis. Unfortunately
many current cephalometric analyses do not discriminate well the
particular elements contributing to vertical dysplasia (see Chapter
12). The following article seems more helpful than most.
Kim VH: Overbite depth indicator with particular reference to
anterior open bite. Am J Orthod 1974; 65:586-611.
D-l2: Temporomandibular Dysfunction
Most of the literature on temporomandibular dysfunction re-
lates to its geriatric sequelae and their treatment. There is increas-
ing evidence that temporomandibular joint dysfunctions have
important developmental etiologies (see Chapter 15). Their treat-
ment in adolescence is only now being formalized, and results
may be expected to be well documented in the future. At the time
of this edition of the Handbook there are a plethora of anecdotal
case reports but scarcely any extensive clinical ..studies of quality.
-.,
-.....
CHAPTER 17

Adult 'Treatment

Robert E. Moyers, D.D.S., Ph.D.

Katherine W. L. Dryland Vig, B.D.S., M.S.
Raymond J. Fonseca, B.A., D.M.D .

.'

OUTLINE

Introduction
A. Orthodontic treatment for adults with good oral health
(R.E.M.) a) Occlusion
1. Diagnosis b) Space
a) Cephalometric analysis 1) Tooth movements
b) Occlusal and temporomandibular evaluation 2) Extraction
c) Soft-tissue profile and esthetics 3) Enlarging teeth
d) Attitude and motivation 4) Reduction of tooth size
2. Planning treatment c) Anchorage
3. Illustrative cases 7. Simple problems in anterior alignment
B. Orthodontic treatment of malocclusions complicated by peri- a) Midline diastema
odontal disease and loss of teeth (R.E.M.) b) Diminished size of lateral incisors
1. Background c) Missing teeth
2. Strategies for treatment
8. Uprighting molars
a) One clinician a) The problem
b) Generalist plus one specialist I) Upper molars
c) Two or more specialists 2) Lower molars
3. General rules b) Goals in treatment
4. Essential diagnostic procedures 1) Rationale
a) Radiographs 2) Uprighting versus uprighting and mesial
translation
1) Cephalograms
2) Periapical survey c) Appliance design
b) Casts I) Removable acrylic appliances
I) Record 2) Bracketed appliances
2) Diagnostic setup d) Diagnosis
'\

c) Periodontal charting I), ¥adiographs

d) Occlusal analysIs 2) The patient
5. Sequence of treatment 3) Casts
a) Hygienic phase of periodontal therapy e) Planning treatment
b) Preliminary single tooth restorations (includ- 1) Complete a diagnostic setup
ing endodontics) 2) Define individual tooth movements
c) Orthodontic treatment 3) Design the appliances
d) Surgical phase of periodontal therapy 4) Imagine possible problems
e) Orthodontic retention f) Treatment protocols
f) Restorative procedures 1) Uprighting mesially inclined lower sec-
6. Choice of orthodontic appliances ond molars

472
 Adult Treatment 473

2) Uprighting mesially inclined second and c) Treatment of severe skeletal dysplasias requiring both or-
third molars thognathic surgery and orthodontics.
3) Contraindications, modifications and Such important areas cannot be treated with full detail here;
complications however, the principles pertaining to each of the three categories
(a) Contraindications will be outlined, some treatment details will be presented, and
(b) Modifications illustrative cases will be shown.
(c) Complications
4) Moving mesially inclined molars forward
(a) Principles of treatment A. ORTHODONTIC TREATMENT FOR
(b) Illustrative cases ADULTS WITH GOOD ORAL HEALTH (REM)
9. Problems due to inadequate space
10. Oligodontia 1. Diagnosis
11. Vertical problems in the anterior region
a) Etiology a) Cephalometric analysis
b) Diagnosis Because craniofacial growth is largely completed in adults,
c) Treatment prediction is less necessary; therefore, tooth movements are planned
I) Simple deep bite to fit the current craniofacial morphology with emphasis on the
2) Deep bite with labioversion of maxillary occlusion and profile esthetics. The Basic Morphologic, Vertical,
incisors Profile Analyses (Chapter 12) are suggested for use on adult pa-
tients. Severe skeletal Class 11 and Class III malocclusions are
3) "Simple" open bite
(a) Diagnosis more apt to require orthognathic surgery, and some patients who
(b) Treatment might have been treated solely by orthodontics in adolescence may,
(c) Retention in adulthood, be treated better by combining orthodontics and
4) Complicated vertical problems surgery.
C. Orthodontic treatment combined with orthognathic surgery
b) Occlusal and Temporomandibular Evaluation
(K.W.L.V. and R.J.F.)
Temporomandibular signs and symptoms, often obscured by
I. Historical aspects
the adaptive aspects of adolescent growth, assume more signifi-
2. Selection of patients cance in the adult; therefore, analysis of the temporomandibular
3. Case Management
joint and its functions must be an integral part of the examination
4. Case Referrals
(see Chapter 11). The centric concept is of greater validity in the
5. Classification of skeletal dysplasias
adult, making precise registration of jaw positions and articulator
6. Timing and sequence of treatments
mounted casts more frequently a necessary feature of the evalu-
7. Case reports ation.
Adult orthodontic treatments are characterized by three features:
(I) waning craniofacial growth; (2) decision making by the patients c) Soft-Tissue Profile and Esthetics
themselves: and (3) malocclusion often complicated by periodontal' Attempts to quantify such adaptive and mobile structures as
disease and loss of teeth. lips have been generally rather crude, yet an orderly study of the
There are important differences between adult and adolescent functioning facial musculature and lips is essential for the adult
orthodontics, differences which create problems yet offer certain patient (see Chapter 10). Facial esthetics is a primary motivating
advantages to the dentist. In adulthood craniofacial growth rarely factor for the adult patient.
complicates or aids treatment, and the cephalometric diagnosis is
a simpler morphologic analysis in which prediction is less impor- d) Attitude and Motivation
tant (see Chapter 12). The bone turnover rate is slower, so tooth If you ask children why they are having orthodontic treatment,
movements do not occur as rapidly. Patient cooperation is a dif- they often say their parents brought them or that everyone has
ferent kind of problem, for there are no parents to enlist for help. their "teeth straightened. Adults-may be If ss forthright and relate
An adult's patience and span of enthusiasm diminishes more rap- what they think the dentist expects to hear, avoiding or repressing
idly, but motivation for treatment is usually high. Orthodontic the real reasons they seek orthodontic therapy. Discussions allow
treatment for adults more frequeI].tly involves intercollegial rela- tqe. true motivating fa<;tors to emerge, which often are esthetics
tionships in an intensely cooperative fashion-the periodontist, the and -the fear of eventual loss o( teeth. It is imperative that both
restorative dentist, and the surgeon may join in the treatment. the patient and the dentist recognize and appreciate the patient's
Finally, temporomandibular disorders are a frequent complication reasons for seeking orthodontic treatment.
of adult orthodontics.
2. Planning Treatment
There is an increasing literature on adult orthodontics, but it
is not yet well codified; however, the problems of adult ortho- The most important difference between planning treatment
dontics segregate logically into three categories: for adults and adolescents is that of growth diminution. In adults,
a) Orthodontic treatment for adults with good oral health, the lessened turnover rate of bone diminishes the percentage of
b) Orthodontic treatment of malocclusions complicated by cases in which ideal results can be obtained without surgery; there-
periodontal disease and loss of teeth, and fo~e, compromised plans result more often. Reduced rates of cra-
474 Treatment
niofacial growth do not mean cessation of dentoalveolar and oc~
clusal adaptations, Behrents ] in the most definitive study to date
of adult craniofacial development, found measurable skeletal and
occlusal changes as late as the fifth decade of life. Pathologic
adaptations of alveolar bone and/or the temporomandibular joints
are more frequently associated with adult malocclusions.
3. Illustrative Cases
Most mal occlusions correctable in adolescence can also be
treated in a healthy adult (Figs 17-1 through 17-5). The treatment
goals will be similar and result can be of equal quality, though
the time to complete the treatment is longer and strategies and
tactics may vary for the adult. Healthy, intact adult dentitions are
no piace for hasty or shoddy orthodontics, for most of the ingre-
dients for quality results are present. Compromised goals are more
logical when the dentition itself has already been compromised by
loss of teeth and periodontal disease, the topic of the next section.
B. ORTHODONTIC TREATMENT OF
MALOCCLUSIONS COMPLICATED BY
PERIODONT AL DISEASE AND LOSS OF
TEETH (REM)
1. Backgroud
This section provides logical rules to help the family dentist
serve some of these patients and presents the rationale for referring
others for treatment by specialists.
2. Strategies for treatment
a) One Clinician
Ideally, the three kinds of treatment these patients require
should be provided by a single clinician, but few of us are equally
capable in orthodontics, periodontics, and reconstructive dentistry.
Sometimes the more skilled we are in one area the less we may
appreciate the knowledge and proficiency required in another.
Furthermore, on graduation from most dental schools the dentist
has more advanced skills and experience in restorative dentistry
than in periodontics and has rarely had but the briefest introduction
to clinical orthodontics. Simple cases can be treated best by a
generalist alone, but they are not plentiful. Training and experi-
ence, not ambition or pretension, should determine whether the
family dentist requires collaboration with the periodontist, resto-
rative specialist, and/or the orthodontist.
b) Generalist Plus One Specialist
The most common situation is that in which the family dentist
is prepared to do the reconstructive dentistry and periodontics but
needs help with the orthodontics. A few simple rules for shared
responsibilities in diagnosis, treatment planning, and treatment are
described later. Their observation protects colleagues and guar-
antees better therapy for the patient.
c) Two or More Specialists
More difficult cases which combine extensive treatment by
specialists require planned interaction and continuing consultation
to guarantee success.
3. General Rules
Three general rules apply irrespective of the strategy:
a) Plan all treatment, including retention, before starting any
therapy.
b) Share all diagnostic data and treatment plans.
c) Consult regularly with one another about progress and
problems during treatment.
THE RESULT WILL BE NO BETTER THAN THE POOR-
EST INDIVIDUAL TREATMENT PROVIDED.
This simple, true, and important statement emphasizes how
carefully one must choose colleagues for collaborative therapy.
Some excellent dentists are neither experienced in, nor inclined
toward, this kind of joint treatment.
4. Essential Diagnostic Procedures
The following diagnostic data and procedures may be required
when treating a single case; it is not necessary fdr each clinician
to gather them all, but collectively they must be available. It is
efficient to duplicate and distribute all radiographs and written
records, though dental casts probably should be taken by each
clinician, since each clinician uses them in different ways.
a) Radiographs
1) Cephalograms.-Usually the orthodontist takes the ceph-
alograms for they are essential to his or her analysis and treatment
planning, but the summarized cephalometric findings may be shared.
Duplicate cephalograms can be provided for study by the others
if needed.
2) Periapical Survey.-AIl clinicians must have periapical
surveys available before, during, and after treatment. The pan-
oramic radiograph is useful but does not provide sufficient alveolar
detail.
b. Casts
(1) Record.-Record casts at the start of treatment are nec-
essary for each clinician. In some instances, they may need to be
mounted on an articulator. After orthodontic therapy is over, the
restorative dentist will require another set of diagnostic casts.
2) Diagnostic setup (see Chapter ll).-Rearranging the
teeth on an extra set of casts provides the opportunity for all
clinicians to visualize the probableoccusal relationships after or-
thodontic treatment (see Figs 17-10 and 11-19). It also makes
possible comparisons of different orthodontic solutions. When the
tentative treatment plans al1,9diagnostic setups are assembled, the
case' can be studied together.
c) Periodontal Charting
The periodontist's charting of pocket depth, attachment level,
mobility, and other data are of special interest to the orthodontist
as well. Many tooth movements which seem possible when study-
ing casts alone are put in more difficult perspective by the findings
of the periodontist.
d) Occlusal Analysis
Perceptions of occlusion are different among the different
 Adult Treatment 475

FIG 17-1.
A-E, closure of midline diastema in a 64-year-old woman. Note that was removed. An acid-etch ("Maryland bridge") retainer is usually
the permanent retention was placed before the orthodontic appliance quite sufficient.

FIG 17-2.
A-E, missing maxillary lateral incisor. Note the diminished size of of Tooth Development, Chapter 6).
the other lateral incisor and the second premolars (see Genetic Fields
 .'

FIG 17-3.
Treatment of a Class I malocclusion in an adult woman. A, before
treatment. 8, after treatment. A fully bracketed, maxillary, edgewise
appliance was used.

F.S.
---Before
--After

FIG 17-4.
Treatment of an adult skeletal Class 11malocclusion complicated by
a skeletal deep bite.

476
 Adult Treatment 4n

o BASIS· ~RPHOl.OGIC ANALYSIS

C.K .
• BEFORE
• AFTER MALES FEMALES
-2 -15.0 X IS.O.2 -3 -2 -IS.O.X IS.O.2 3
Crankll Base
Bo-SE-FMN

Bo-S-No
j~..~5 .i4!o- . ..:l-. '1' I.. 'I~'
. r,is ..
·1···,I ... ,I. ... I .••. h .. ~' ... ,.,
Crania/Base-Maxilla
S-N-A
II
••
I' I I
125 130.2 I
135 I140 1145
I
10
SE-FMNA •• 1

CraniaIBa$(l-Mand1~fHJ
Bo-SE-Me

Bo-SE-Pog
Cranial Bau-MandiblefVJ
Bo-SE/Mand. Line

PM Vert lMond. Une

Mazilla-Mandible
Mand. Line/A - B

Funct. 0ccI. Ln.1 A- B

(not 0 constant)

Skeltlfal Profile
FMN-A'B
ISO 155
1 I

FIG 17-5.
Mandibular prognathism. This patient was treated in adolescence apparently had diminished greatly and mandibular first premolars
(see Fig 16-12 for details on controlling the adolescent growth spurt were extracted. B, counterpart analysis. C, counterpart analysis after
in the mandible). A, intra-oral views at age 16 years when growth treatment. D, basic morphologic analysis before and after treatment.
478 Treatment
fields in dentistry, and the possibilities and methods of correction
vary greatly. Therefore, each dentist forms ideas independently
yet shares them with colleagues to take advantage of one another's
experience and strategies.
These records may seem superfluous; they are not. They
constitute the minimal information required before treatment plan-
ning can begin.
5. Sequence of Treatment
The sequence of treatment described here is best for most
cases, though one alternative is discussed later: e.g., periodontal
surgery prior to orthodontics.
a) Hygienic Phase of Periodontal Therapy
The hygienic phase of periodontal therapy must be completed
before any orthodontic treatment is begun. No orthodontics can
begin until the mouth is clean and the patient is maintaining good
oral hygiene. The other dentists may gather data and plan treatment
while the hygienic phase is completed, but no teeth should be
extracted without consultation. Often a tooth which is condemned
periodontally may be useful during the orthodontic treatment to
help stabilize the orthodontic appliance, and orthodontic treatment
sometimes salvages teeth assigned for extraction. Orthodontics
should not be perceived as alignment of crowns and improved
occlusal relations alone, for root movements are also essential,
producing far more extensive alveolar bone remodeling than is
sometimes realized. Indeed, surprising amounts of favorable bone
remodeling during orthodontics often changes the initial treatment
plan.
b) Preliminary Single Tooth Restorations (Including
Endodontics)
Some teeth may be so brokendown or pulpally involved that
some restorative dentistry is necessary before orthodontics can
begin. Only temporary restorations should be placed at this time"
since the occlusal relationships will be altered by the orthodontic
treatment.
c) Orthodontic Treatment
Maintenance of good oral hygiene in-patients who have a
history of periodontal disease may be a special problem during
orthodontic treatment. The frequency of periodontal reevaluation
and hygienic therapy varies greatly depending on the severity of
the ravages of the periodontal disease and the patient's persistence
(it's much harder to keep the mouth clean when appliances are in
place) .
d) Surgical Phase of Periodontal Therapy
Ordinarily any surgical treatment follows the orthodontic phase,
but there may be occasions when it is necessary to do some surgery
prior to the orthodontics. Orthodontic treatment remodels the al-
veolar process, often diminishing the need for periodontal surgery.
The timing of surgery is decided by the periodontist in consultation
with the orthodontist, but if the hygienic phase is successful, the
surgery usually can wait advantageously. These are good cases
for a conservative approach to periodontal therapy.
e) Orthodontic Retention
After active orthodontic tooth movements, the retention,
planned before treatment began, is necessary. Sometimes it is
possible to use the passive orthodontic appliance itself as the re-
tainer; on other occasions conventional orthodontic retainers are
needed. There are also cases in which temporary bridges can be
placed while the passive orthodontic appliance is still in place;
then, when the orthodontic appliance is removed, the bridges be-
come the retainers.
f) Restorative Procedures
6. Choice of Orthodontic Appliances
The choice of orthodontic appliance for a specific case is
based on three fundamental factors: occlusion, space, and an-
chorage. Understanding the importance of each of these enables
the dentist to design the most efficient appliance for a specific
problem. The periodontic and reconstructive lit'erature contains
many articles in which "simple" removable, appliances are ad-
vocated as if they were always the most efficient for these cases;
but as a general rule, they are not. The cases shown later in this
chapter were chosen as typical of each category and demonstrate
the use of a variety of appliances. Bracketed appliances are usually
favored for two practical reasons: (I) control of anchorage; and
(2) versatility.
a) Occlusion
Occlusal relationships must be studied carefully: statically on
casts (intercuspal position) and functionally in the patient. The
relationships of the cusps and inclined planes during the uncon-
scious swallow, in the retruded contact position (centric relation),
and in mastication are all-important, since occlusal function itself
either aids or counteracts desired tooth movements although the
teeth are apart most of the time. When occlusal function counter-
acts desired tooth movements or temporary traumatic occlusal re-
lationships are established by orthodontics, it is necessary to insert
a discluding appliance-a temporary bite plane which does not
cover the occlusal surfaces of the posterior teeth-permitting or-
thodontic tooth movements to continue (Fig 17-6). These bite
planes must be worn faithfully, for each time they are taken out
of the mouth, the teeth-in their transitory positions-will be at
the mercy of occlusal function. Bracketed appliances have a dis-
tinct advantage since the archwires serve as splints for the teeth
at all times, yet are easily adjusted. "Jiggling" of teeth during
function, due to occlusal interferences creat~d by the orthodontic
treatment, can be very damaging and should be obviated.
. Resist the temptation.,tli!-equilibrate the teeth as they are moved.
Do 'not remove each new interfer~nce which appears, since the
very cusp tip, which is interfering transitorily, may be needed later
as a centric stop at retention time. Restorations, which were carved
to fit the original malocclusion, may be recontoured during or-
thodontic treatment, but even this must be done with caution until
the final occlusal relationship is near. The role of equilibration in
retention of these cases is discussed later.
b) Space
A careful analysis of the space available is essential before

FIG 17-6.
Schematic drawing of a maxillary, flat bite plane used to dis-
elude teeth during certain adult orthodontic treatments. (See also
Fig 17-20.)
starting any orthodontic treatment: it is particularly important for
adults who have periodontal disease and missing teeth. Possibilities
for improved use of available space are : (I) moving teeth to
increase the arch perimeter; (2) extraction; (3) enlarging the crown
size with restorations; or (4) judicious reduction in the crown size.
There are limitations with each of these possibilities.
1) Tooth Movements.- There are restrictions to the amount
and direction of tooth movements, for example, arches cannot be
expanded ad libitum, loss of bone prohibits movement in certain'
directions, and the bone'turnover rate in aged patients is so slow
some movements are quite impractical. Therefore, the movements
desired for a specific patient must be tested against the specific
conditions of that patient's alveolar process, arch size, skeletal
profile, health, age, etc.
2) Extraction.-Extraction must be considered in some cases,
but the decision to extract should be forced by the evidence of the
data (e.g., a diagnostic setup). Of interest is the effect of extrac-
tions on the ultimate occlusal relationships, restorations required
FIG 17-7.
A:-E, orthodontic treatment of a "peg" lateral incisor and a microform
lateral incisor on the opposite side. There was also a complicating
Adult Treatment 479
at the end of orthodontic treatment, and the amount of space needed
relative to the amount made available by extractions. It is easy to
remove a tooth; it is often difficult to close the remaining excess
space left after alignment.
3) Enlarging Teeth.-Often a diagnostic setup or the Bolton
analysis (see Chapter 11) reveals disharmonies of tooth size within
an arch or between the combined sizes of the upper and lower
teeth. Sometimes an esthetic stabilizing solution is to enlarge one
or more teeth (Fig 17-7).
4) Reduction of Tooth Size.- When small amounts of space
are needed to bring teeth into better alignment, reduction of the
size of teeth is sometimes possible. A diagnostic setup and radio-
graphs are used to disclose the amount of enamel available on
each tooth (or the possibilities for reshaping restorations), and the
site where the space is most needed (see Fig 17-20).
c) Anchorage
In orthodontics, anchorage is resistance to tooth movement
(see Chapter 13). Adults with loss of teeth and periodontal disease
have reduced sources of anchorage. The ravages of periodontal
disease constitute a primary problem in appliance design. Some
of the strategies employed to augment anchorage are ligating teeth
together on the archwire, reinforcing anchorage with bite plates,
discluding with bite planes, and using extra-oral traction.
7. Simple Problems in Anterior Alignment
The cases discussed here are those in which the posterior
occlusion is stable and needs little or no correction.
a) Midline Diastema
The causes and treatment of excessive space at the midline
(see Chapter 15) should be reread before starting treatment of an
adult midline diastema because the principles outlined there apply
here. As a general rule, the teeth are brought together prior to any
developmental defect in the midline alveolar septum.
480 Treatment
surgical correction of the midline fault, though supernumerary
teeth, of course, are removed before the start of orthodontic treat-
ment. A common situation is that of lateral incisors, which are
diminished in size. It does no good to bring the central incisors
together if tight contact cannot be obtained in the lateral region.
A diagnostic setup will show the ultimate alignment and which
teeth may be built-up with composite or jacket crowns to improve
esthetics and aid retention. Retention of the central incisors in a
new position may consist of (I) a thin casting, bonded to the lingual
surfaces (as for a "Maryland" bridge); (2) a mesh wire embedded
in composite on the lingual surfaces; or (3) nothing but tight in-
terproximal contacts, depending on the needs of the individual
case (see Fig 17-1).
b) Diminished Size of Lateral Incisors
Maxillary lateral incisors may be diminished in size, varying
from a well-shaped microform to a "peg" (see Chapter 6). It is
essential to examine carefully the periapical radiographs to make
certain that no septal fault is present (see Chapter 15) and to identify
any reductions in root size. Precise measurements must be made
of all anterior teeth (see Chapter II for techniques in analyzing
the effects of asynchronous tooth size on occlusion). The size of
the left lateral incisor must be compared with that of the right and
both to other teeth in the arch. A diagnostic setup provides precise
information about the best positions of each tooth needed by the
end of treatment. Inlay wax may be added to the small teeth on
the casts, carving new crowns to appreciate the effects of the
orthodontic treatment and the ultimate restoration prior to begin-
ning treatment. An illustrative case is shown in Fig 17-7.
c) Missing Teeth
Maxillary anterior teeth are frequently lost in accidents, and
maxillary lateral incisors are among the teeth most often absent
congenitally. The same principles outlined earlier pertain to this
treatment also. It is advisable to use a precision bracketed appli-
ance, since parallel placement of the roots of the teeth is necessary
for the best possible bridge. When one lateral incisor is missing,
the size of the other must be measured carefully for it is usually
diminished in size. Generalized size reduction can also be expected
(see Chapters 6 and 7). After space has been created a maxillary
acrylic palate with a pontic may serve as a retainer during the
construction of the bridge. It is also possible to attach a pontic
directly to the archwire during the latter part of treatment (see Fig
17-7, 17-22, and 17-23).
8. Uprighting Molars
a) The Problem
The tooth most frequently losf to caries and/or periodontal
disease is the first permanent molar. As a result, the second and
third molars may drift mesially, leaving the region more susceptible
to periodontal disorders and complicating the replacement of the
first molar. Other complications which may result include occlusal
interferences and attendant temporomandibular joint dysfunction,
loss of vertical dimension, extrusion of antagonistic teeth, etc.
Upper Molars.- When first molars are lost, the maxillary
second molar tips mesially while rotating around the palatal root.
It may also translate bodily (Fig 17-8).
Lower Molars.-In the lower arch the reaction of the second
molar is similar, but lingual tipping accompanies mesial tipping.
Because the forces of occlusion are buccal to the centroid of the
lower molar, the more the tooth tips mesially, the more the oc-
clusion tends to drive the tooth lingually. There is less rotation in
the lower molar since there are only two roots, but translation is
common, particularly if the first molar was lost early in life .(see
~I~). /
b) Goals in Tr(!atment
A normal angulation of the molar is desired since it provides
(I) improved alveolar support, (2) better oral hygiene, and (3) a
more advantageously designed bridge.
1) Rationale.- The advantages of an upright tooth parallel
to the anterior abutment of a possible bridge are" obvious. Lang8
has shown that molar uprighting also reduces the Gingival and
Periodontal Indexes, the pocket depth, and attachment loss. These
improvements begin in the hygienic phase of periodontal therapy
and further improvement is seen after the orthodontic treatment is
completed. Convincing evidence for the advantageous remodeling
of the alveolar bony support for uprighted molars is shown in Fig
17-9.
2) Uprighting Versus Uprighting and Mesial Transla-
tion.-It is relatively easy to upright the second molar and even
the third molar when the first molar has been lost (see Figs 17-
II to 17-16). After they are uprighted the occlusal relationships
may not be correct and a decision must be made about how much
translation is needed and in which direction. Three alternative final
positions are available, resulting in (I) a final edentulous space
equal to the width of the lost first permanent molar, (2) an eden-
'tulous space equal to the width of one cusp after uprighting and
some mesial translation, and (3) complete closure of the second
molar forward into contact with the second bicuspid. The choice
is dictated by the conditions present, the age of the patient, and
the skills of the dentist. What is ideal for one patient may be
impossible for another. Treatment procedures for each of these
conditions are described later in this section.
c) Appliance Design
The choice of appliance is dictated by the required tooth
movements. The appliance must be able to replicate, in reverse,
the tipping, rotating, translating, and extrusion that occurred to
prod,u.ce the malposition .• CO
1) Removable Acrylic Appliances.-Although the perio-
dontic and restorative literature often advocates the use of remov-
able appliances with auxillary springs for molar uprighting, they
are indicated only in the most ideal of circumstances. These ap-
pliances are very usefull for simple space regaining in the early
mixed dentition (their use is described in Chapter 15). They may
be used in adult patients only when there is no major occlusal
discrepancy, no extrusion, good periodontal health, and v.ery little
 Adult Treatment 481

alveolar bone loss, and the third molar is either absent or presents
no complications. Such conditions rarely obtain.

2) Bracketed Appliances.-Most problems can be handled

best by bracketed appliances. The descriptions herein utilize 0.022-
inch edgewise brackets with no built-in torque or angulation.

d) Diagnosis
Several questions must be in mind. How does this local prob-
lem affect the total occlusion? What effects will molar uprighting
have on occlusal relationships? On vertical occlusion?

1) Radiographs.- The periapical radiographs must be stud-

ied to assess the health and extent of the alveolar process, the root
lengths, and any root resorption.
The positions :>f the roots of the second molar, third molar,
and second bicuspid must be noted. Are they parallel? Have the
teeth tipped or translated? These observations in the radiographs
define the tooth movements (see Fig 17-9). One must realize that
the periapical radiograph does not record the organic matrix of
bone, only the radiopaque inorganic fractions. In Figure 17-9 the
uprighting movements provided an environment into which the
deposition of the inorganic salts could recur. Far too frequently
we think, or say, "no bone is present," when viewing a radiograph
like that in Figure 17-9, which is wrong for it is obvious that the
critical and useful organic matrix was present.

2) The Patient.-Study the patient's profile and evaluate the

lips and soft tissue. Study the vertical dimensions of the patient,
both in occlusion and at rest.

3) Casts.-From the dental casts, one can study the basic

occlusal relations noting the positions of the second and third
molars and the bicuspids, extrusion of antagonistic teeth, the over-
bite and overjet, malpositions of other individual teeth, etc. Also,
the shape and height of the alveolar ridge of the edentulous space
FIG 17-8.
can .be seen best on casts.
Typically mesial drifting movements of first permanent molars.

FIG 17-9. amount of mesial transilatory movements which have taken place
A and B, uprighting of mandibular second molar. Note the amount after uprighting can be seen in the trabecular pattern of the bone
of bone which replaced the "pocket" on the mesial surface. The just distal to the distal root.

:
482 Treatment

FIG 17-10.
A diagnostic setup prior to molar uprighting.
c 1 •• I

e) Planning Treatment
1) Complete a Diagnostic Setup.-A dignostic set-up pro-
vides an idealized depiction of the possibilities of orthodontic
treatment (Fig 17-10).

2) Define Individual Tooth Movements.-Are these tooth

movements possible? In what sequence should they occur?

3) Design the Appliances.- Which teeth should have tubes

and brackets? Will an acrylic bite plane be necessary to remove
occlusal interferences? Is this a locally defined problem or are
there other aspects of mal occlusion that can be treated with the
same or a slightly modified appliance?

FIG 17-12.
A-C, other methods of uprighting and distal movement of molars.
A . (After van Arsdale.)

4) Imagine Possible Problems.-What can go wrong? How

can problems be obviated? Design, in your mind, backup proce-
dures should any of these problems actually occur.

f) Treatment Protocols
1) Uprighting Mesially Inclined Lower Second Molars
(Refer to Figs 17-11 to 17-16).-
B a) A sectional appliance involving double molar tubes on
second molars and brackets on the premolars and cuspid only is
required in the quadrant in which the tlrst molar is missing, if
there are no extruded opposite teeth or other occlusal problems.
A bopded lingual archwi'rt? may be inserted from cuspid to cuspid
in the' lower arch to maintain the arch width and aid anchorage.
It may not be needed if the mandibular arch is perfectly aligned,
c there is a normal overbite and overjet with tight, vertical centric
stops in the incisor region, and no "slide" into occlusion (Fig
17-11).
b) In more complicated cases all teeth should be bracketed
or banded. Level the arch first with a twisted wire (0.015 inch or
~
0.017 inch) from the cuspid through the third molar. This may be
FIG 17-11. followed by a rectangular braided wire (0.017 inch x 0.025 inch).
A-C, the use of a segmental uprighting spring. Arch leveling usually takes two to four appintments spaced 3 to

A (Fig 17-13 ,A). Place simultaneous uprighting springs for both the
B (Fig l7-13,D) and proceed with the tooth preparations. Insert a
c alveolar bone loss of anterior teeth, and (5) severe dysfunction of
FIG 17-13.
A-D, simultaneous distal movement of second and third molars.
Careful control of anchorage by this and other means obviates the
need for extraction of the third molar. (After van Arsdale.)
4 weeks apart and will achieve a sutprising amount of the tooth
movements needed.
c) Insert a round 0.018-inch archwire in the bracket slot and
in the main tube of the second molar. Add a sectional uprighting
spring inserted in the lower tube on the second molar (Fig 17-
IIA).
d) After the molar is upright, place a rectangular wire (0.018
inch x 0.025 inch) to secure final positioning of the crowns and
alignment of the roots (Fig 17-11,C). A Hawley retainer may be
worn while the teeth are prepared fora bridge. A temporary bridge
may be placed prior to the insertion of the ultimate bridge. Other
methods of uprighting molars are shown in Fig 17-12.
2) Uprighting Mesially Inclined Second and Third Molars
(Refer to Fig 17-13).-
a) Place double buccal tubes on both second molars and a
single buccal tube on the third molar of the side to be treated.
Place brackets on all other teeth in the lower arch.
b) Level the arch with twist wires, braided rectangular wires,
and round wires (0.015, 0.016, and 0.018 inch wires in sequence)
Adult Treatment 483
second and third molars (Fig 17-13,B).
c) When both the second and third molars are upright, insert
a 0.018-inch round, straight wire to engage all of the brackets
and tubes. If there are interdental spaces at this time, they may
be closed by use of elastic chains or a compressed coil spring at
the edentulous site (Fig 17-13,C).
d) Insert a 0.018 inch x 0.025 inch rectangular finishing wire
temporary bridge and place the final bridge later.
3) Contraindications, Modifications, and Complica-
tions.-
(a) Contraindications.-Conditions in which molar upright-
ing may be undertaken, but which are beyond the scope of this
book, include: (1) most cases found in severe skeletal dysplasias,
(2) open bite, (3) absence of several anterior teeth, (4) extensive
the temporomandibular joint.
(b) Modifications.-Mild extrusion of antagonistic teeth may
be handled by the insertion a maxillary bite plane, judicious grind-
ing of the lower molar as it is uprighted (if that tooth is to be used
as an abutment), and, in most cases, by placing an appliance in
the upper arch to level the occlusion.
Maxillary cases are treated in a fashion similar to the lower.
It can be expected that more rotation will take place as the maxillary
molar moves distally, and provision for that rotation must be made
in adjustments of the uprighting springs. Maxillary molars also
tend to drift mesially a bit more rapidly suggesting a solution to
the problem by mesial movement obviating the need for a bridge
(see Section 7-f-(4), but this solution is much more difficult in the
upper arch due to the palatal root.
Typical cases are shown in Figs 17-14 through 17-16.
(c) Complications.-Unwanted opening of the occlusion may
appear with uprighting of lower molars, particularly if only partial
arch wires have been used as suggested earlier.
Undesirable bite opening is a clear sign of improper mechanics
or adjustment of the appliance. Frankly, this is an undesirable
complication arising from failure to adjust the appliance for intru-
sion while tipping. It is not enough to grind away the cusp of the
offending tooth on the premise that it will be included in the bridge,
unless the appliance mechanics continue tO,depress the tooth. This
problem is a principal reason for not using removable appliances
for simple molar uprighting, for they have no vertical control of
th~ .uprighting tooth .• ~.
• Occasionally a patient will tire of the whole procedure before
uprighting is completed. When this happens only two alternatives
present themselves: (I) persuade the patient to continue: or (2)
have the bridge constructed under unfavorable circumstances.
4) Moving Mesially Inclined Molars Forward.-Moving
second and/or third molars mesially to obviate the need for a bridge
is a fine orthodontic service for adult patients and can be done in
highly selected cases, but it requires considerably more skillful
control of the appliance then simple uprighting. This procedure is
484 Treatment

FIG 17-14. ,.
Treatment of absent mandibular first molars: uprighting for a bridge treatment casts. B, various stages of treatment including the finished
on one side, uprighting and mesial movement on the other. A, pre- result ready for placement of a bridg~.

FIG 17-15.
Molar uprighting and transilatory movement. A, the basic uprighting
spring. B, a closing vertical loop, bringing the molar mesially.
easier in adolescents, particularly when the third molar is erupting,
and is much simpler in patients who have had no periodontal
disease. The alveolar area of the edentulous region should be
studied carefully in the radiographs, in the mouth, and on the
dental casts. Mapping of pocket depths and alveolar crest heights
on the teeth to be moved, and detailed study of the alveolar bone
are necessary. One hopes for a healthy high and broad alveolar
process with a distinct "collar" of bone on the mesial of the
molar(s) to be moved. Teeth do not just move through bone, they
carry bone with them. A poor alveolar housing at the start of
treatment is not improved by mesial movement of the tooth. This
orthodontic procedure should be carried out only by dentists thor-
oughly experienced in orthodontic mechanics.
(a) Principles of Treatment.-It is absolutely necessary to
level both arches with complete appliances as the first step of
treatment. Except where there is a very shallow bite, a flat bite
FIG 17-16.
Molar uprighting in an orthognathic surgery case. A, early uprighting
biomechanics. B, radiograph of the result after uprighting, orthog-
nathic surgery, and mesial movement of the molar.
Adult Treatment 485
plane is worn at all times. Only after the arch is leveled and the
molar uprighted is forward traction applied with a gentle, contin-
uous force and depressing action. Since these cases have a tendency
to reopen interproximal contact quickly, retention is begun by
tightly tied steel ligatures holding the molar forward while the com-
plete archwire is still in place. A well-fitted Hawley retainer will
suffice after this step and after occlusal equilibration is completed
(see Fig 17-17).
(b) Illustrative Cases.-The cases shown in Figures 17-16
and 17-17 offer proof that this can be a sensible conservative
procedure when carried out properly. They also show certain dan-
gers and complications (Fig 17-18). If tempted to treat a case of
this type, reread this section carefully and study thoroughly the
cases shown before beginning.
9. Problems Due to Inadequate Space
In this section are considered minor space problems treatable
without extraction of teeth. The diagnostic setup often reveals that
the consolidation of interdental spacing, coordination of arches,
and uprighting and rotating of crowns will provide surprising
amounts of space, which may be distributed throughout the arch
(see Figs 17-19 and 17-20). Two other opportunities for the
creation of space are available; the distal movement of posterior
teeth and careful reduction of the mesiodistal diameter of crowns.
For these cases the precision bracketed arch wire appliance is much
more useful and conservative than removable appliances, since the
arch wire allows precise control of each tooth and a maximal uti-
lization of any space found or created.
The cases chosen for illustration (Figs 17-20 and 17-21)
have one thing in common; optimal utilization of the total arch
perimeter by idealizing the angulation and rotations of individual
teeth. Their placement in an ideally shaped arch is the first re-
quirement. Reducing the diameter of the crowns is not undertaken
until near ideal positions have been obtained. If such' 'stripping"
of the crowns is to be done, it should be meticulously planned and
utilize recontouring of fillings as much as possible. It is better to
take the time to reduce every tooth a bit than to attempt to acquire
space in one or two sites alone. Fig 17-19 illustrates a case where
tiny reductions of each tooth in the arch permitted the unlocking
of a lateral incisor. Extra-oral traction was worn throughout. Be-
ginning on the posterior teeth, one tooth on each side per appoint-
ment was reduced a fraction of a millimeter and elastomeric chains
drew each tooth posteriorly and kept it in tight contact. At the
next appointment the procedure was carried out on the next tooth
mesially. In this way, th~. teeth were stripped and moved distally
like ~beads on a string until the midline correction occurred and
the space had all accumulated wHere it was needed. A maxillary
acrylic bite plane is necessary, and must be ground concomitantly
to permit the tooth movements (see Fig 17-20).
10. Oligodontia
Oligodontia, often erroneously called "partial anodontia,"
presents some of the most demanding problems in adult ortho-
dontics and collaborative restorative dentistry. There are few sim-
ple rules for general aplication because the;:cases vary so much.
486 Treatment

FIG 17-17.
Mesial movement of molars to obviate the need for a bridge. A, before treatment. S, after treatment.

-.
-~ ..,
"
 Adult Treatment 487

FIG 17-18.
Uprighting molars and unsuccessful attempt at mesial movement. A, mesial movements were attempted. C. result after removal of ap-
after uprighting was completed. S, denuding of the lingual root when pliances. D, similar problem on the opposite side of the arch.

FIG 17-19.
Diagnostic setup prior to treatment of a lingually locked lateral cross-
bite (see also Fig 17-20).

-.'
'. "
488 Treatment
FIG 17-20.
Treatment of a single-tooth crossbite in a periodontic patient on Di-
lantin therapy. Before the start of orthodontic treatment, this patient
had a radical gingivectomy to remove the fibrotic gingivae which
resulted from the drug therapy. A, records at the start of orthodontic
treatment. A-l, postsurgical and hygienic phase of periodontic treat-
ment. A-2, the periodontal chart. A-3, the appliance in place. It had
been ascertained that judicious, minimal stripping of restorations and
all the contact points in the posterior part of the arch would provide
sufficient space to bring the lateral incisor into the line of occlusion.
A2
B, progress during treatment. B-1, the patient wore a headgear. At
each appointment one contact point was slightly reduced. An elas-
tomeric chain was then placed to move the most posterior tooth
distally. At the next appointment the second tooth mesially was stripped
and the elastomeric chain was extended one more tooth. In this
photograph the chain has been moved to the cuspid region. B-2,the
discluding bite plane in situ (see Fig 17-6). B-3, after the lateral
incisor had been brought through the crossbite. B-4, during retention.

FIG 17-21.
A-C, stripping teeth to provide space for a blocked out mandibular
second premolar. Extensive restorations may be recontoured
Perhaps nowhere in orthodontics is it more important to have all
of the treatment planned before any is begun. In these cases, the'
orthodontist's goals are defined precisely by the needs of the re-
constructive dentist. When there are many congenitally missing
teeth, the morphology of crowns and roots of remaining teeth often
is atypical in size and shape (Chapter 6). The cases shown (Figs
17- 22 and 17-23) illustrate some of the potentials for orthodontic
treatment. The congenital absence of single teeth is discussed in
Chapter 15, since it ought to be treated as early as possible.
11. Vertical Problems in the Anterior Region
Open bite and deep bite may present difficulties to the re-
storative dentist, and it is natural to think of orthodontic improve-
ments as a possible first step in treatment. A reading of the per-
iodontic and restorative dental literature on this problem is a
frustrating and enlightening experience for an orthodontist, for
some of the "treatments" advocated show a lack of appreciation
of the variety of open and deep bites, their complications, and the
orthodontic possibilities for their correction. Before orthodontic
therapy is begun it is essential that all clinicians involved under-
stand the etiology and the nature of the vertical occlusal problem.
a) Etiology
The etiologies of deep bite and open bite are many and com-
plicated, as these are among the most deceptive of malocclusions.
It is necessary to understand the basis for the open bite or the deep
bite and whether or not it is still possible to effect a satisfactory
orthodontic treatment (see Chapters 7, 12, 15 and 16). Difficulties
are enhanced if periodontal disease and tooth drifting have exac-
erbated the basic malocclusion and if there has been extensive
alveolar bone loss.
Adult Treatment 489
advantageously.
b) Diagnosis
The primary diagnostic problem in both deep bite and open
bite is to ascertain the site of the dysplasia. It may be localized
within the dentoalveolar area or it may be inherent in the cranio-
facial skeleton itself.
Study the patient, noting the lip line, tongue posture, and the
resting vertical dimension. Definitive answers on the role of the
craniofacial morphology itself can only be found in the cephalo-
metric analysis (Chapter 12). Even in the healthy, growing child,
vertical dysplasias are generally considered to be difficult to treat
and retain. Since differential control of growth itself is the only
real treatment, other than surgery, for severe vertical dysplasias,
it follows that tooth movements and alveolar remodeling alone can
only suffice for those mal occlusions in which the skeletal contri-
bution is minor.
c) Treatment
1) Simple Deep Bite.-When it can be shown that abnormal
depth of bite is localized in the dentoalveolar region of one or both
arches and there is a normal intetocclusal pi stance in the mandib-
ular postural position, treatment by arch leveling mechanics alone
may be possible. If there is, in addition, an excessive overjet,
c~o:",ding in either anterior region or excessive alveolar bone loss,
thelreatment becomes more comglicated. Leveling tends to elevate
the posterior teeth and depress the anterior teeth while improving
incisal centric stops and reducing the depth of bite (Fig 17-24).
2) Simple Deep Bite With Labioversion of Maxillary In-
cisors.-If neither occlusal plane is flat and the maxillary incisors
are labially tipped and spaced, a diagnostic setup before beginning
treatment will reveal the extent to which mandibular arch leveling
490 Treatment
FIG 17-22.
Severe case of oligodontia. A, casts prior to treatment. Note the
retained and built-up ankylosed primary molars still in situ. B, during
orthodontic treatment. Note the failure of alveolar development be-
cause of the unnecessarily retained primary molars. C, after active
orthodontic therapy. There is a serious problem in left-right tooth size
disharmonies (e.g., the central and lateral incisors). D, a temporary
bridge in place. E, the final results. Note the accessory cusp on the
only maxillary molar. This cusp could not be removed without en-
dodontic therapy, and it was decided that the abnormally shaped
tooth would be left in place.
 Adult Treatment 491

FIG 17-23.
Severe oligodontia. A, prior to orthodontic treatment. Notice the depth
of bite, the many retained primary teeth, and the two prostheses,
especially the mandibular and its dependence on retained primary
cuspids. B, radiographs of the teeth before and during treatment.
Note in B-1 and B-2 the active resorption on the roots of maxillary
teeth. B-5 and B-6, progress radiographs used to monitor the re-
sorption during treatment. (Continued.)

", '.-
-.
".
492 Treatment
FIG 17-23 (cont.).
C, mandibular reconstructive dentistry was completed prior to the
maxillary orthodontics. C-1, the initial twist leveling wire with which
most of the orthodontic treatments were carried out. C-2 and C-3,
FIG 17-24.
A and B, the effects of arch leveling mechanics alone on the amount of incisal overbite. This is the same case shown in Figure
and retraction of upper incisors alone will correct the problem.
Before undertaking such treatment, a Bolton analysis should be
made (see Chapter 11) since it will show clearly how much residual
overbite and overjet will remain due to differences between the
total upper tooth mass and the lower.
When the lower arch is uncrowded and flat, and the depth of
bite is isolated to the maxillary anterior dentoalveolar region, the
problem is more complicated because extensive intrusion of the
upper incisors must be carried out during their retraction. Main-
tenance of anchorage in these cases, particularly when there has
been periodontal disease, is often difficult. Fig 15-25 compares
two skeletal deep bite cases, one with labioversion of the upper
incisors and one without.
.'
later stages of the very brief treatment. 0, the final restorations in
place.
17-18.
3) "Simple" Open Bite.- There really is no such thing as
a "simple" open bite. The term here means an open bite due to
loyaJ factors, not a resulr:'Of gross vertical skeletal dysplasia.
(a)Diagnosis.-An important question before planning treat-
ment is, what causes the open bite to be maintained? Often in
adults it is an abnormal tongue posture ,or a localized open bite
caused by some habit such as pipe smoking but maintained by the
tongue to seal the open bite during the swallow. A diagnosis cannot
be completed unless three questions can be answered: (1) Is the
open bite due to vertical skeletal imbalance? (2) if not, what is
the etiologic factor which created the open bite? and (3) how are
centric incisal stops maintained? If there are no enamel-to-enamel
 Adult Treatment 493

130
115110
115
110322I ~..-
3-2
-2
130
125
I125
105
115 95
X90
PM
-15.0.
lS.D. X
15.0.
0 c~lonlln
Cranil1l
MHif1R
1-'S.O. (nOI Btll.MALES
VerI/Mane!. MALESCta"10IFEMALES
I
Line
MALE~, Dl 90 170
I IFEMALES
-3 85
VERTICAL
VERTICAL
120
105 105II110
120
PM Vtlrl/FMN-SE
ANALYSIS
75 ANALYSIS R I I PM 85
VerI/Pal
I~
I Line
I
90
I I
82 I
I IA2 75
C.B.47-1
FEMALE~I~ PM Vert IOcel. Line

@
90~
1
85:
MALES ~.·~\~·"~1~

FIG 17-25.
A, deep bite in an adult periodontic patient. Note the severity of the Fig 17-27.)
mandibular line angle. B, another complex deep bite case. (See also

centric stops in the incisal region, one may suspect that the tongue
at rest provides "centric stops". In this regard, it is important to
analyze the unconscious swallow-for any "simple" open bite,
by definition, has a normal tooth-together swallow. It will be useful
to reread the sections in Chapter 7 on etiology, in Chapter 10 on
the analysis of the musculature, and in Chapter 15 on the treatment
of these problems in young children, in Chapter 16 on adolescent
treatment, and in Chapter 18 for comments on myotherapy.
(b) Treatment.-First, remove all etiologic factors, if pos-
sible. Next, plan tooth movements in the arch (or arches) in which
the anterior teeth are away from the functional occlusal line. For
instance, if the mandibular occlusal plane is perfectly flat from
molars to incisors and all teeth lie along it but the maxillary anterior
teeth are elevated above the maxillary occlusal plane, it may be
necessary to place an appliance only in the upper arch. When the
teeth have been brought down to a normal relationship and incisal
stops are established throughout the entire arch, check again to be
reassured of the absenc.~of any etiologic factors. Fig 17-26 shows
the- treatment response to a mod~rately severe skeletal open bite.
c) Retention.-Retention in these cases is difficult and varied
depending particularly on the amount of alveolar bone loss and
cessation of etiologic factors. A "permanent" fixed splint, usually
from upper cuspid to upper cuspid is often necessary.
4) Complicated Vertical Problems.-A wide variety of very
difficult vertical dysplasias are seen in the adult population. See
494 Treatment

B
1. L. 19-1 VERTICAL ANALYSIS

-3 -2 -lS.o. X \S.o. 2 3
Cranial 80S.
PM Vert/FMN-SE MALES
90 85
90 1 85
Maxilla
PM Vert/Pal Line MALES

FEMALES
85 90
Occlusion
PM Verl/Oeel. Line MALES
100 105 1110 115
(not 0 constant in Closs il) ~5 1

FEMALES
100 1051 110

Mandibl.
PM Vert/Mond. Line MALES

FIG 17-26.
A and B, orthodontic treatment of a moderately severe skeletal open 20.) Note the extent of the maxillary dentoalveolar remodeling by
bite in an adult patient. (For more details of this case see Fig 10- treatment.

Figures 17-25, 17-26, 17-27, and 10-20. Some malocclusions
that are treatable with difficulty during growth become impossible
by orthodontics alone after growth is largely over. Those discussed
earlier, it will be noted, were limited to the anterior dentoalveolar
region. The most complicated problems are invariably the result
of vertical skeletal imbalance, that is, complex or skeletal Opell
bite (see Chapters 12, IS, and 16). They are made even more
diffi~ult when teeth are lost and periodontal disease has diminished
the alveolar process. The orthodontic aspects of treatment usually
consist of alignment of the teeth in preparation for orthognathic
surgery or orthodontic tooth movements prior to restoring the ver-
tical dimension with full-mouth rehabilitative reconstructions.
C. ORTHODONTIC TREATMENT
COMBINED WITH ORTHOGNATHIC
SURGERY (KWLV, and RJF)
Combining orthognathic surgery with orthodontic treatment
was a logical development. As appliances became available to
move teeth in any desired direction, severe skeletal discrepancies
became a major problem'iil preventing ideal arch relationships
from being attained with correction of tooth position alone.
Extra-oral traction appliances, in the United States, were in-
troduced by Kingsley7 and Case' at the turn of the century. This
method of treatment provided distal vectorial forces to the maxilla
sufficient to modify developing Class II malocclusions (see Chap-

FIG 17-27.
Severe case of incisal overlap in a patient with loss of teeth and in the mandibular incisal region. A, photo before treatment. B, after
periodontal disease. The patient was treated by orthodontics to open treatment. (This is the same patient as in Fig 17-25, B.)
the bite, underwent restorative dentistry, and received a gingivoplasty

ters 13 and 15). The applications of extra-oral force to unfavorable
mandibular patterns of growth were also attempted using the chin
cap. The modification and redirection of certain unfavorable man-
dibular Class n growth patterns in some children may be resolved
by functional jaw orthopedic appliances (see Chapter 15).
In the nongrowing individual, orthodontic manipulation or
camouflage of severe skeletal dysplasias* is difficult and often
impossible. Orthognathic surgery provides a method of correcting
the skeletal dysplasia and follows a presurgical phase of ortho-
dontic treatment to correct the dentoalveolar component of the
mal occlusion .
1. Historical Aspects of Orthognathic Surgery
Of the current surgical techniques for repositioning the facial
bones, many were pioneered in Europe to treat trauma and gunshot
wounds during World Wars I and n. The technical advances during
the Second World War, provided the basis of many of the elective
surgical procedures in use today. Rene Le Fort9 noted that the
midface consistently sustained fractures at sites of weakness which
provided the logical site for osteotomy cuts in the Le Fort I, n,
and ill procedures. These form the basis of the Le Fort classification.
To eliminate facial scars, an important aspect of elective
surgery, intra-oral surgical approaches were developed. A major
contribution was made by Obwegeser and TraunerlO when they
described a method of sagittally splitting the mandibular -ramus.
Although the foundations for present-day procedures were.
laid in Europe, the development and refinement of orthognathic
surgery occurred in the United States. Techniques and research in
vascularization and perfusion of pedicled flaps provided the sur-
geon with a viable means of manipulating the mid facial skeleton.2. 3
2. Selection of Patients
Perhaps one of the most important aspects of this combined
treatment approach is to decide which patients will benefit from
this complex treatment. 2.4. 6 Most patients who would benefit from
combined orthodontics and surgery exhibit extremes of normal
skeletal variation, often family characteristics (e.g. the mandibular
prognathism of the Hapsburgs). Not surprisingly, many individuals
with severe dental malocclusions do not have facial esthetic con-
cerns. As surgery is elective in these patients, it is particularly
important that the patient is well informed before a decision is
made to start treatment. This type of surgery requires hospitali-
zation, and a general anesthetic, and it is therefore important when
recommending this type of procedure to inform the patient of the
"risks" and benefits involved.
3. Case Managememt
Before a combined surgical-orthodontic approach was de-
veloped, the best result that orthodontic treatment alone could
*The term "skeletal discrepancy" is used in the literature of sur-
gery, but "dysplasia" is more frequently used in orthodontics and is
used in this chapter for consistency with the rest of the book. However,
the difference in meaning is important. A discrepancy is a wide variance
between two things which should be alike or harmonious, while dyspla-
sia is bad or unfortunate development. Irrespective of the term, the
cases may be extremes of normal variation or anomalous morphology.
Adult Treatment 495
provide for severe malocclusions associated with craniofacial skel-
etal dysplasias was camouflaging the skeletal pattern by dentoal-
veolar compensations. This orthodontic treatment created problems
for the surgeon, for when the maxillo-mandibular discrepancy was
resolved by surgery, the dentoalveolar components were not ideally
related. Cooperation between surgeon and orthodontist during in-
itial diagnosis and treatment planning provides a coordinated ap-
proach. The orthodontist and surgeon determine, before any
treatment is begun, the optimal relationship of the skeletal and
dentoalveolar components. * The orthodontist first moves the teeth
into an optimal relationship to their underlying dental bases, so
that when the skeletal dysplasia is surgically corrected, the teeth
fit together in coordinated arch relationship with favorable changes
in facial appearance. The orthodontic appliance used to prepare
the dental arches before surgery is kept in place to provide inter-
maxillary fixation during healing after surgery or as adjunctive
fixation if rigid osseous fixation has been used.
4. Case Referral
Before referring a patient for orthognathic surgery, the dentist
should provide the patient with general information about available
surgical procedures to correct the problem and address the patient's
concerns. The general dentist will need judgment and diagnostic
ability to recognize the relative contributory factors of a severe
mal occlusion , namely, skeletal and dental (see Chapter 12). If a
child has a severe skeletal dysplasia, then referral to an orthodontist
may be the first choice, since modific.ation or redirection of the
unfavorable growth pattern using a functional appliance or ex-
traoral traction head gear may be indicated. However, an adult
with a severe skeletal dysplasia does not respond well to growth-
modifying appliances. Correction of skeletal malrelationships in
adults may be achieved by surgical manipulation rather than growth
modification. It is important to elicit the patient's concerns, which
may be focused on the appearance of the teeth or their function.
Often an individual with a skeletal open bite will complain that
"my front teeth do not come together when I bite." However,
further questioning may also reveal facial esthetic concerns de-
scribed as "I am unable to keep my lips together" or "my chin
is too far back. "
Screening patients prior to referral to the appropriate spe-
cialists is an important aspect in provision and delivery of care,
especially when the treatment is of an elective nature. The family
dentist's judgment and advice are important and helpful to the
prospective orthodontic-surgery patient. Care should be taken to
give a clear, objective explanation of the bdnefits to be gained and
also the risks. There is little evidence to support the contention
that correction of any malocclusion will result in increased lon-
givity of the more ide;lly related dentition. Patients should not,
therefore, embark on a complex orthodontic and surgical correction
for the wrong reasons.
5. Classification of Skeletal Dysplasias
In classifying the relationship of the maxillary complex to the
*Many texts are available that provide detailed information in the
diagnosis and treatment planning of the surgical/orthodontic manage-
ment of these patients (see Suggested Readings).
496 Treatment
Normal
Mandibular Excess
Dento-Alveolar Compensation
FIG 17-28.
Diagrammatic representation of craniofacial dysplasias (see text).
mandible (Fig 17-28) it is convenient to subdivide the midface
into the skeletal maxilla or dental base and the maxillary dentition.
Likewise in the mandible, the dentition needs to be eveluated in
relation to the mandibular skeletal or dental base (Fig 17-28).
The overall relationship of the maxilla to the mandible can
now be divided into skeletal and dentoalveolar components and
various combinations. In defining the problem it is useful to gen-
erate a problem-oriented approach and then to establish priorities
of importance.4•
The jaw relationship and its contribution to the malocclusion,
together with the patient's facial and dental concerns, are important
factors in treatment planning and patient selection. It is also nec-
essary to relate the facial complex to the cranium (see Fig 17-
28). This simplistic analysis of the relations of dental and skeletal
components to the cranium has become conventional in the ceph-
alometric literarure. No attempt will be made here to describe the
numerous methods of cephalometric analysis available. Suffice it
to say, that in spite of its two-dimensional limitations and other
limiting factors, it still provides the basis for clinical diagnosis
and treatment planning (see Chapter 12).
Having clinically evaluated the skeletal and dental compo-
nents in three dimensions, it is important for the general dental
practitioner to be in a position to determine the ideal age at which
the patient should be referred to the orthodontist/surgeon.
.'
Maxi Ilary Deficiency
Combination of
Maxillary Deficiency
and
Mandibular Excess
6, Timing and Sequence of Treatmets
" Often skeletal discrepancies may be modified in the growing
child by means of an orthopedic appliance. These appliances ap-
pear to have the most predictable response in the mixed dentition
but rarely can correct severe skeletal dysplasias. When the general
dentist recognizes a severe skeletal dysplasia, referral to the ap-
propriate specialist should be made. Modification of a severe skel-
etal discrepancy in adults is not possible by redirection of growth,
but surgical correction may be indicated. Orthodontic treatment
places the teeth in the correct relationship to the jaws before sur-
g~ry. The orthodontic appliance will rem~in in place during surgery
arld;.lllay provide fixati"on during healing. After surgical fixation
is released, another shorter period (4 to 6 months) of orthodontics
is indicated to detail the occlusion before retainers are fitted.
The goals of this section have been to provide an overview
for a combined treatment procedure which is a fundamental part
of the orthodontist's and the oral and maxillofacial surgeon's train-
ing and clinical practice. The optimum facial and dental result,
necessitates close collaboration between the general dentist, sur-
geon, and orthodontist. To illustrate the principles of patient se-
lection and treatment planning, some representative case reports
are described. For more detailed information, see Suggested Read-
ings at the end of the chapter.
 Adult Treatment 497

7. Case Reports* interalar width combined to achieve an esthetic balance of nose,

lip, tooth, and chin. The addition of a 5 mm advancement of the
a) Case Report 1
chin achieved better facial balance.
P.E., a l2-year-old girl, was initially seen at the University
of Iowa for treatment with a chief complaint of disliking her ex-
b) Case Report 2
cessive "gummy" smile (Fig 17-29). Presurgical evaluation was
J .S., an l8-year-old man was referred to the Dentofacial Team
performed, and a problem list and treatment plan w~re formulated.
at the University of North Carolina for correction of his prognathic
1) Problem List.- lower jaw (Fig 17-30).
(a) Esthetics
1) Problem List.-
• Frontal: lip incompetence; excessive exposure of teeth and
(a) Esthetics.-Frontal and profile: Good facial balance ex-
cept for a prognathic mandible.
gingivae at rest and in function. Eight millimeters of inci-
sor exposure with lips in repose. Narrow alar width.
• Profile: Slightly obtuse nasolabial angle relative mandibular
(b) Cephalometric Radiographic Analysis.-Mandibular ex-
cess in profile view.
retrusion, convex profile, deficient chin.

(c) Occlusal Analysis.-Aligned maxillary and mandibular

(b) Cephalometric Analysis.-
arches. Anterior open bite with tendency to bilateral posterior
• Moderately steep angle of mandibular plane.
crossbite.
• Ten millimeters of lip incompetence.
• Retrogenia.
2) Treatment Plan.-Orthodontics to align and decompen-
• Increase in vertical maxillary height.
sate teeth. At surgery, bilateral vertical ramus osteotomies of the
mandibular rami were performed by an intraoral approach. The
mandible was set back 6 mm and immobilized for 6 weeks. Fol-
(c) Occlusal Analysis.-Moderate crowding of maxillary and
mandibular incisors Class 11 malocclusion. lowing release of fixation, function was reestablished by the use
of interarch elastics.

2) Treatment Plan.-
3) Follow-up.-Restoration of normal facial proportion was
(a) Presurgical Orthodontic Treatment Plan Is to Align and
achieved. Follow-up assessment of the occlusion after surgery and
Decompensate Dental Arches. orthodontics indicated a stable result.

(b) Surgical Treatment-Maxillary Osteotomy.-

c) Case Report 3
• Le Fort I osteotomy (one-piece)
T.F., a 17-year-old girl, had been under orthodontic treatment
since age 14 for her skeletal and dental malocclusion. (Fig 17-
a)Anterior impaction of 6 mm.
31). She was presented at the Dentofacial Program at the Uni-
b) Posterior impaction of 5 mm.
versity of North Carolina and a problem list and treament plan
c)Advancement of 2 mm.
was formulated.
d) Allow autorotation of mandible to achieve optimal in-
cisal relationship
• Advancement genioplasty of 5 mm.
.1) Problem
a) Esthetics.-
List.-

(c) Postsurgical Orthodontic Treatment to Detail the Occlu-

• Frontal: Increased lower third of the face, narrow alar
bases, and deficiency in paranasal areas.
sion.-
• Profile: Concave profile, full everted lower lip, prominent
chin, flattening in paranasal and infraorbital regions.
3) Follow-Up (Subjective).-Postoperative healing was un-
complicated and associated with minimal morbidity. Intermaxillary
fixation was maintained for 6 weeks. Within 6 weeks after the
(b) Cephalometric Analysis.-Posterior vertical maxillary
excess with Class III skeletal pattern: maxillary deficiency and
surgery the maxillary and mandibular osteotomies were clinically
stable. Postsurgical orthodontic treatment was completed unevent- ma~dibular excess. Mod~te chin prominence.
fully within another 3 months ...
(c) Occlusal Analysis.-Minimal crowding of labially in-
By total maxillary osteotomy, genioplasty, and orthodontic
clined maxillary and retroclined mandibular incisors. Class III
treatment the objectives were achieved. Superior movement of the
canine and molar relationship and 6-mm negative overjet.
maxilla surgically improved facial esthetics by decreasing anterior
facial height, differentially decreasing the amount of gingivae and
2) Treatment Plan.-
tooth exposure, and achieving lip competence. The more acute
nasolabial angle, improved lip posture and a small increase in the
(a) Presurgical Orthodontic Treatment.-Correct incisal in-
• clinations. Align and level maxillary and mandibular arches.

"'
498 Treatment
FIG 17-29.
Case report 1. A, patient aged 12 years. A-1, note increased vertical
lower facial height with lip strain. A-2, convex profile with long face.
8, dental occlusion before treatment. C, patient aged 15 years.
C-1, orthodontic treatment involved extraction of first premolars. Note
increased vertical facial dimension with growth. C-2, at full smile,
note excess gingival display. C-3, profile view. Note lip incompetence.
.'
D, presurgical phase of orthodontic treatment complete. Surgical
archwires with soldered lugs for intermaxillary fixation. Note align-
menJ and leveling of dental arches with closure of extraction space.
Anterior open bite has developed vyith increased vertical face height
during growth. (Facing page) E, patient at 17 years of age. E-1, note
facial esthetic change following orthognathic surgery. E-2 and E-3,
profile views indicate good facial balance and proportion with lip
competence. F, comparison of patient smiling before and after sur-
gery. G, excellent dental occlusion with closure of anterior open bite.
(Periodontal condition was under treatment). H, cephalometric su-
perimposition showing vertical superior impaction of the maxilla with
autorotation of the mandible and genioplasty. I, comparison of facial
profile before and after surgery. Note reduction in vertical lower facial
height with lip competence and good chin projection.
Adult Treatment 499
500 Treatment
FIG 17-30.
Case report 2. A, patient at 17 years of age following orthodontic
treatment; patient had unfavorable growth resulting in mandibular
prognathism with asymmetry of chin'.' A-2, dental occlusion with lower
retainer in place. Note that midlines are not coincident. Mandibular
."
midline reflects skeletal asymmetry. B-1, after presurgical phase of
orthodontic treatment. Note mandibular asymmetry. B-2, profile view
shovying mandibular progfiathism. C, 'dental occlusion before sur-
gerj. Note midlines are not coincidElnt, but mandibular dental midline
is on the skeletal (chin) midline. (Continued.)
 Adult Treatment 501

G
-4/2/76
--6/23/77

J~S'

- ..-.,

FIG 17-30 (cont.). occlusion was achieved, with correction of asymmetry and anterior
0-1, facial symmetry following mandibular surgery. 0-2, profile view open bite. G, cephalometric superimposition of presurgery and post-
indicates balanced facial proportions. E, at full smile, note correction surgery lateral skull radiographs. Note correction of skeletal man-
of skeletal and dental midlines to coincide with the midsagittal facial dibular excess and asymmetry following mandibular surgical set-
midline. F, following surgery and orthodontics, an excellent dental back procedure.
502 Treatment

.'

FIG 17-31,
Case report 3. A, 15-year-old girl. A-1, note vertically increased facial
height and lip incompetence. A-2, profile view confirms increased
vertical facial proportion with mandibular prognathism. A-3, at full
smile no excess of gingival display is noted. B, dental occlusion
indicates open bite and enamel hypoplasia. C, cephalometric tracing ~ ..
shows Class III malocclusion and skeletal mandibular prognathism.
0-1, facial change following surgical maxillary impaction and man-
dibular setback. 0-2, at full smile, note incisor display has not been
reduced by maxillary intrusion, which was planned to superiorly move
the posterior maxilla by tipping. E, profile view confirms balanced
facial proportions. (Continued.)

FIG 17-31 (cont.).
F, cephalometric tracing of postsurgical result. Note change in po-
sition of lower lip with mandibular setback and vertical autorotation.
G, dental occlusion following orthodontics and surgery. Note correc-
(b) Surgery.-
• One-piece Le Fort I osteotomy to reposition maxilla 3 mm
superiorly in molar area to allow for autorotation of mandi- .
ble and favorable vertical proportions.
• Mandibular set-back of 6 mm by bilateral sagittal split os-
teotomies to produce a Class I canine and molar
relationship.
(c) Postsurgical Orthodontic Treatment.-Occlusal detail-
ing and finishing with settling in of the occlusion aided by interarch
elastics.
(3) Follow-up.-After the teeth were orthodontically aligned
and leveled, the maxilla was superiorly repositioned and the man-
dible was set back surgically. The full lower lip was still present
postoperatively, but the patient decided against chieloplasty ..
d) Case Report4
M.Z. is a 34-year-old woman who attended the dentofacial
program at the University of Michigan with concerns about her
protruding upper front teeth and the gingival display when she
smiled. She also had concerns regarding her retruded chin and
obtuse throat-neck angle.
1. Problem List.-
(a) Esthetics.-Frontal: slight facial asymmetry with an in-
creased lower facial height and at full smile she shows increased
gingival display (Fig 17-32,At). Profile confirms the increase of
lower facial height with lip strain to produce an anterior oral seal.
This accentuates the severe mandibular deficiency and the obtuse
throat neck form (Fig 17-32,Az)'
(b) Cephalometric Analysis.-Increased mandibular plane
Adult Treatment 503
tion of anterior open bite by maxillary and mandibular procedures
and excellent interdigitation of posterior occlusion.
angle with proclined maxillary and mandibular incisors in a po-
sition of increased overjet and incomplete overbite. The mild asym-
metry is shown by the duplicated lower borders of the mandible .
(c) Occlusal Analysis.-Mandibular first molars were miss-
ing with mesial drifting and tipping of the second molars. Un-
erupted third molars were removed. The canine relationship was
Class II on the right and Class I on the left because of the shift
of the dental midline to the right together with the mandibular
asymmetry.
2. Treatment Plan.-
(a) Presurgical orthodontic treatment involved uprighting the
mandibular molars, which tends to increase the vertical facial
height. This is, therefore, an important presurgical orthodontic
tooth movement. If this was accomplished in the postsurgical phase
of orthodontic treatment it would build in a relapse tendency. In
the maxillary arch, extraction of the maxillary first premolars was
indicated. This provided space for alignment and some retraction
of the maxillary incisors while providing space for the osteotomy
cuts for a segmental (three-piece) maxilla.
(b) Surgical Treatment.-Segmental maxillary osteotomy to
superiorly reposition the.!llaxilla, aU,torotation of the mandible to
clo~e the anterior open bite together with a sagittal split osteotomy
to advance the mandible and a genioplasty to augment the chin.
(c) Postsurgical orthodontic treatment to settle in the occlu-
sion, with light archwires and rubber bands/elastics using a Class
II vector of force. Following removal of the fixed appliances and
fitting of retainers, bridges were indicated to replace the missing
mandibular first molars.
Note: Intermaxillary fixation was not used in this patient as
rigid osseous fixation for both the maxillary and the mandibular
osteotomies provided adequate stabilization following simultane-
ous two jaw surgical correction.
504 Treatment

M.Z.

3-15-85

Initial \

er-+- ~ ~
~

FIG 17-32.
A, and A2• initial full face and profile views of the patient. Note
increased vertical facial height with excessive gingival display on
smiling. Profile shows the lip strain and obtuse throat neck angle.
A3. cephalometric lateral skull radiograph showing anterior open bite,
proclined maxillary and mandibular incisors and mesially tipped man-
dibular second molars. A•• tracing of·the initial cephalogram. (Facing
page.) B" anterior view of occlusion. Note anterior open bite and
the mandibular midline deviated to the right. B2 and B3• right and left
buccal views. Note the tipped mandibular second molars. C, and C2•
full face and profile following presurgical orthodontic treatment. With
uprighting of the mandibular first molars the open bite and vertical
fac.ial height has been increased with lip strain on the profile view to
achiev.e a lip contact. (Continued.)
Adult Treatment 505
506 Treatment

FIG 17-32 (cont.).
(Facing page) 0" segmental aligning of the maxillary arch with sol-
dered lugs on the surgical archwires. O2 and 03, left and right pos-
terior views to show uprighting of the mandibular molars with space
for prosthetic replacement following surgery for the missing mandib-
ular first molars. 0" occlusal view of maxillary arch showing align-
ment with some retraction of some maxillary incisors and adequate
space for the osteotomy cuts. E" patient 2 years postsurgery. Or-
thodontic treatment was completed 4 months after surgery. Note the
Adult Treatment 507
acceptable smile with no gingival display. The alar base which had
a nasal cinch has not increased significantly (E2). Profile view shows
well balanced vertical proportions with an excellent chin neck contour
and a labiomental fold following an augmentation genioplasty. (Above)
F" occlusal view to show coincident dental midlines with closure of
the anterior open bite which has remained stable after retainers were
discontinued. F2, posterior view of buccal occlusion to show bridge
to replace the mandibular first molar. F3, maxillary occlusal view
showing closure of space at the osteotomy sites. (Continued.)
",
508 Treatment

FIG 17-32 (cont.).

G" orthodontic debanding. The terminal molars are upright and ready
for bridge placement. G2, following bridges to replace the missing
first molars. H, panoramic radiograph after presurgical phase of or-
thodontic treatment to upright the mandibular terminal molars. Note
alignment of the dentition and space for the osteotomy cuts in the
maxillary arch. I, cephalometric radiograph immediately postsurgery
showing rigid osseous fixation in the maxilla together with screws
for fixation after the sagittal split mandibular osteotomy. (Continued.)

-
-.
.
 Adult Treatment 509

J M.l.

Pre-Surg __ - - -12-4-85
Post-Surg- 1-10-86 \ I

v4 ~~

L M.Z.
ot YfiMlr Post-Surgery

FIG 17-32 (cont.).

J, tracing to show superimposition of the pre- and postsurgicallateral
skull radiographs. K, panoramic film following postsurgical result prior
to bridge placement. Note the three screws bilaterally to stabilize the
mandibular osteotomy and the transosseQus wires at the mandioular
'symphysis for the genioplasty. In the maXillary arch, note the plates
and screws for stabilizing the three-piece maxillary osteotomy. L,
tracing 2 years postsurgery indicating stability of both the dental and
skeletal components.

3. Follow-up

Post operative healing was uneventful and as she did not have be carefully supervised and kept to a liquid/soft diet during the
intermaxillary fixation she was able to function immediately. Pa- early phase of healing. However, the ability to talk and swallow
tients prefer this method of stabilization, although the diet has to (and even to laugh) during the period when there is maximum
510 Treatment
swelling provides a more comfortable situation. Orthodontic treat-
ment was commenced within the first month after surgery at which
time the surgical arch wires were removed and light archwires were
placed. Traditionally, the orthodontist does not,start postsurgical
treatment for 6 weeks after surgery because of intermaxillary fix-
ation. The segmental osteotomy in the maxilla allowed differential
repositioning of the anterior and posterior segments to close the
open bite which also allowed closure of the extraction space.
Acnowledgment
We are indebted to the orthodontic departments at the Uni-
versities of North Carolina and Iowa for their participation in the
treatment of these case reports (K. W .L. V ., R. J .F.).
REFERENCES
1. Behrents G: Growth in the Aging Craniofacial Skeleton,
monograph 17. Ann Arbor, Mich, Craniofacial Growth
Series. Center for Human Growth and Development, Uni-
versity of Michigan, 1985.
2. Bell WH, Levy BM: Revascularization and bone healing
after posterior maxillary osteotomy. J Oral Surg 1971;
29:313-322.
3. Bell WH, Fonseca RJ, Kennedy JW, et al: Bone healing
and revascularization after total maxillary osteotomy, J
Oral Surg 1975 33:353-362.
4. Bell WH, Proffit WR, White RP: Surgical Correction of
Dentofacial Deformities, vols 1 and 2. Philadelphia, WB
Saunders, 1980.
4a. Proffitt WR: Contemporary Orthodontics. Philadelphia,
WB Saunders Co, 1986.
5. Case CB: Occipital and cervical anchorage, Trans Am Soc
Orthod 1912; 136-147 .•
6. Epker BN, Wolford LM: Middle-third facial osteotomies:
Their use in the correction of acquired and developmental
dentofacial and craniofacial deformities, J Oral Surg 1975;
33:491-514.
6a. Epker BN, Fish LC: Dentofacial Deformities, Volumes I
and 2. St Louis, CV Mosby Co, 1986.
7. Kingsley NW: Oral Deformities. New York, Appleton and
Coy, 1880.
8. Lang NP: Das proprosthetische Augrichten von gekippten
untem Molaren in hinblickal1f den parodontalen Zustand.
Schweiz Mschr Zahnheilk 1977; 87:560-569.
9. Le Fort R: Etude experimentale sur les fractures de la
machoire superieure, Rev Chirurgical190l; 23:08.
10. Obwegeser H, Trauner R: Surgical correction of mandibu-
lar prognathism and retrognathia with consideration of
genioplasty. Oral Surg Oral Med Oral Patho11957;
10:677. ,.
SUGGESTED READINGS
Section B: Orthodontic treatment of malocclusions complicated
by periodontal disease and loss of teeth
Alstad S, ZachrissonBU: Longitudinal study of periodontal
conditions associated with orthodontic treatment in adoles-
cents. Am J Orthod 1979; 76:277-286.
Atherton JD, Kerr NW: Effect of orthodontic tooth movement
upon the gingivae. Br Dent J 1968; 124:555-560.
Barrer G: The adult orthodontic patient, Am J Orthod 1977;
72:617-640.
Brown IS: The effect of orthodontic therapy on certain types of
periodontal defects, J Periodontol1973; 44:742-756.
Dorfman HS: Mucogingival changes resulting from mandibular
incisor tooth movement. Am J Orthod 1978; 74:258-277.
Geiger: AM: Gingival response to orthodontic treatment, in
McNamara JA Jr, Ribbens KA (eds), Malocclusion and the
Periodontium, monograph 15. Ann Arbor, Mich, Center
for Human Growth and Development, University of Michi-
gan, 1984.
Horn BM, Turley PK: The effects of space closure of the man-
dibular first molar in adults, Am J Orthod 1984; 85:457-
469.
Karring T, Nyman S, Thilander, B: Bone regeneration in alveo-
lar bone dehiscences related to orthodontic tooth move-
ments, Eur J Orthod 1983; 5:105-114.
Norton A: Periodontal considerations in orthodontic treatment.
Dent Clin North Am 1981; 25:117-129.
Poison M: Long-term effect of orthodontic treatment on the
periodontium, in McNamara JA Jr, Ribbens KA (eds),
Malocclusion and the Periodontium, Monograph 15,
Craniofacial Growth Series, Center for Human Growth and
Development, Ann Arbor Mich, 1984.
Rygh P: Periodontal responses to orthodontic forces, in Mc-
Namara JA Jr, Ribbens KA (eds), Malocclusion and the
Periodontium, monograph 15, Craniofacial Growth Series,
Center for Human Growth and Development, Ann Arbor,
Mich 1984.
Sadowsky C: Long-term effect of orthodontic treatment on the
periodontium during adolescence, in: McNamara JA Jr,
Ribbens KA (eds), Malocclusion and the Periodontium,
monograph 15, Craniofacial Growth Series, Ann Arbor
Mich; Center for Human Growth and Development, 1984.
Sadowsky C, BeGole EA: Long-term effects of orthodontic
treatment on periodontal health. Am J Orthod 1981;
80:156-172.
Stepovich ML: A clinical study on closing edentulous spaces in
the mandible. Angle Orthodont 1979; 49:227-233.
Thilander B: Indications for orthodontic treatment in adults, in
Thilander B, Ronning 0 (eds), Introduction to Orthodon-
tics. Stockholm, Tandlakarforlaget, 1985.
Tuncay, OC et al: Molar uprighting with T-Loop springs. JAm
Dent Assoc 1980; 100:863-866.
Wagenburg BD, Eskow RN, Langer B: Orthodontic procedures
that improve the periodontal prognosis, J Am Dent Assoc
1980; 100:370-373.
Zachrisson BU: Cause and prevention of injuries to teeth and
supporting structures during orthodontic treatment, Am J
Orthod 1976, 69:285-300.
Zachrisson BU: Periodontal changes during orthodontic treat-
" . ment, in McNamara JA Jr, Ribbens KA (eds), Malocclu-
·sion and the Periodontium"monograph 15, Craniofacial
Growth Series, Center for Human Growth and Develop-
ment Ann Arbor Mich, 1984.
Section C: Orthodontic Treatment Combined with Orthognathic
Surgery
Bell WH, Proffit WR, White RP: Surgical Correction of Dento-
facial Deformities, vol 1 and 2. Philadelphia, WB Saun-
ders, 1980.
Epker BN, Fish L: Dentofacial Deformities: Integrated Ortho-
dontic Surgical Correction. St Louis, CV Mosby, 1983.
CHAPTER 1-8

Orthodontic Techniques
Robert E. Moyers, D.D.S., Ph.D.

OUTLINE a) Twin-wire appliance

b) Universal appliance
D. Attached removable appliances
A. Basic construction technics 1. Active appliances
1. The bending of wire a) Extra-oral traction devices
2. Joining metals I) Head gears
a) Soldering 2) Face masks
b) Spot welding 3) Chin cups
3. Record casts b) Lip bumpers ("plumpers")
B. Basic clinical technics c) "Active plates"
1. Orthodontic impressions 1) Schwartz appliance
2. Separation of teeth 2) Space-regaining appliances
3. Molar band formation 3) Anterior spring aligners (Barrer
a) Fitting preformed bands appliance)
b) Attachments for molar bands d) Crozat appliance
1) Buccal tubes e) Vacuum formed appliances ("invisibles")
2) Lingual sheaths 2. Passive appliances
c) Cementation of bands a) Bite planes
4. Brackets for incisors, cuspids, and premolars b) Occlusal splints
a) Preformed bands with attached brackets c) Multiple space maintainers
b) Bonding attachments d) Retainers
5. Elastics E. Loose removable appliances (functional appliances, func-
C. Fixed appliances tional jaw orthopedic appliances, etc.)
1. Lingual arch wire 1. Background
a) Description a) Definition
1) Removable b) Purposes
2) Fixed c) History
b) Modifications d) Modes of action
1) Loop lingual 1) Muscles
2) Porter lingual archwire 2) Dentition' and alveolar processes
3) Quad-Helix lingual archwire 3) Craniofacial skeleton
c) Attachments (a) Claimed skeletal responses
1) AuxilIary springs (b) Role of timing in treatment
2) Lingual locks intervention
2. Fixed space maintainers 2. Vestibular appliances (oral shields, oral screens)
3. Palate-separating devices a) Description
4. Edgewise mechanisms b) Construction
5. Light-wire appliances 3. Functional jaw orthopedic appliances
6. Other fixed appliances a) Definition

511
512 Treatment

b) Uses and indications

c) Types
d) Activators and derivatives
e) Frankel Function Regulator
f) Myodynamic or elastic appIlances
g) Others
4. Repositioning splints
5. Tooth positoners
a) Description
b) Construction
c) Limitations
6. Herbst appliance
7. Hybrids and perversions
F.' Myotherapeutic exercises
1. Purposes
2. Limitations
3. Principles
4. Specific procedures
a) Orbicularis oris and circumoral muscles
b) Mandibular posture
G. Correction of deleterious oral habits
1. Basic considerations
2. Digital sucking (finger-sucking, thumb-sucking)
a) Phase I: Normal and subclinically significant
sucking
b) Phase II: Clinically significant sucking
c) Phase Ill: Intractable sucking
d) Choice of appliance
3. Tongue-thrusting
a) Causes
b) Diagnosis
c) Treatment FIG 18-1.
1) Simple tongue~thrust Bending of wire for orthodontic appliances. A, correct way. Wire is
2) Complex tongue-thrust near the hinges of the pliers, and the pliers are used as a portable
3) Retained infantile swallow vise. All force of application is done with the finger. e, improper way
4. Abnormal tongue posture of bending wire.
5. Lip-sucking and lip-biting
c) Grasp the wire in the pliers so that it may be bent downward
6. Fingernail-biting
by the fingers of the free hand against the rounded beak of the
H. Occlusal equilibration (occlusal adjustment)
pliers to avoid nicking the wire (see Fig 18-1). Never bend a
1. Equilibration in the primary dentition
round wire over a sharp beak.
2. Equilibration in the mixed dentition
d) Check the first bend made, before marking the location of
3. Equilibration in the permanent dentition
the next bend, and repeat the process.
a) Rationale
e) Take care to make all bends at right angles to the long axis
b) Procedure
of the wire, unless a different angle is specifically required: it is
much easier to control the arch wire by ke~ping all bends in the
same plane.
A. BASIC LABORATORY TECHNIQUES
,
. .1) Never make a ne::v~bend until the last bend made is perfect.

1. The Bending of Wire

All bends in orthodontic wires usually ar~ placed by the fin-
gers; one should regard the pliers as a portable vise for holding
the wire while making the bend (Fig 18-1).
The procedure is as follows:
a) If possible, establish a fixed relationshin of the wire before
making any bends.
b) Place the wire in position and mark it with a wax pencil
(a mascara eyebrow pencil works well) where the bend is to be
made.
2. Joining Metals
a) Soldering
Soldering should f;>edone without appreciable alteration of
the qualities of the metals being joined. Orthodontic soldering is
carried out with a small, specially designed orthodontic burner or
torch or with various electric devices. A good flame for orthodontic
soldering has a small, well-defined point. It is easiest to solder
when the metal is held just at the apex of the middle flame cone.
The operator should be seated in a relaxed manner with the elbows
 Orthodontic Techniques 513

FIG 18-3.
Typical modern orthodontic spot welders. (Courtesy Unitek
Corporation.)

a flow of electric current through the portions of the pieces in

juxtaposition. The parts to be joined are held together by electrodes
(Fig 18-3). As the current passes through the electrodes and the
metal pieces between them, resistance is built up within the ~etals
to be welded. The heat generated is sufficient to cause a union of
the parts touching each other. A true weld is formed, and no solder
or flux is used.

FIG 18-2.
3. Record Casts
Various methods of bracing fingers and hands while soldering wires
and attachments.
Casts (often erroneously called "models") are one of the
most important sources of information about each orthodontic case,
close to the body. Some brace the heels of the hands together,
since they provide a permanent three-dimensional record of the
whereas others prefer to use the fingertips (Fig 18-2). The fingers,
malocclusion. A base is a necessity for it aids in proper articulation
hands, and arms remain braced as the body, bending at the hips,
leans toward the flame. of the teeth and protects them against breakage. Bases are made
in two ways: by oriented base-formers (Fig 18-4), or by a model
Orthodontic solder is available in several forms (e.g., disks trimmer.
and bars) but the fine wire is most suited for orthodontic use .
. Modern model trimmers have devices attached to them that
A fluoride flux is necessary when one is soldering stainless
steel. A true solder joint does not result when stainless steel and m;ure trimming swift and easy. 1'he casts may be polished with
talc or soaked in a soap solution and rubbed after drying (Fig
solder are joined; rather, there is an intimate mechanical union.
18-5).
With modern stainless steel alloys, however, surprising results may
be obtained. Slightly more solder and a slightly cooler flame is
needed than for soldering the gold alloys.
All auxiliary springs should be wrapped around the arch wire B. BASIC CLINICAL TECHNIQUES
twice to protect the solder joint and the annealed portion of the
1. Orthodontic Impressions
spring wire (see Fig 18-19).
A'suitable tray is chosen to provide proper clearance from
b) Spot Welding the teeth and soft tissues. When the teeth are in extreme malpositon
Spot welding is the joining of two metal pieces by heat from or the arch is abnormally shaped, soft wax may be added to the
514 Treatment

FIG 18-4.
Rubber base formers .

..

FIG 18-5.
A good set of orthodontic study casts.
 Orthodontic Techniques 515

h) Always hold the tray in place until the impression material

is fully set.

2. Separation of Teeth
To separate teeth before bands can be fitted, a length of 0.020-
inch brass ligature wire may be rotated through the embrasure
beneath the contact point but above the soft tissue (Fig 18-7).
Twist the two loose ends and tuck them into the embrasure. When
a series of separating wires is to be placed, put the wires through
the embrasures and allow them all to lie loosely before twisting
the first one. After the separating wires have been in place no
longer than a few days, cut and remove them by rotating the wire
out of the embrasure just as it was inserted. Other methods of
separation are shown in Fig 18-8.

3. Molar Band Formation

A number of different methods are available for forming and
fitting molar bands, but only fitting preformed bands will be de-
scribed here. Regardless of the method chosen, the finished band
should be adapted closely to the contour of the tooth, be free of
occlusion, and extend 0.5 to I mm below the free margin of the
gum (Fig 18-9). On the mesial and distal surfaces, the occlusal
edge of the band should lie just at the marginal ridge and should
be festooned so that it will not cut the transseptal periodontal fibers.
There is an important difference in the crown-root angulation
FIG 18-6. between upper and lower molars which affects band formation.
Good upper (A) and lower (B) impressions.
The path of insertion of the upper molar band is in line with the
long axis of the tooth, whereas in the lower band, the path of

impression tray; for example, to carry the impression material well A

up into the vestibule in Class n, Division I cases. Fig 18-6 shows
a well-taken set of impressions. Note how the impression material
was carried to the limits of the vestibule. The following points
may aid in taking correct impressions of malocclusions.
a) Always use the exact size of tray required.
b) Add wax where needed to ensure a complete impression
of the supporting bony structures.
c) Mix the impression material in the proportions suggested
by the manufacturer. Do not beat air into the impression material,
as if mixing cake batter. Rather, smooth the material against the
side of the bowl with the flat side of the spatula. Time the mixing.
d) Have the patient rinse his or her mouth well before the
impression is taken.
e) Seat the patient upright, with the eye-ear plane parallel ~o
the floor.
/) When taking the upper impression, tip the tray up in the
back to drive the excess material forward so that it is extruded
into the labial vestibule and not down the throat. For the upper
impression, stand behind the patient and hold the tray level with
the occlusal plane.
g) When taking the lower impressions, rotate the tray into
the mouth, keeping the tray parallel with the occlusal plane. Have
the patient extrude his or her tongue to push any excess impression FIG 18-7.
material forward and maintain the tray in position by placing each Method of separating teeth. A, soft brass separating wire is wrapped
index finger over the occlusal part of the tray and each thumb around a fountain pen, then cut. B, individual loops of cut wire are
under the mandible. rotated into position around the contact point.
516 Treatment

DentCJt Floss

Step I Step 2 Step 3 Step 4

"

FIG 18-8.
Other methods of separating teeth. A, elastic thread method. B, Maxian elastic separator. C, elastic separating loops.

1.Seat the band by

al-ternate pressure at the line angles

2. Ginog;ival edge must lie

:'111 \ I 1\ ",. 3.
~"
..
,:,
..:.:~:.::.\h
..,.".,
..:]\ ... ~.

FIG 18-9. FIG 18-10.

Upper and lower molar bands correctly contoured to avoid interfer- Fitting of maxillary molar bands. Note use of band driver.
ence with intercuspation .

. ,

FIG 18-11.
Examples of preformed orthodontic bands. (Courtesy of Rocky Moun-
tain Metal Products Company.)

FIG 18-12.
Attachments for molar bands. A, single buccal tube and lingual but-
ton. B, a double buccal tube for the molar. C, the lingual tube, which
insertion is in line only with the crown. The technique is to force
the band on to the crown so that it adapts to the contours of the
tooth (Fig 18-10).
a) Fitting Preformed Bands
Preformed bands are popular because one can easily achieve
a good fit routinely and their cost is low. They are made of stainless
steel and come in a sufficiently large number of sizes to fit nearly
all teeth with only occasional contouring (Fig 18-11). It is, how-
ever, necessary to maintain a large inventory of bands at all times.
b) Attachments for Molar Bands
1) Buccal Tubes.-Buccal tubes hold labial archwires and/or.
the inner bow of head gear appliances in position on first molars.
Each of the multi banded appliance systems has one or more special
buccal tubes. When second molars are erupted, they may receive
the buccal tube, and brackets are placed on the first molar bands.
2) Lingual Sheaths.-Lingual sheaths of many variations
receive and attach lingual archwires (Fig 18-12).
c) Cementation of Bands
Molar bands do not fit as well as inlays; therefore, the ce-
mentation is different. Generally, a heavier mix is required with
a longer setting time to permit final seating and adaptation. Zinc
phosphate cement is popular, but I prefer a heavy mix of silico-
phosphate cement (e.g., Kryptex) which is very strong and has
the additonal advantage of freeing FI- ions on dissolution.
FIG 18-13.
A and B, bonded appliances in situ. (B courtesy of Unitek Corporation.)
:
Orthodontic Techniques 517
receives the Ellis-type lingual archwire. (Courtesy of Rocky Mountain
Metal Products Company.)
Isolate and dry the teeth to be cemented, mix the cement for
a prolonged setting time, and coat thoroughly the inside of the
band. Wax or masking tape covering the occlusal surface helps
control the escape of the cement during the transfer from slab to
mouth and while driving the fitted band to place. After the cement
has fully set, clear the excess from the occlusal surface and the
gingival crevice.
4. Brackets for Incisors, Cuspids, and Bicuspids
a) Preformed Bands With Attached Brackets
Bands for the anterior teeth and the bicuspids are also avail-
able with a variety of attachments. Each of the several bracketed
orthodontic appliances has its own particular bracket design.
Preformed bands are available in a large assortment of sizes.
They are selected in much the same manner as described for the
molars and adapted to the tooth by driving into position and bur-
nishing. Preformed bands usually are supplied with brackets and
lingual seating lugs attached.
Anterior bands must be fitted accurately, placed at the correct
height on the tooth and cemented well. Since the bands and brack-
ets provide a means of joining teeth together, one misplaced band
or bracket affects the position of several teeth. A set of dividers
may be used to obtain correct placement of the bands, but special
gauges for doing this more easily are available. Anterior bands
are cemented much as molar bands, but a thinner mix is used.
b) Bonding Attachments
Bonding of brackets directly to the crownr. has largely
518 Treatment
FIG 18-14,
Uses of elastomeric chain. (Courtesy of Unitek Corporation.)
superseded the use of anterior bands and even of some molar bands.
The brackets are bonded to etched enamel with composite materials
similar to those used to restore anterior teeth. Brackets may be
bonded directly, one at a time, or indirectly by placing the brackets
for an entire arch simultaneously. Direct bonded appliances are
more esthetic than anterior bands, can be placed more accurately,
and provide better oral hygiene (Fig 18-13).
5, Elasties
Elastics are available as robber bands, elastic thread, and
formed shapes for specific proposes (Fig 18-14). They are used
to move teeth, to ligate archwires to brackets, for intermaxillary
traction, and for separation. Elastics are always attached to brackets
and archwires-NEVER around the naked tooth. Data are avail-
.'
able from each manufacturer showing the actual forces for a given
size of elastic stretched over various distances.
C. FIXED APPLIANCES
1. Lingual Arehwire
a) Description
The lingual archwire is a round wire (0.032 to 0.040 inch in
diameter) that is closely adapted to the lingual surfaces of the teeth
and attached to bands, usually on the first permanent molars (Fig
18-15). It is a most useful appliance, particulary during the mixed
dentition period, since the archwire maintains the arch perimeter.
Auxiliary springs may be added to move teeth (see Fig 18-19).
FIG,1~8-15,' "'
The lingual archwire. A and B, details of archwire adaptation to the
gingival margin of the working cast. C, position of the horizontal
lingual tube. The archwire is doubled on itself and is held in place
within the tube by friction.
 Orthodontic Techniques 519

1) Removable.~ The removable lingual arch wire has pre-

cision fitting shafts that fit into corresponding sheaths on the molar
bands (see Fig 18-12 and 18-15). It is used as an active appliance
or as a device to maintain the arch perimeter.

2) Fixed.- The fixed lingual archwire is soldered to molar

bands and is used for the maintenance of arch length or retention.
When it is used to maintain the arch perimeter, it sometimes is
called a holding arch.

b) Modifications
1) Loop Lingual.~Placing a vertical loop in the archwire
just mesial to the point of attachment to the molar band permits
adjustment of the length of the wire and easier positioning and
rotating of the molars (Fig 18-16).

2) Porter Lingual Archwire.-A useful modification of the

lingual archwire is the Porter appliance which is used to correct
crossbites and mild maxillary contraction (Fig 18':: 17) . It utilizes
reciprocal anchorage to tip the teeth buccally.

3) Quad-Helix Lingual Archwire.~ The Quad-Helix, a use-

ful improvement of the Porter archwire, makes possible continuous
slow expansion of the buccal segments and/or separation of the
midpalatal suture (Fig 18-18).

c) Attachments
1) Auxiliary Springs.~ The attachment of auxiliary springs
is made in an embrasure (Fig 18-19).

2) Lingual Locks.-Some locks hold by friction while others

FIG 18-16.
The loop lingual archwire. A, use in a space supervision case. Note
the relationship of the archwire to the gingival margin. B, in place
on a cast.
use a lockwire of dead, soft steel whose malleability permits re-
peated bendings without breaking.
2. Fixed Space Maintainers
Fixed space maintainers usually are made of preformed steel
crown forms or bands with bars or wire projections to maintain

FIG 18-17.
A, the' Porter lingual archwire. In this instance, the appliance was removable Porter lingual archwire. (Courtesy of Dr. James A.
made for correction of a functional crossbite in the primary dentition, McNamara, Jr.)
one of its most frequent uses. B, an example of a modified maxillary
520 Treatment

FIG 18-18.
The Quad Helix appliance. This removable version utilized horizontal
lingual tubes.

FIG 18-20.
A. the band and loop space maintainer. B. a band and loop space
maintainer and a space maintainer using a primary crown form. The
band and loop space maintainer may also incorporate an occlusal
FIG 18-19. rest. (Courtesy of Rocky Mountain Metal Products Company.)
Correct positioning of auxiliary springs.

FIG 18-21.
A, rapid palatal-expansion appliances (see also Fig 16-7). B,. a type framework. B2• a similar appliance incorporating hooks for attach-
using acid-etch bonding of acrylic that has been cured to a wire ment of a face mask (see Fig 18-27).

space after premature loss of primary teeth (Fig 18-20). They may
also be constructed of wires held in place by composite. The
advant;ige of fixed space maintainers is their permanence; a dis-
advantage is their lack of adaptability to growth changes. Some-
times two "simple" space maintainers may be more difficult and
costly to make and less satisfactory than one lingualarchwire. Do
not disregard the entire arch perimeter and the developing occlusion
simply because one tooth is missing. A variety of ingenious space
maintainers have been suggested, and several types are available
in prefabricated form (see Fig 18-20).
3. Palate-Separating Devices
•Rapid separation of the midpalatal suture in cases of maxillary
insufficiency is obtained by means of screw devices fixed to the
teeth (Fig 18-21 ,A). The suture is opened rather quickly (in about
2 to 3 weeks) and the space created at the midline then fills with
bone, permitting the central incisors to return to juxtaposition (Fig
18-21). (See also Fig 16-7.)
4. Edgewise Mechanism
The edgewise mechanism was the last and most advanced of
the several appliances invented by Dr. Edward H. Angle. It is a
multibanded precision appliance consisting of a rectangular labial
arch wire fitted and ligated into horizontal slots in brackets and
terminating in rectangular tubes on the second molar bands (Fig
18-22). The archwire originally was 0.022 x 0.028 inch, with
the narrow (0.022 inch) dimension lying against the facial surfaces
of the teeth: hence its name. Control in all directions is posible,
FIG 18-22.
The basic edgewise bracket, showing a method of ligation and the
Orthodontic Techniques 521
and all individual teeth may be moved simultaneously in three
directions.
The edgewise bracket is versatile since it will accept any shape
of wire up to 0.022 inch in diameter (edgewise brackets with 0.018
inch slots have become popular in recent years). A series of pro-
gressively larger light twist and round wires are used initially to
align, rotate, and tip the teeth and to level the occlusal plane,
permitting the greatest movements with light forces yet allowing
more easy insertion of the the rectangular wire. Loops can be
incorporated into the archwire to affect individual tooth and sec-
tional arch movements. The modem edgewise mechanism is quite
different from Angle's original appliance but its ingenious design
enabled the adoption of many ideas from other multibanded sys-
tems .
The idea that each tooth has a proper position and angulation
within an ideally shaped arch in order to achieve an ideal coor-
dinated occlusal relationship with teeth of the opposing arch is an
important concept if used in treatment with edgewise appliances.
The edgewise appliance is not particularly well suited for use
during the mixed dentition and is difficult to use in the primary
dentition. It finds its greatest application in the treatment of com-
prehensive malocclusions of the adolescent permanent dentition.
Though difficult to master, the edgewise mechanism is the most
popular because of its versatility. Several systems (often erro-
neously called "philosophies") of treatment, (e.g., Tweed,
Straightwire, Bioprogressive) are based on use of the edgewise
mechanism. Though the brackets are similar, the steps of treat-
ment, means of obtaining anchorage, methods of delivering torque,
etc., differ. Descriptions of its construction and manipulation can
be found in the publications in Suggested Readings at the end of
this chapter.
use of adjunctive springs. (Courtesy of Rocky Mountain Metal Prod-
ucts Company.)
522 Treatment

5. Light-Wire Appliances
The so-called "light-wire" appliances were designed by P.R
Begg, an Australian orthodontist. Since some types of tooth move-
ments evoke more tissue resistance than others, and some move-
ments occur faster than others (see Chapter 13), Begg reasoned
that by selectively choosing the movements required and relating
the reciprocal reactions properly, several tooth movements might
be carried out simultaneously, if each movement were carried out
within its ideal force range and as many movements as possible
were mutually reciprocal and beneficial. Such ideas prompted many
innovations in bracket and archwire design (Fig 18-23). Light-
wire appliances now differ from the original design, but employ
Begg's concepts of tooth movement and anchorage control. Stan-
dard light-wire therapy does not utilize extra-oral traction, fre-
quently involves extraction of teeth and, uses fewer auxiliaries
than edgewise therapy .

."
6. Other Fixed Appliances
a) Twin-Wire Applillnce
The twin-wire appliance consists of a pair of steel wires 0.010
or 0.011 inch in diameter placed in stainless steel end tubes which
fit into buccal tubes on the first molar bands. The twin wires in
FIG 18-23. the anterior section fit into a lock type of bracket (Fig 18-24).
Examples of light-wire brackets and the use of locking pins and root- The twin-wire appliance is much less popular today than it once
aligning springs. (Courtesy of Rocky Mountain Metal Products was, since it is simply not efficient for many important tooth
Company.) movements, (e.g., translation and paralleling of roots). It has,
therefore, been largely superseded by the edgewise and light-wire
appliances.

FIG 18-24.
The twin arch bracket and sliding cap, and a typical twin arch band- the anteriors, which are banded. (Courtesy of Rocky Mountain Metal
up. Note the end tubes, which fit into buccal tubes on the molars. Products Company.)
From the end tubes, the two small twin wires extrude to attach to
 Orthodontic Techniques 523

FIG 18-25.
A, universal bracket. The two wires are held in place by lock pins with the universal appliance. Sequence indicates progression of
(courtesy of Unitek Corporation). 8, photographs of a case treated treatment (courtesy of Dr. Jorge Fastlicht).
524 Treatment
FIG 18-26.
Extra-oral traction appliances. A-C, the Jenkins director, a combi-
nation modified Activator and face bow. Note that the appliance is
made in three segments, which allows for easy adjustment of the
b) Universal Appliance
The universal appliance, the design of Dr. Spencer Atkinson,
is a multibanded precision appliance consisting of one flat and one
round wire used in combination (Fig 18-25). The appliance is
versatile, and has loyal adherents, though it has never attained
great popularity.
D. ATTACHED REMOVABLE APPLIANCES
Removable appliances-those designed to be taken from the
mouth by the patient-are divided into two classes: attached and
loose. Attached removable appliances maintain a fixed relationship
to the dentition by means of clasps. Loose removable appliances
fit imprecisely and are designed to alter neuromus~ular function
during specific oral activities. Both attached and fixed removable
appliances will be considered under two general headings: (I)
active appliances and (2) passive appliances. The appliances de-
.'
buccal segments to various sizes of arches. A, an upper view. B,
an under view. C, cephalograms of patient before and after treatment
with this appliance (courtesy of Or. O. Harvey Jenkins). (Continued.)
scribed are but popular and useful examples of each category; it
is impossible to mention all of the many variations on each theme.
1. Active Appliances
a) Extra-Oral Traction Devices
, Extra-oral traction devices utilize anchorage outside the oral
cavity lor efficient application of force in directions not otherwise
possible. Extra-oral traction may be used to move teeth, to rein-
force the anchorage of intraoral appliances, to produce orthopedic
responses in the midface and mandible or to restrain or alter cra-
niofacial bony growth.
1) Head Gears.-The mode of attachment and direction of
head gear force application varies with the task assigned. Fig 18-
26 illustrates a variety of "head gears" most of which are used
to produce dorsal forces in the maxillary region. '
 Orthodontic Techniques 525

....;c \."~5~~--~
_

FIG 18-26 (cont.).

D, simple neck strap, sometimes called cervical traction. An elastic
strap attaches to a face bow. The inner, smaller bow fits into buccal
tubes on molar bands; the outer bow attaches to the neck strap. E,
straight-pull head gear, which attaches to a face bow. F, hi-pull head
gear (occipital traction) attached to a face bow. The high pull obviates
extrusion of upper molars. G, hi-pull head gear with "J" hooks which
attach through the corner of the mouth to an archwire Iigated in
brackets on bands cemented to the teeth. H, combination hi-pull head
gear and neck strap.

2) Face Masks.-Face masks, an old method which has
undergone a dramatic revival in recent years, are used largely to
produce ventral effects in the maxillary region (Fig 18-27).
3) Chin Cups.-Chin cups are devices to utilize extra-oral
traction to restrain or alter mandibular growth (Fig 18-28).
b) Lip Bumpers ("Plumpers")
The lip bumper is a heavy labial arch wire which is inserted
into buccal molar tubes. The wire has a flange of plastic added
anteriorly to engage the lip and is stopped anteriorly to the molar
tubes with a vertical loop or compressed coil spring (see Figs 18-
29 and 15-23). Lip bumpers may be used to maintain the arch
perimeter, position the molars distally, or permit changes in incisal
position.
c) "Active Plo1es"
Active plates is the term applied to attached, removable appli-
ances which derive their anchorage from the palatal or alveolar
mucosa and the teeth which they contact. Although active plates
are used in many ingenious ways, they do not constitute a complete
appliance system. Important points in construction are the means
of retention and the fit of the plastic to the teeth (Fig 18-30).
1) Schwartz Applia~ce.-The original Schwartz appliance
and iJs many derivatives' use arrowhead, or similar, clasps to fix
the plate tightlfm position
'" while' auxiliary springs are added to
tip teeth (see Fig 18-30r (Upper and lower Schwartz plates joined
by a pair of safety-pin springs-"Schwartz Double Plate"-are a
kind of functional appliance.)
2) Space-.Regaining Appliances.-One of the most popular
and practical uses of active plates is to regain space in the arch
perimeter after premature loss of primary molars (see Fig 18-30).
These same mechanical principles sometimes may be used in adults
to upright second permanent molars which have tipped mesially
526 Treatment
FIG 18-27.
Patient in a face mask.
FIG 18-28.
The chin cup used for extra-oral traction.
after the loss of first permanent molars (see Chapter 17).
3) Anterior Spring Aligners (Barrer Appliance).- The an-
terior spring aligner (Harrer appliance) is a device used to align
anterior teeth slightly by means of tension stored in the spring
clips used to retain it in place. The appliance is constructed on a
work cast on which the incisors have been aligned ideally (see Fig
18- 30). It is usually necessary to reduce slightly the mesiodistal
diameters of the teeth.
d) Crozal Appliance
The Crozat appliance consists of body wires, lingual arms,
and a high labial archwire (in the maxillary appliance) held in
place by specially designed molar clasps (Fig 18-31). The Crozat
appliance is best fabricated from precious alloy wire components
soldered together. . example, that it obviates the extraction of teeth, that one need not
Its advantages are: (1) it is sightly, (2) it is easy to maintain
oral hygiene, (3) it uses light forces, (4) it requires little time for
FIG 18-29.
Lip bumpers (see also Fig 15-13).
A-I
A-2
FIG 18-30.
Active plates. A, some methods of retaining attached removable
acrylic appliances. A-1, eyelets, also modified into arrowhead shapes;
A-2, the Adams clasp. (Continued.)
adjustment, and (5) it requires a small inventory of supplies and
instruments.
Its disadvantages are: (1) it demands a high degree of skill
to fabricate: (2) it looks deceptively simple, whereas it is exceed-
ingly difficult to master; (3) it takes much longer to affect results;
(4) closures of space after extraction of teeth is most difficult; (5)
maintenance of anchorage without loss requires great skill; (6) few
dental schools teach the use of the appliance.
In recent years, family dentists and pedodontistis in North
America have shown a great interest in the Crozat appli-
ance:-which is surprising, as many skilled and experienced or-
thodontists have tried it and found it wanting. It is an old and
respected appliance of limited use and with numerous disadvan-
tages that often are unnoticed. Many extravagant and ill-founded
claims have been made in recent years for this appliance, for
take a cephalogram, and that it is a functional orthopedic or gnath-
ologic appliance. Such rash statements are misleading to those
attempting to learn and evaluate the appliance and are unfair to
the skilled orthodontists Who have taught its use and utilized it
w~11~inpractice for man"y ·years. I occasionally use the appliance,
but only in highly selected cases; usually in adults for whom
maintenance of oral esthetics during treatment is essential (e.g., I
once used it to treat a malocclusion in a television announcer).
e) Vacuum-Formed Appliances ("Invisibles")
Thin sheets of thermoplastic material are fabricated over
working casts on which one or a few teeth have been slightly
repositioned (Fig 18-32). The appliance can bring about only slight
tooth movements as a part of retention or as the sole treatment.
 Orthodontic Techniques 527

PASSIVE BEND
NO. I
BEND
NO.2
BEND
NO.3·
4

FIG 18-30 (cont.).

B, examples of active plates. Note the need for good retention. C,
space-regaining appliances. C-1, recurved helical spring regainer
(courtesy of Dr. Fred DuPrai). Note the use of the Adams clasp on
the opposite side. C-2, knee spring for use in tipping molars distally.
C-3;, !!plit-saddle acrylic space-regainer, useful when greater dis-
tances must be regained than in C-2. Note another type of regainer
spring on the opposite side of the arch, a helical spring lying beneath
acrylic yet acting against the first molar. C-4, method of adjusting
the spring on the split-saddle regainer. C-5, method of increasing
the adjustment in a split-saddle regainer. As the molar moves distally,
the appliance becomes more fragile. It is then possible to tie the
distal portion forward with a piece of dental floss or stainless steel
ligature and add acrylic posteriorly. In this manner, the appliance is
reactivated without adjustment of the spring. (Continued.)
528 Treatment

.'

FIG 18-30 (cont.). "

C-6 and C-7, "slingshot"regainer. Note the use of a light elastic
joined to buccal lingual hooks (courtesy of Or. Fred OuPrai). C-S and
C-9, the sliding yoke space-regainer. CoS, buccal view; a 0.022- x
0.028-inch steel edgewise wire is used. A ball of solder is placed
mesial to the cuspid bend of the wire. A coil spring is then threaded
onto the wire, the sliding yoke is added, and the wire is bent well
distal to the molar to be moved. C-9, the sliding yoke is an edgewise
buccal tube, the inside diameter of which is exactly that of the wire.
To the buccal tube is soldered, at a right angle, a small piece of stiff
wir~ 10 engage the mesial'of the molar. Note that the acrylic must
be trimmed in a straight line on the lingual. This appliance is best
anchored on the opposite side by an Adams clasp. It is more efficient
in the maxillary than in the mandibular arch. C-10, the expansion
screw regainer. These units are bought prefabricated and are in-
serted into the acrylic appliance. (Courtesy of Or. Fred OuPrai.) D,
spring incisal alignment appliances (Barrer appliances). Incisors are
cut off the working casts and aligned into position. The appliance is
constructed on the perfected cast.
 Orthodontic Techniques 529

FIG 18-31.
The Crozat appliance. A, the basic upper appliance; B, the basic Gore, Jr.). D, a lower appliance with auxiliaries (courtesy of Great
lower appliance (both courtesy of Dr. Robert Smythe). C, the Crozat Lakes Orthodontic Laboratories).
appliance used in a patient with cleft palate (courtesy of Dr. S. D.

2. Passive Appliances They are also used during mixed-dentition treatment of deep bite
ma]occlusions or as a prelude to bite registration for patients with
Passive appliances are used (1) to maintain the status quo
acute temporomandibular dysfunction or myalgia (Fig ]8-33).
within the dentition (e.g., space maintainers and retaining appli-
ances), (2) to disclude the dentitions during orthodontic treatment,
b) Occlusal Splints
(3) to disclude the teeth prior to registration of bite relationships,
Occlusal splints are a sort of bite plane which cover the
and (4) as adjuncts to the treatment of temporomandibular
dysfunction. occlusal surfaces to provide a new occlusal relationship (Fig ]8-

a) Bite Planes
Bite planes are used to disclude the teeth in order to achieve
tooth movements more easily during bracketed appliancqherapy.
cl"
LJ

FIG 1'8-32.
The vacuum formed retainer, sometimes called the "invisible" ap- FIG 18-33.
pliance. Before forming this appliance, one may cut a few teeth from A bite plane for use during active orthodontic treatment (see also
the cast to make minor alignments. Fig 17-20).
530 Treatment

FIG 18-34.
An occlusal bite splint.

o'

FIG 18-35.
A, acrylic multiple space-maintainer. B, acrylic space-maintainer with
built-in regainer. The first permanent molar has not yet erupted, and
the first and second primary molars are lost. Sometimes the first
molar tends to drift mesially before eruption. In this appliance, the
saddle is constructed high enough to touch the occlusion. Often this
is enough to keep the permanent molar distally. However, if it has
tipped mesially, the saddle may be split and the appliance used as
a space-regainer to tip the molar distally.·

FIG 18-36.
A, Hawley retainers. Note the different methods of retention and the use of a flat bite plane. B, Ricketts retainers.

34). They are used for mandibular repositioning (see Section E-
4, Repositioning Splints) arid discluding the dentitions in tempo-
romandibular therapy. Their use during multi bracketed appliance
therapy is confounding and usually contraindicated, since they
restrict tooth movements.
c) Multiple Space Maintainers
Acrylic appliances, which cover the lingual mucosa and lin-
gual surfaces of the teeth with plastic extending into the areas
where primary teeth have been lost, make useful multiple space
maintainers (Fig 18-35). The plastic not only holds the space in
the line of arch but also may be built up to engage opposing teeth,
to maintain the plane of occlusion, and prevent extrusion of teeth
in,the opposite arch.
d) Retainers
The Hawley retainer and its many modifications are passive,
removable plastic appliances used to retain the new positions of
teeth after active orthodontic therapy is completed (Fig 18-36),
but the term "Hawley appliance" is often misapplied to a wide
variety of removable active appliances. The maxillary retainer may
incorporate a flat bite plane, and a variety of labial arches and
clasps may be utilized depending on the type of tooth movements
which have just been carried out.
E. LOOSE REMOVABLE APPLIANCES
(FUNCTIONAL APPLIANCES, FUNCTIONAL
JAW ORTHOPEDIC APPLIANCES, ETC.)
1. Background
It may be difficult for the reader to gain a fair perspective
about the proper place of functional appliance therapy in dental
practice and teaching. Differences arise because of the variance
in terminology associated with functional therapy, imprecise un-
derstanding of the purposes of functional therapy, a lengthy and
convoluted history of the methods employed, and disputes about
how (or even if) such appliances really work. Therefore, before
descriptions of specific loose removable appliances are given, it
is necessary to (1) define them, (2) list their clinical purposes, (3)
recall their history and (4) examine the evidence for their modes
of action.
a) Definition
Loose removable appliances are those designed to alter the
neuromuscular environment of the orofacial region to improve
occlusal development and/or craniofacial skeletal growth (see Figs
18-37 through 18-48). Most loose removable appliances, though
not all: ,.
a) utilize muscle forces to effect dental and bony changes,
b) disarticulate the teeth,
c) encourag~ a new mandibular position,
cl)require a tight lip seal during swallowing, and
e) selectively alter the eruptive paths of teeth.
b) Purposes
.Functional jaw orthopedic appliances are designed to alter the
function of the facial and jaw muscles in order to (I) provide a
Orthodontic Techniques 531
more favorable environment for the developing dentition, (2) op-
timize the growth of the craniofacial skeleton, (3) change the
directions of craniofacial skeletal growth, (4) inhibit skeletal growth
selectively, and/or (5) guide erupting teeth into more favorable
positions. All functional appliances are not capable of achieving
all of these purposes: certain appliances sometimes improperly
labeled as functional or orthopedic appliances (e.g. the Crozat
appliance) certainly cannot.
c) History
One of the oldest concepts in orthodontics (dentofacial
orthopedics) is the importance of muscle function in the eti-
ology and treatment of malocclusion. It was noted in American
orthodontic textbooks before the start of the 20th century and
in the writings of Robin25 (France, 1902) and Andresen3 (Norway,
1910). Therapeutically, the concepts evolved into two strategies:
(1) myofunctional exercises, first advocated by Rogers26 in the
United States about 1918; and (2) the use of appliances to alter
mandibular position and muscle function (Kingsl~y, 19 1880; Robin25
1902; and Andresen,3 1910). Time and clinical experience have
proved myofunctional exercises to be generally inefficient, and
the ideas of Kingsleyl9 and Robin25 have had little lasting impact
on dentistry. However, by 19364 Andresen' s work began to receive
serious attention, though the rationale expounded for "functional
jaw orthopedics" had a very shaky theroretical basis. Simply put,
Andresen's "Activator" was an intraoral appliance which looked
like Robin's Monobloc (which Robin proposed for curing "glos-
soptosis") and acted like Kingsley'sdevices for "jumping the
bite," but Andresen's Activator lies passively in the mouth until
"activated" by contractions of jaw and facial muscles. During the
swallow the Activator causes the jaw to be held forward and the
lips to seal, while preventing mouth breathing.
European dentists took up Andresen's ideas and, before any
theoretical basis could be proven or controlled clinical studies
appear, variations on Andresen's original theme were suggested
while a number of perversions of his concept were presented and
competed for attention. A European colleague once remarked to
me that during this period (just before and after World War 11)
there was no self-respecting German professor of orthodontics who
had not designed a removable orthodontic appliance which was
held to be superior to all others and, of course, carried his name.
(A few years later, North American orthodontists played the same
game with cephalometric analyses).
Meanwhile, across the Atlantic, American orthodontists had
forgotten their colleagues KingSley and Rogers and were busy
perfecting Angle's bracketed appliances, which were affixed to
the teeth. Americans were generally unsatisfied with the published
pl;1C!tographsof treatment results shown in European journals of
thafperiod and avoided trying. or teaching functional jaw or-
thopedic therapy. In 1951 Harvold, a pupil of Andresen, joined
our staff at the University of Toronto and began to teach us the
concepts of functional jaw orthopedics. Later, largely because of
his teaching at Toronto, Michigan, and California, American or-
thodontists began to take some notice. Still it was not until the
1970s that more than a few graduate departments included serious
functional jaw orthopedic teaching in their programs. About the
same time, sound experimental studies of the effects of altered
neuromuscular function on skeletal growth appeared in the liter-
532 Treatment
ature on both sides of the Atlantic. Then an interesting transfor-
mation in North American orthodontic thinking suddenly took
place. Some orthodontists who had for years derided teaching such
as ours at Toronto and Michigan, embraced the concepts of func-
tional appliance therapy and, like new religious converts, began
to propound their favorite appliances through articles,_ short courses,
and table clinics. Appliances and ideas that had been used in
Europe for up to 40 years were presented as "new" to American
dentists, and numerous additional appliances and variations ap-
peared in repetition of the European experience a generation earlier.
Now, thanks to the years of clinical experience, good ex-
perimental data, and sound clinical evidence, we are in a better
position to evaluate their use. Today we have a clearer clinical
perspective, but there is no reason for the extravagant claims and
rash excesses which sometimes are associated with the commer-
icalized teaching and promotion of functional jaw orthopedic ther-
apy in the United States of America. Such activities are a sad
commentary on our profession and are demeaning to one of the
oldest and most useful clinical methods we have. Perhaps this
phase will soon be over and these methods can be evaluated in a
more objective, professional perspective.
d) Modes of Action
Functional appliances alter purposefully the neuromuscular
environment of the orofacial region by either (1) applying forces
in new amounts, directions, and times or (2) eliminating or di-
minishing forces against the teeth and bones.
Functional jaw orthopedic appliances have been used on thou-
sands of patients for many years and hundreds of articles have
been written describing their utility, but there are differences in
opinion about their modes of action. That they often succeed to
the satisfaction of many discerning clinicians is not disputed: that
we understand precisely (I) how they work, (2) why they do better
in some cases than others, and (3) how they achieve differential
effects on muscle action, tooth development, and bony changes
are still not fully understood. Experimentation on animals has
provided important information (see Chapter 4), but the conditions
of the laboratory experiment are different than those in clinical
practice, and the craniofacial morphologies of experimental ani-
mals are dissimilar to that of humans. Well-designed clinical stud-
A B
FIG 18-37.
A, usual method of constructing the Andresen appliance. Wax bite
is constructed in this instance within the limits of the freeway space.
ies are few indeed, and prospectively planned clinical research on
functional jaw orthopedic treatment effects scarcely exists. Most
clinical papers are generally flawed by (I) too much emphasis on
anecdotal clinical case reports, (2) absence of objective reporting,
(3) small sample sizes, (4) biases in the selection of cases, (5)
inefficient and ineffective cephalometric methods, (6) lack of proper
controls, and similar flaws. Despite these criticisms, logic, clinical
experience, and research results provide some general agreements.
What follows is an attempt to provide perspective and facts
about functional jaw orthopedic effects: perspective amidst a
plethora of well-intentioned but poorly planned clinical studies;
facts, not hunches, hopes, or professorial pontifications. This is a
formulation of the most sensible, reasonable clinical conjectures
possible at this time. The reader should be neither dismayed nor
disenchanted: good clinical research is difficult, but the number
of sound studies is steadily increasing and we shall soon know
more with certainty.
1) Muscles.-Andresen's3.4 original concept of an "acti-
vated" muscle transmitting a functional stimulus to bone is un-
supported. Rather, functional appliances are held to be devices
which alter the amount, direction, and/or the duration of forces
while transmitting them against the teeth and bones. This concept
draws attention to the importance of the construction bite for func-
tional appliances. There are two schools of thought: that the con-
struction bite should be taken (I) within or (2) purposely beyond
the vertical interocclusal distance (Fig 18-37). Most clinicians
now advocate varying the construction bite according to the in-
dividual patient, but exceeding the interocclusal distance is more
common than not, and discussion centers on how far beyond the
interocclusal distance to make the construction bite. Sander2? 28
noted that when the construction bite is taken in an extremely
forward position, the mandible, during sleep, often discludes from
the appliance, thus negating the desired effects. Graf15 observed
that for each millimeter of forward mandibular displacement
100 g of force were created. It has also been shown that contrac-
tions of the lateral pterygoid muscle are inhibited while the jaw
occludes against a functional appliance in a forward biting posi-
tion.5 The appliance in place thus creates two new sorts of forces:
stretch, if the construction bite is taken past the interocclusal dis-
- .
.......
e, Harvold's method. The mandible is held down and forward well
past the freeway space .

FIG 18-38.
Adaptation of the facial muscles to altered mandibular position. A
and B, the original position; C, after insertion of a wax bite used for
tance, and the forces resulting from muscle activities prompted by
the foreign body within the mouth.
The temporomandibular joints, like most other joints in the
body, provide a sensory guidance system for jaw functions and
positions. Masticatory and adaptive positions of the jaw must alter
continuously during growth and dentitional development. Such
natural adaptive changes are at least partially controlled from the
temporomandibular joint receptors coordinated within the brain
itself. Ahlgrenl•2 showed that children with malocclusions dis-
played much more complicated chewing patterns than those with
normal occlusion and that treatment of the malocclusion (with an
Activator) resulted in a normalizing of the chewing cycles.
Sander,27.28 who studied neuromuscular responses to functional
appliance therapy, observed phases of disorientation of masticatory
patterns following the insertion of the appliance and preceding a
phase of adaptation as chewing activities normalized. He showed
that functional treatment should not be stopped until the patient
has adapted to an harmonic three- or four-phase pattern of chewing.
These favorable neuromuscular adaptations are not seen in patients
wearing Class II elastics because the actions of the elastics interfere
with the capacity of the sensory guidance mechanisms to adopt
new harmonic chewing patterns. McNamara20. 21. 23reached similar
conclusions on the basis of experiments in altered mandibular
positioning of Rhesus monkeys (Macaca mulatta), noting that the
activities of muscles alter and adapt predictably and rather rapidly
to mandibular repositioning whereas structural changes are more
gradual (Fig 18-38). "In contrast to the functional protrusion
experiment, no uniform neuromuscular response could be deter-
mined," he noted regarding the results of experiments using ex-
trinsic Class II traction forces to protrude the mandible. It is obvious
on the basis of both experimental and clinical research that feed-
back from the subjects' own joint and muscle receptors are an
important factor in functional appliance therapy. Both Sander's
and McNamara's reports emphasize that stability is not achieved
until occclusion, function, and masticatory reflexes are harmo-
Orthodontic Techniques 533
construction of a functional jaw orthopedic appliance.
nized. Fully adapted muscle activities are as esential to orthodontic
stability as any other goal of treatment.
A functional appliance within the mouth causes contractions
of the mandibular elevators during swallowing; the same neuro-
muscular response seen in children with tooth-together (normal)
swallows. Further, the presence of the appliance alters tongue and
lip posture and activities. If the appliance is loose, the tongue must
position it during the swallow, which repeated often alters tongue
posture favorably. FrankeP' drew attention to the importance of
the lip seal when determining the construction bite, reasoning that
the lips must seal around the appliance to hold it" in" place and
enable the swallow to be completed. Thus, the tight lip seal and
tongue contractions against the appliance contribute to the alter-
ation of forces created by the presence of the appliance. More
importantly, the appliance retrains the muscles promoting a normal
tooth-together swallow, a tight lip seal during the swallow, and
improved tongue posture at all times. To summarize, functional
appliances not only create new favorabIe forces within the mouth
which act ag"ainst the teeth and bones but also are muscle-training
devices. Rogers'26 concept of myotherapeutic exercises,has really
only found practical application in functional jaw orthopedic
appliances. ;-
2) Dentition and Alveolar Processes.- There is general
agreement that one of tile major contributions to successful treat-
'inept with functional appliances lies in their ability to control
differentially the vertical height' of the teeth. Stopping some teeth
and permitting others to develop vertically aids in leveling the
occlusal plane and the correction of deep or open bites. Both
Harvold'6 and Woodside31 have noted the advantages of altering
the cant and position of the occclusal plane in Class II treatment
with functional jaw orthopedic appliances in the mixed dentition.
Frankel13 observed that under functional therapy there were sig-
nificant increases in the distances between the mandibular border
and the forming apices of the teeth when treatment occurred during
534 Treatment
FIG 18-39.
Diagram illustrates the fitof Activator-type appliances inside the mouth.
A, ground to allow eruption of both upper and lower molars. Typically,
in Class malocclusion, upper molar eruption is "indexed" and not
11
ground in order to maximize adaptation of mandibular eruptive move-
ments. e, method of grinding the inside of Activators. These appli-
ances fit loosely in the mouth. As the tongue lifts the appliance during
swallowing, the patient bites into the appliance, at which time the
muscle forces are transmitted through the plastic, coming in contact
with the mesial surface of each upper tooth, as shown. The wire
spring itself is not active against the molar until biting takes place;
thus, force is applied by the muscles, through the spring, but not until
a swallow or bite. C, method for trimming the acrylic around the
incisors. Note that the acrylic is removed lingually to the maxillary
incisors after they have been tipped somewhat by the labial archwire.
Their incisal edges may be engaged in acrylic in order to prevent
their extrusion. In the mandibular arch the acrylic never touches the
lingual surfaces of the crowns of the incisors. Acrylic is placed over
the incisal edge and onto the labial surface of the lower incisor in
order to minimize labial movements. Both upper and lower incisal
edges may be stopped with acrylic, particularly when the eruption of
posterior teeth is required. They may be left unstopped and the
posterior teeth in both arches indexed in the treatment of open bite.
eruption and dental development. The result is important positional
changes in the apical base and alveolar process en toto with respect
to the corpus mandibularis.
Functional appliances are used to guide the teeth during erup-
tion which, as noted above, helps in alterations of the occlusal
plane, but also may determine new occlusal positions of the teeth
(Fig 18-39). Harvoldl6 maintains that such is the principle mode
of correcting Class 11malocclusions with Activators. Several stud-
ies have shown that the mandibular dentition tends to move forward
under functional jaw orthopedic therapy for Class 11malocclusion,
even when precautions are taken to prevent such changes. Janson18
observed that with Bionators, much of the Class 11 correction is
gained in alveolar remodeling when the craniofacial skeleton shows
anteroposterior harinony. She also observed that the dentoalveolar
changes noted by Harvold16 and Woodside31 as the principal ele-
ments in Class 11 correction occurred more favorably during the
prepubescent period than during the pubescent spurt itself; that is,
the timing of a favorable response is more related to eruptive
development than increases in skeletal growth rate. It has generally
been found that the functional appliances can, when the maxillary
teeth are left covered, restrict vertical maxillary alveolar devel-
opment. In the absence of extra-oral traction to a functional ap-
pliance, little actually distal movement of the molars takes place
to correct Class 11malocclusion; rather, the teeth are guided during
eruption to a relatively more distal and buccal position. Attention
has been carefully drawn to the role of the severity of the skeletal
dysplasia on the clinician's ability to achieve success only through
dentoalveolar adaptation-a most important fact. Finally, it should
not be forgotten that vertical alveolar development in the maxilla,
because of the divergence of the alveolar processes, results in an
increase in both the width of the maxillary arch and its perimeter,
useful responses forsome crossbite and space problems.
3) Craniofacial Skeleton.- The greatest arguments about
the modes of action of functional appliances center on the question,
"Do functional appliances alter the craniofacial skeleton?" Before
plunging into this interesting debate, it should be mentioned that
most cephalometric analyses applied to this probl~m have not been
up to the task (see Chapter 12). The skeletal changes looked for
might be (1) increases in size, (2) restraint of expected size in-
creases, (3) alterations in the relative size or position of skeletal
parts, (4) changes in the shape of bony parts, etc.
The experimental evidence is overwhelming that, in con-
trolled laboratory animals, alterations in the neuromuscular en-
vironment bring about all four kinds of changes noted above. The
classic studies of McNamara, Carlson, and Petrovic (see Chapter
4) show conclusively that significant changes in the development
of the condylar and other regions can be produced in experimental
animals. Few modem bone biologists dispute these points. How-
ever, it is proper tOlnote the implications of these experimental
findings to clinical practice with functional appliances.
a) Claimed Skeletal Responses.- The descriptions in the
clinical literature regarding the skeletal responses to functional
jaw orthopedic appliances can be grouped roughly under the fol-
lowing explanations:
a) "Stimulation" or enhancement of mandibular growth.
b) No changes in the amount of mandibular growth, but cre-
ation of more favorable directions of growth.
c) No demonstrable skeletal effects, but important alterations
in eruptive positions of teeth and adaptations of the teeth and)
adaptations of the alveolar processes.
d) Restraint of midface growth.
e) Deformation (i.e., shape change) of skeletal structures.
Experimental evidence of skeletal changes with ;ilterl"d func-
tion may be summarized as foilows:
'. a) Important change~ 1n .amount, timing, and/or direction of
condjIar growth. ,
b) Adaptive alterations within the basilar portion of the tem-
poromandibular articulation.
c) Changes in the muscle-bone interface (i.e., the attachment
sites of muscles to bone).
cl) Shape changes in bones and/or regions of bones.
e) Immobilized repositioning of the mandible (denied mas-
ticatory function). This shows an immediate and profound effect
on the morphology of the condylar cartilage and a dramatic dim-
inution in growth changes of the region.

The experimental conditions of the laboratory, of course,
cannot be replicated in practice, but there is no logic or theory to
conclude, as some do, that craniofacial growth is so rigidly pat-
terned that it cannot be altered by vaiiations in its functional en-
vironment. Such inferences from the available experimental data
are strange conclusions for orthodontists to make, since those
deductions would imply that altered function resulting from ap-
pliance forces applied directly to teeth produce adaptive responses
in alveolar bone but that no other altered function or force appli-
cation to bone (e.g., via the patient's own muscles) would have
any effects. The biology of bony adaptation and growth does not
change according to the favored appliance or clinical biases of the
orthodontist treating the case.
In attempting to make clinical sense out of apparently con-
flicting research findings, it is well to remember that bone growth
and remodeling are under a variety of naturally controlled mech-
anisms and respond to many kinds of environmental changes.
Function, and hence some form of stimulation, is a necessary factor
'in all bone growth and even repair remodeling. The critical ques-
tion remains: Can purposeful alteration in environmental stimuli
result in natural bony responses which can be used advantageously
in orthodontic therapy? I draw the following conclusions at this
time:
a) The experimental evidence is overwhelming that alterations
in the functional environment of bone brings changes in the mor-
phology and growth of bony tissues.
b) The supportive clinical evidence is less compelling but
conflicts in no way with laboratory findings.
c) Difficulties in design of clinical studies and simplistic
measuring methods have often led to ill-founded and even mis-
leading conclusions (see Chapter 12).
d) All orthodontic treatment produces bony changes which
are more extensively distributed in the head and face than can be
appreciated with the usual methods of cephalometric analysis.
e) There are some similarities in the treatment effects of quite
different appliances.
b) Role of Timing in Treatment Intervention.-If one would
alter craniofacial growth, a logical question arises, "Are there not
some times in which such alterations can be more easily achieved?"
Obviously, basal bony changes occur at a much less rapid rate in
,adulthood, and most rapidly in early childhood and during the
pubescent growth spurt, while alveolar bony changes are most
changing during the eruption of teeth. One school of thought em-
phasizes the advantage of treatment during the pubescent growth
spurt and hence the importance of being able to predict, for the
individual, the time of the adolescent spurt. Both theoretical and
practical difficulties arise in making such predictions, since much
of the spurt is over before it can be predicted by the methods
developed thus far. Further, some individuals, particularly girls,
display no significant spurts. Finally, much of this reasoning is
based on data from spurts in stature, yet some facial regions do
not show spurting and some that do are not well synchronized with
spurts in stature. In some instances the amount of growth increase
during the spurt is trivial. If emphasis is taken from trying to
predict the time of Peak Height Velocity in stature increments to
the rate of bone turnover and the amount of expected growth
remaining in the child's face, a more logical argument for early
Orthodontic Techniques 535
treatment is made. Demisch9.1O concluded, after studying the re-
sponse to Activator ther¥. that favorable bony treatment effects
occurred quite independently of the spurts in craniofacial skeletal
growth.
2. Vestibular Appliances (Oral Shields, Oral Screens)
a) Description
The oral shield is a device fitting in the vestibule which shuts
off the ingress of air through the mouth and directs contraction of
the lips against any anterior teeth in labioversion (Fig 18-40). It
is used to retrain the lips, to correct simple labioversion of the
maxillary anterior teeth and as a habit-correcting appliance-for
it helps retrain and strengthen lip action (Fig 18-41). It probably
should I}ot be inserted if the child has nasorespiratory distress or
a nasal obstruction. The oral shield is of no use for correction of
a Class 11 malocclusion.
b) Construction
The vestibular shield is constructed on work casts to the
vertical vestibular limits of both arches after all undercuts, em-
brasures, voids, etc., have been filled (see Fig 18.,...40). A sheet
of thermoplastic material, such as Plexiglas, or the usual powder-
liquid acrylic resin may be used. Breathing holes may be bored if
necessary.
3. Functional Jaw Orthopedic Appliances
a) Definition
Functional jaw orthopedic appliances are loose, removable,
intra-oral devices which reposition the mandible in order to alter
the muscle forces against the teeth and craniofacial skeleton. They
are of many varieties and types according to the rationale of the
user and the nature of the malocclusion to be treated.
b) Uses and Indications
Functional jaw orthopedic appliances are used where dys-
function has played a role in the etiology of the mal occlusion
an<,IJorwhere enhanced or altered normal functional activities may
provide optimal conditions for the growth and development of the
craniofacial skeleton and the occlusion.
They are used to correct anteroposterior malocclusions, par-
ticularly Class 11, both open and deep bites, as well as crossbites
or lack of arch coordination.
Because they are dynamic appliances, depending on altered
neuromuscular activities to effect bony growth and occlusal de-
velopment, their use is much more frequent in the mixed dentition.
Very few clinicians advQ5=atetreatment of adult mal occlusions with
flll1ctional jaw orthopedic appliances.
c) Types
Functional jaw orthopedic appliances have been classified
many times and in many ways. Graber'sI4 classification, while not
all inclusive, is very useful. He labels as myotonic those appliances
which depend primarily on mandibular displacement anteropos-
teriorly or vertically. Myodynamic appliances (sometimes termed
elastic appliances) not only translate the mandible anteroposteriorly
and vertically, but also attempt to utilize and translate muscular
536 Treatment
FIG 18-40.
The oral shield. A, cast ready for construction of the oral shield. A
vestibular impression is taken and filled with plaster to the outline of
the labial surfaces of the teeth. Plexiglas or acrylic is then fitted to
the cast. B, cast with completed oral shield in place. C-E, use of
the oral shield in treating Class I, type 2 malocclusion. C, at the start
of treatment. D, after 3 months. E, after 6 months. Note the recession
."
,.... \
of gingival tissue around the neck of the mandibular cuspid. As the
incisor relationship improves, one must grind away the inside of the
oral shield so that the shield itself does not cause traumatic occlusion
of one of the teeth. Here such clearance was not provided and, of
necessity, the gingival margin had to recede.
 Orthodontic Techniques 537

FIG 18-41.
The modified oral shield used for training of the mentalis muscle. A,
an oral shield is made in the usual fashion, and base plate wax is
added to the lower labial surface in a quantity sufficient to inhibit
contraction of the mentalis muscle on swallowing. Wax is added and
contoured until inhibition of mentalis contraction is seen in the patient.
Then, the wax is converted to acrylic. B, electromyograms of a patient
before and immediately after insertion of the oral shield. Note the
diminution of activity in the mentalis muscle. Usually the patient must
wear the appliance for several months before the muscle becomes
quiescent. Then the labial plumper is gradually ground down before
being abandoned. When used to train the mentalis muscle, the oral
shield is not inserted until the incisor correction has been obtained.
C-1, face of a girl at the beginning of treatment for open bite. C-2,
same patient at the end of treatment. Note the persistence of the
hyperactive mentalis muscle. This is the kind of case on which the
modified oral shield works very well.

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538 Treatment
FIG 18-42.
Activators. A-1, an Activator appliance before trimming. Note that
the molar spring is free, as it was covered during the curing of the
acrylic. It is a common mistake to allow the laboratory to grind the
Activator before delivery to the dentist, as the technician cannot
possibly know the correct individual grindings required for a particular
patient. Further, one typically wants to leave the maxillary teeth "in-
dexed" in Class 11 treatment at the start, permitting more mandibular
eruptive adaptations. A-2, this Activator has been worn for some
time. Note that the acrylic has now been ground to permit the max-
illary teeth to be guided distally as they erupt and the mandibular
..
teeth to erupt vertically. The spring serves simply as an adjustable
guide plane down which the maxillary molars may erupt. 8, -classic
Activator being used in treatment. 8-1, intra-oral view at the begin-
ning of treatment; 8-2, facial profile at that time. 8-3, the appliance
in place ,in the mouth 1 y~ar l~ter; 8-4, the occlusion 1 year later.
Note the reduction of the overjet, the improvement in the open bite,
and the correction of the molar relationship as the cuspids and pre-
molars erupt. 8-5, the profile 1 year after start of treatment. 8-6,
patient profile at the end of treatment. 8-7, cephalogram at the end
of treatment. (Continued.)
 Orthodontic Techniques 539

11

\',

\\
I',
I'
1\
\\\,' ....•....
.•...•.• -' ."'.
........•.

,,'. '.

FIG 18-42 (cont.).

B-8 and B-9, the casts after retention. B-10 to B-12, cephalometric of the retention period. 8-10, cranial base orientation. B-11, orien-
tracings: solid line signifies patient features at the start of treatment; tation on the palatal plane. 8-12, oriented on the mandibular plane
dotted lines, at the end of active treatment; dashed lines, at the end and registered at the lingual symphysis.

movements and activities to move teeth and reshape alveolar arches.
d) Activators and Derivatives
The Activator, the original functional jaw orthopedic appli-
ance, has been frequently modified from its original design, and
many derivatives have appeared (see Fig 18-42). The Activator
itself consists of a loose plastic device fitted on the lingual side
of both upper and lower dentitions and constructed to a bite which
has altered the mandible's functioning position (see Fig 18-42).
A labial bow contains the maxillary incisors, while the lower
incisors are capped with acrylic. There are many variations on the
Activator (Fig 18-43). The Bionator, developed by Balters,.· 7 is
one of the more popular derivatives of the Activator (Fig 18-44).
The Bionator design reduces the amount of acrylic, has a palatal
wire, and has a wire with buccinator wings to reduce cheek pres-
sures. The Bionator's reduced bulk makes it possible to be worn
both day and night.
e) Frankel Function Regulator
Frankel, 12 seeking the advantages of mandibular displacement
as developed for the Activator, plus a means of reducing the
compressive forces of the buccal musculature, devised an appliance
which fits between the teeth and the cheeks and lips rather than
between the tongue and teeth (Fig 18-45). The vestibular position
of the appliance alters the effects of abnormal lip and buccal wall
contractions on the dentition and enhances the role of tongue ac-
tivities.
/) Myodynamic or Elastic Appliances
The Bimler appliance,8 the best known of the myodynamic
appliances, is essentially a flexible bimaxillary wire appliance with
two palatal pads acting against the maxillary alveolar processes
and auxiliary springs to achieve tooth movements. Bimler's ideas
influenced the development of other elastic appliances (e.g., the
Kinetor of Stockfisch).
g) Others
The literature is filled with many variations on the functional
jaw orthopedic theme. Most, however, fit conceptually under one
of the three categories above, or are active plates (see Section D-
c.) or hybrids (see Section G).
4. Repositioning Splints
Repositioning splints are used in certain phases of temporo-
mandibular therapy (I)'tO reposition the mandible forward in order
to;eestablish normal meniscus-condyle relations or (2) to allow
the condyles to seat superiorly on the dorsal slopes of the articular
eminence. Repositioning splints look similar to regular splints (see
Section D-2-b. and Fig 18-34) but are provided for different rea-
sons, namely, to alter purposefully the positions of the mandibular
condyles.
5. Tooth Positioners
540 Treatment
FIG 18-43.
A, the open-front Activator, occlusal view, with the appliance on the
lower arch. Note that there are no acrylic stops for the incisors. This
appliance may be worn during the day, and it is possible to speak
easily with it in place. B, an activator with a coffin spring. The ap-
pliance may be split in two for mild expansion forces or the coffin
a) Description
The tooth positioner is a flexible appliance made of soft rubber
or plastic which surrounds the crowns of all teeth in both jaws
(Fig 18-46) and has been fabricated on casts whose tooth positions
have been idealized. It is used as a retainer and to complete the
niceties of tooth positions after removal of fixed appliances.
b) Construction
To construct a tooth positioner, two very accurate impressions
are taken of each dental arch and poured in stone or plaster.
One set of casts is used as a reference; the other set is mounted
on an adjustable articulator by means of a .wax recording of the
patient's retruded occlusal position and a transfer facebow. This
FIG 18-44.
A-C, the Bionator appliance. Baltes designed the Bionator as a
streamlined version of the Activator, incorporating wire buccal loops
to minimize the contractive forces of the buccal wall musculature,
,"
spring may be left in unactivated, to teach a more superior tongue
posture. C, the expansion Activator. Because only the maxillary arch
is expanded, the acrylic must be freed from the lingual of the lower
teeth. (Courtesy of Great Lakes Orthodontic Laboratories.)
registration is important since it permits the patient to bite into tne
tooth positioner without displacing the condyles. The teeth to be
aligned are cut off the cast and reset to improved positions.
c) Limitations
It is easy to overextend this appliance. It is no substitute for
proper manipulation of the arch wires and should not be used to
attempt gross tooth movements, to attempt significant occlusal
change, to direct the growth of the jaws, or to reposition the
mandible. Nor is it a substitute for proper occlusal equilibration.
If the positioner is not constructed exactly to the patient's retruded
occlusal position (and thus within accommodating limits of the
much as Frankel did in the Function Regulator. The Bionator has no
jack screw expansion mechanism. (Courtesy of Great Lakes Ortho-
dontic Laboratories.)

FIG 18-45.
The Frankel Function Regulator (FR). A, the FR-II appliance from
the lateral view. Note the labial lip pads in the lower arch. B, the
appliance in place on the maxillary cast. C, a screw mechanism
ideal occlusal position) and at a tolerable vertical dimension, the
result may be undue straining of the temporomandibular joints.
An improperly made positioner can do harm. Since the patient
cannot speak or eat with the appliance in place, it can only be
worn for a limited time each day. Short periods of vigorous "chew-
ing" into the appliance seem more beneficial than long periods of
passive wear, as when sleeping.
6. Herbst Appliance
The Herbst appliance,17 an old idea recently revived by Pan-
cherz,24 consists of maxillary and mandibular metal frameworks
cemented or bonded to the teeth and joined by two hinged sleeve-
plunger joints which permit jaw closure only in a determined
occlusal relationship (Fig 18-47). The Herbst appliance is most
FIG 18-46.
A, teeth setup for construction of positioner. B, the positioner.
Orthodontic Techniques 541
.'
permitting gradual advancement of the mandibular lip pads. D, the
FR-III appliance. Note that the labial lip pads are now in the maxilla.
(Courtesy of Great Lakes Orthodontic Laboratories.)
frequently used in correction of severe Class IT malocclusion due
to retrognathia. Unlike the functional jaw orthopedic appliances,
it cannot ordinarily be removed by the patient; therefore the pro-
truded jaw function is continually assumed. It is likely that the
classic animal experiments of McNamara, Carlson, Petrovic and
others (see Chapter 4) are more nearly replicated clinically with
the Herbst appliance than with any other functional jaw orthopedic
appliance. Details of construction, indications for its use, and
reports of its treatment effects will be found in the Suggested
Readings at the end of this chapter.
7. Hybrids and Perversions
A wide variety of ingenious modifications of functional jaw
orthopedic appliances have been presented through the years (Fig
542 Treatment
FIG 18-47.
Hybrids and perversions of functional appliances. Some modifica-
tions in use defeat or pervert the basic concepts and principles of
functional jaw orthopedics. For example, an Activator held in position
with Adams' clasps or attached to a head gear and face bow (A2)
can no longer function in the manner originally envisioned. While
some hybrid appliances may have particular uses, I think they should
18-48) since Andresen's concepts were first ennunciated. Others
have wedded functional jaw orthopedics with other clinical strat-
egies, for example, moving individual teeth or using extra-oral
traction in combination with an "Activator." As a general state-
ment, it seems true that many of the hybrid appliances result in
denying certain aspects of functional jaw orthopedic theory and
practice and therefore 'are often contraindicated. For example, head
gear forces attached to' an "Activator" immediately deny the ap- '
pliance the opportunity to act as an Activator. This particular
hybrid seems indicated only for Class II Type F mal occlusions
(mild skeletal problems involving both maxilla and mandible; see
Chapters 12 and 15), whereas pure extra-oral traction is more
appropriate for type B (maxillary prognathism), and typical func-
tional jaw orthopedic appliances are indicated for type D (man-
dibular retrognathism). Those who have completed a definitive
differential Class II cephalometric analysis of the patient are in a
better position to select the most efficient appliance for a particular
case. It is not unfair to say that some so-called "functional"
appliances are a perversion of the concept and hence of limited
use except in mild skeletal dysplasias (i.e, where almost any ap-
pliance will secure some improvements).
A2
.'
not carry the original name when the original function has been
altered (e.g., in this instance, the appliance is no longer an Activator).
Another popular modification, sometimes called a Bionator, is shown
(B2). This removable appliance is not a Bionator, since its basic forces
and principles are not those of Baltes' design, nor are they in keeping
with the principles he enunciated
F. MYOTHERAPEUTIC EXERCISES
One person, more than any other, alerted American ortho-
dontists to the relationship of muscles to malocclusion. As early
as 1906, A.P. Rogers26 suggested that muscle exercises be used
as an adjunct to mechanical correction of malocclusion. He de-
scribed the role of muscle imbalance in the etiology of malocclu-
sion and pictured the muscle environment of the teeth as "living
orthodontic appliances."
1. Purposes
The principal purpose .?f myotherapy is the creation of normal
orora~ial muscular function to aid growth and the development of
normal occlusion. It is not to increase the size or strength of
muscles, often the primary purpose of exercises for large muscles
elsewhere in the body. Coordinated normal function is the principal
reason for orofacial myotherapeutic exercises.
2. Limitations
The theory of myotherapeutic exercise is sound: its routine

FIG 18-48.
The Herbst appliance. A, lateral view with the appliance in place on
the work cast. Note the arbitrarily advanced position of the mandible
and the hinged tube and cylinder mechanisms attached to the two
appliances. B, as the jaw is opened and closed, it can only function
in the forward position. Note the piston and cylinder and their hinge
attachment to the two halves of the appliance. C, front view. D,
use in daily practice is difficult, and even impractical in most
instances. Clinicians have found that myofunctional appliances are
generally more useful than exercises alone (see Section E, Loose
Removable Appliances, and Section F-4, later in this section).
3. Principles
a) Study the possible role of muscle dysfunction in the etiol-
ogy and maintenance of the malocclusion.
b) Remove, if possible, such etiologic factors as deleterious
habits (see Section G), tonsils, and/or adenoids (see Chapter 7).
c) Establish early, with minimal mechanotherapy, the proper
arch form and cuspal relationship.
d) Remove by occlusal equilibration any interferences in the
primary dentition (see Section H).
e) Begin appropriate myofunctional appliance therapy (see
Section C and E).
f) Be certain of occlusal functional harmony during reflex
activities before ceasing applianc,e therapy.
4. Specific Procedures
a) Orbicularis Oris and Circumoral Muscles
If the lips cannot seal because of procumbency of the incisors,
it is best not to begin exercises until the incisors are retracted
sufficiently for the lips to exert some effect against the teeth; then,
the new tooth positions may prompt normal lip and swallow ac-
tivities (see Fig 18-51). An oral shield (vestibular screen), mod-
ified as shown in Fig 18-41 may be useful. Simple small adhesive
Orthodontic Techniques 543
occlusal view of the disengaged maxillary appliance. This version
utilizes acrylic cured to a metal framework. The acrylic may be bonded
to both upper and lower teeth, or one arch or both may be left free.
Ifthe acrylic is not bonded, great care must be exercised to maintain
good oral hygiene. E, the mandibular appliance disengaged. (Cour-
tes~ of Great Lakes Orthodontic LabQratories::
stickers placed on the lips may serve as reminders to the patient
during muscle relearning.
Do not forget the role of musical instruments in lip dysfunc-
tion. Playing any brass instrument will soon produce improved lip
tonicity. It is equally important to avoid, if possible, the single-
reed instruments (e.g., the clarinet) for patients with hypofunction
of the maxillary lip, labioversion of the upper incisors, and/or a
Class II malocclusion.
b) Mandibular Posture
Solow and Tallgren29. 30 have shown aSSOCIatIOnsbetween
head posture and body posture arid between head posture and
craniofacial morphology. When a child has faulty body posture it
is difficult to hold the mandible in its most advantageous position.
When the spine is straight and the head is well placed over it with
the person's eyes looking ahead, the mandible is in a favorab1e
position of posture. Simply asking the patient to walk upright with
shoulders squared and eyes ahead sometimes produces immediate
~ffe.cts in appearance-and self-image. Functional jaw orthopedic
appliance therapy may have favorable effects on mandibular pos-
ture (see Section E3). The relationship between "mouth breath-
ing" and mandibular posture are discussed in Chapter 7. //
G. CORRECTION OF DELETERIOUS ORAL
HABITS
Before attempting to control any suspected deleterious oral
habit, it is important to bear in mind the role of the musculature
 544 Treatment
in normal development of occlusion (Chapters 5 and 6) and the
role of habits in the etiology of mal occlusion (Chapter 7). Usually
there is no strong reason for plunging into a rigorous regimen of
habit control; therefore, time can be taken to study the problem
thoroughly. It seems wise to concern ourselves with the control
of oral habits that actually are deleterious to the occlusion; other
undesirable oral habits may be the responsibility oCother profes-
sionals. We dentists should confine our efforts to the clinical prob-
lem we must treat: occlusion. It is unfortunate that so much
misinformation concerning this important subject appears in lay
and professional journals, and it is noteworthy that much of the
loose writing comes from those who do not have to treat the
occlusal problem.
One should define at the start that which is to be treated.
Sometimes it is an open bite, sometimes a psychological problem,
sometimes a neuromuscular reflex. Always ask such questions as
"What precisely is the habit to be controlled?" "Should any of
the therapy be directed toward the parents?" The most common
oral habits disruptive to occlusion are thumb-sucking, finger-suck-
ing, tongue-thrusting, nail-biting, lip-biting, and lip-sucking.
Functional mal occlusions also cause lip or tongue habits delete-
rious to occlusal development (see Chapters 7 and 15).
1. Basic Considerations
Regardless of which oral habit is being corrected, two basic
considerations apply:
a) The rationale. Since the problem is one of controlling a
FIG 18-49.
Correction of thumb-sucking with an appliance. A, malocclusion be-
fore treatment. 8, appliance in place on cast. Appliance is made of
O.036-inch stainless steelwire soldered to four stainless steel primary
crown forms. The spurs are very, very short, sharp, and strategically
placed. C, appliance in place and the teeth in occlusion. D, corrected
biologic process, the rationale of therapy must be physiologic, not
mechanical. The attempt always should be to alter the afferent arm
of the neuromuscular response, which should be perceived in terms
of muscle releaming. It follows that devices such as restraints,
mitts, and elbow braces, which supply little but mechanical re-
straint, are to be shunned. The rationale of therapy is that of
conditioning responses, not punishment or physical control (see
Chapter 7).
b) The primacy of the malocclusion. It must be determined
whether the mal occlusion is of primary or secondary concern. We
are dentists, and our minds and eyes are tuned to dental problems
and dental solutions, but orthodontic appliances do not treat emo-
tional disturbances or reduce family tensions.
2. Digital Sucking (Finger-Sucking, Thumb-Sucking)
The term "thumb-sucking" has been used to cover a wide
variety of oral sucking habits. In this discussion we shall limit our
remarks to the strictest interpretation of the term (i. e., repeated
forceful sucking of the thumb with associated strong buccal and
lip contractions, the type of sucking most likely to be related to
mal occlusion (fig 18-49). The facial morphology present makes
an important difference. A straight profile with a firm Class I
occlusion seems to withstand the effects of thumb-sucking better
than a typical Class 11 facial skeleton. Do not disregard the face
in which the habit appears, for a mild habit in some faces is more
detrimental than a severe one in others. Just as the factors that
malocclusion; time required for treatment was 4 months. The appli-
ance did not correct the malocclusion; it treated the patient's habit.
The return of normal lip and tongue function acted to close the open
bite and align the incisors.

make up the habit vary, so do the faces in which it acts. It is the
combination of the habit plus a growing face that gives the clinical
problem. The clinical aspects of the problem may be divided into
three distinct phases of development.
a) Phase I: Normal and Subclinically Significant Sucking
This phase extends from a child's birth to about 3 years of
age depending on the child's social development. Most infants
display a certain amount of thumb- and finger-sucking during this
period, particularly at the time of weaning.
Ordinarily, the sucking is naturally resolved toward the end
of Phase I. However, should the infant show any tendencies to
the "thumb-specific" type of vigorous sucking, a definite pro-
phylactic approach may be taken because of possible occlusal
harm. The use of a proper pacifier (Le., a fIat oval shape (Fig 18-
50) toward the end of Phase I is usually less harmful, at least from
a dental point of view, than repeated vigorous thumb-sucking.
Some children chew on a finger during teething, but this activity
ceases when the teeth erupt.
b) Phase ll: Clinically Significant Sucking
The second phase extends roughly from age 3 to age 6 or 7
years. Continual purposeful digital sucking during this time de-
serves more serious attention from the dentist for two reasons: (I)
it is an indication of possible clinically significant anxiety, and
(2) it is the best time to solve dental problems related to digital
sucking. A firm and definite program of correction is indicated at"
this time.
c) Phase Ill: Intractable Sucking
Any thumb-sucking persisting after the child's fourth year
presents the qentist with a problem, for its persistence may be
proof of problems other than simply malocclusion. A thumb-suck-
ing habit seen during Phase III may require psychotherapy. Fre-
quent consultation between dentist and psychologist or physician
is indicated in order that an integrated approach may be made.
Any thumb-sucking habit persisting until Phase III may be a symp-
tom of a problem more significant than the associated malocclu-
sion.
The steps in treatment are gradual and sequential.
a) Control of undesirable oral habits is usually begun in Phase
IT. It is wise to begin with a discussion of the problem with the
child alone. No threats or shaming should be used; instead, a calm,
friendly attempt should be made to learn about the child's attitudes
toward the habit. Many children will say that they suck their
thumbs only when they are asleep, and also declare sincerely that
they want to be rid of the habit. One can use these statements to
advantage by saying, "It's mighty difficult to control what you
do while sleeping, isn't it?" "Wou'ld you like a little help to remind
that thumb to stay out of your mouth when you are not awake to
do so?" If the child can be brought along gently to give an honest
and cooperative reply, one can suggest that such a reminder is
available if the child cannot handle the problem al()Ee. The child
may be shown casts or photographs of mouths of children who
have had detrimental sucking habits. S}1ow the treated result, too,
to establish what can be done with the dentist's help. In other
words, use this first discussion to learn about the child and to
teach the methods available for correction of the habit. Be gentle,
----
Orthodontic Techniques 545
A
B
FIG 18-50.
A, the Nuk Sauger nipple. B, the Nuk Sauge~exerciser.
for this may be the child's first friendly discussion concerning the
matter. Leave the child with the idea that there is much the two
of you can do together and that later you will dicuss the situation
again.
Excellent results have been obtained by use of a card that the
child is given for scoring each morning to indicate whether the
thumb was sucked during the night. It should not be a printed
form, but rather a card with the child's name written on especially
for this purpose. Two columns are drawn and labeled simply YES
and NO or + and -. Make an appointment for the child to return
in 2 weeks or less and to bring the card. Instruct the child that the
thumb may be sucked, but a score must be kept for you so that
you can learn about the severity of the habit. Do not encourage
the disturbed, insecure child to lie to please you. Rather, affirm
that one adult is interested in the problem and can discuss the
sucking without scolding or shaming. A surprising number of
children will bring the habit under control themselves under this
program. It may be varied a bit by prescribing finger-size plastic
bandages that can be purchased in any drug store (e.g., "Band-
Aids") to be placed on the thumb each night by the child (NOT
the parent) to remind the thumb to stay out of the mouth. And
even when it is necessary to resort to an appliance (see later in
this discussion), the child is ready psychologically for it and the
appliance serves merely to remind the thumb when the child is
asleep and cannot do so.
b) As the child enters the period of trying to control the habit
alone, a talk should be had with one or both parents. Emphasize
that no one should discuss the problem with the child nor should
it rn;"a subject forfamily discussion, since the dentist and the child
will take care of it between them. Above all else, no disparaging
remarks are to be made by anyone concerning the habit.
Specifically ask the parents to watch the other children and
grandparents within the family circle. The child thus loses the
attention-getting aspects of the habit and is encouraged to work in
a mature way with the dentist. A few children will cease the habit
completely at this stage. Most will not, but will benefit greatly by
the removal of family tensions centered on his or her thumb-
sucking and will thus be prepared to work with the dentist.

546 Treatment
c) If the child is in Phase IT, the next step is the insertion of
a habit-correcting appliance. If the child is in Phase III, the next
step is consultation with the family physician, a competent clinical
psychologist, or a psychiatrist. Many school systems have such
personnel who are conversant with this proble~. After such con-
sultative advice is sought, the therapy becomes a joint effort.
Usually, appliances are not inserted until the child's overall prob-
lems are defined and the thumb-sucking is seen in proper perspective.
d) Choice of Appliance
The ideal appliance to aid in the correction of a thumb-sucking
habit would (I) offer no restraint whatever to normal muscular
activity, (2) not depend on one's remembering to use it, (3) have
no shame attached to its use, and (4) not involve parents. Perhaps
the best appliance is a lingual arch wire with short spurs soldered
at strategic locations to remind the thumb to keep out (see Fig 18-
49). This appliance is not a mechanical interference with the thumb
and so should not take the form of an ungainly lingual screen or
so-called "rake." It should be well adapted, out of the way of
normal oral functioning, and contain sufficient sharp, short spurs
to provide mild afferent signals of discomfort each time the thumb
is inserted. Note carefully the rationale for this appliance. A clear
signal of discomfort or mild pain reminds the neuromuscular sys-
tem, even when the child is asleep, that the thumb best not be
inserted. At that point, the child knows the need for help to remind
the thumb to keep out when unable to do so, for example, when
asleep. It is wrong to place any appliance as the first step in
treatment, since the adjustment is likely to be too difficult. The
permissive and more gradual approach outlined here is kinder,
more practical, easier, takes less time, requires fewer appliances,
and provides better conditioning of responses than the traditional
mechanistic approach. It allows the child to conquer the problem.
The oral shield can be u'sed to aid in the correction of thumb-
sucking (see Section C), but it requires an unusual amount of
patient cooperation and is not used continually. Some of the huge
and grotesque appliances suggested are mechanical deterrents only
and thus provide nothing but frustation for the child. Thumb-
suckers usually have that in abundance anyway. Advise the parents
of the rationale and ask their help the first night or two. It is
advisable for them to take time to qUiet the child just before bedtime
and give an extra amount of attention and affection for a few days.
Children in Phase III often will remove the appliance several times.
It should always be recemented and the incident reported to the
other clinician working on the problem. Always credit the child
with successful therapy for this helps their self-image and gains
them favorable faiTIiiy support. Children who overcome thumb-
sucking themselves in this fashion are grateful and appreciative
patients thereafter and greatly matUl;e psychosocially during the
treatment.
3. Tongue-Thrusting
a) Causes
There are several causes of tongue-thrusting; it may be seen
as a residuum of thumb-sucking or as a habit by itself. Frequently,
it is learned early in life when there was tonsillitis or pharyngitis.
Any chronic pain in the throat may prompt the tongue to be po-
sitioned forward, particularly during swallowing (see Chapter 7).
,
b) Diagnosis
Careful differentiation must be made among a simple tongue-
thrust, a complex tongue-thrust, retention of an infantile swallow-
ing pattern, and faulty tongue posture (see Chapters 7 and 10).
The prognosis usually is excellent for correction of a simple tongue-
thrust, good for a complex tongue-thrust, and very poor for retained
infantile swallowing patterns. Chapter 10 provides detailed pro-
cedures for examining orofacial muscular activities and determin-
ing a differential diagnosis.
c) Treatment
1) Simple Tongue- Thrust.- The simple tongue-thrust is de-
fined as a tongue-thrust with a teeth-together swallow. The mal-
occlusi~n usually associated with it is a well-circumscribed open
bite in the anterior region (Fig 18-51). Read Chapter 10 for de-
tailed descriptions of the procedures for examining the tongue and
swallowing.
If there is excessive labioversion of the maxillary incisors,
treatment of the tongue-thrust should not begin until the incisors
have been retracted. Many simple tongue-thrusts correct sponta-
neously during orthodontic therapy (see Fig 18-51).
Steps in treatment are as follows:
a) Acquaint the patient with the abnormal swallow by placing
the index finger on the tip of the tongue and then on the junction
of the hard and soft palate and saying to the patient, "Most people
swallow with this part of the tongue on this part of the palate.
Now put your tongue tip up here, close your teeth, close your lips
and swallow while holding the tongue in this position." The use
of tactile signals helps the patient understand where the tongue
should go (Fig 18-52). The patient should be instructed to practice
correct swallowing at least 40 times a day and to record the fact
on a card. Practice may be with small amounts of water or bite-
size dry breakfast food. Small orthodontic elastics can be held by
the tongue tip against the palate during practice swallows. If the
swallow is correct, the elastic will be retained; if incorrect, the
elastic will be swallowed. Space the practice over two or three
sessions each day.
b) When the new swallowing pattern has been leamed on the
conscious level, it is necessary to reinforce it subconsciously. At
the second appointment, the patient should be able to swallow
correctly at will. However, abnormal unconscious swallows will
be seen. Flat, sugarless fruit drops now can be used to reinforce
the unconscious swallow. Preferred drops are biconcave and of
some citric acid flavor, such as lemon to promote the flow of
saliva. The patient is instructed to place one of the fruit drops on
the tip of the tongue and to hold the fruit drop against the palate
in the correct position until. the candy has dissolved completely
(Fig '1&::-53).The candy must not ~ sucked outside the therapeutic
program. Have the patient time how long the candy is held in
place, using a watch with a second hand (Fig 18-53), recording
the time in minutes and seconds, and immediately replacing the
fruit drop in its correct place to start retiming. At first the child
will be able to hold the fruit drop in place for only a few seconds,but
gradually the periods will lengthen. While reenforcing the correct
swallowing unconsciously, the timing procedure~ provides a bit of
distraction and self-competition. This is the best procedure I have
discovered for transferring control of the reflex from the conscious
to unconscious levels. One practice session per day involving the

~.-.
FIG 18-51.
A, an open bite resulting from a simple tongue-thrust. Note how
circumscribed the open bite appears. Band C, corrected simple
tongue-thrust. B, the casts of a patient with simple tongue-thrust in
mild Class 11malocclusion at the beginning of extra-oral traction and
FIG 18-52.
The use of tactile signals to the tongue (A and B) and visual signals
(C and D) for teaching correct tongue position during swallowing.
Orthodontic Techniques 547
space supervision therapy. C, after the molar relationship had been
improved, the incisors retracted, the open bite spontaneously
corrected.
Photographs C and D show a set of casts cut in two and a soft red
plastic sponge that may be used to simulate tongue positions.
548 Treatment
A-I
- ,..., A-2
!
FIG 18-53.
A, use of sugarless fruit drops to aid in tongue correction. B, the
distractive technique for correcting the unconscious swallow.
dissolution of one fruit drop is usually satisfactory. The timing
procedure should not be omitted, since its distractive effects are
most important. These steps will correct a large percentage of
simple tongue-thrusts. However, one additional step is sometimes
necessary.
c) A well-adapted soldered lingual archwire having short (2-
mm), sharp, strategically placed spurs can now be inserted (see
Fig 18-49). Protectively, the tongue is withdrawn from Jlle ab-
normal position and placed properly during swallowing. Do not
place such an appliance as the first step in therapy. It is much too
traumatic to the patient, and many patients will simply rip it out
of the mouth. However, if steps a and b have been carried out
properly, the patient can then accept the appliance. Simple tongue-
thrusts are usually correctable by these three sequential procedures.
When one is not, the condition may have been misdiagnosed and
is not truly a simple tongue-thrust.
FIG 18-54.
An open bite resulting from complex tongue-thrust. In this instance,
the mandible dropped before the tongue-thrusts; the neat, circum-
scribed area of the open bite seen in the simple tongue-thrust (Fig
18-51,A) is not observed.
To summarize, the treatment moves through three phases:
conscious learning of the new reflex, transferral of control of the
new swallow pattern to the subconscious level, and reinforcement
of the new reflex.
2) Complex Tongue-Thrust.-A complex tongue-thrust"is
defined as a tongue-thrust with a teeth-apart swallow. The mal-
occlusion seen with a complex tongue-thrust has two distinguishing
features: (I) a poor occlusal fit is present which usually prompts
a slide into occlusion, and (2) there is a generalized anterior open
'bite (Fig 18-54). One almost can diagnose a complex tongue-
thrust from the casts alone. When the casts are taken in the hands
and fitted together, there is uncertainty about what is precisely the
patient's usual occlusal position: there is no firm secure intercus-
pation.
The prognosis for correction of a complex tongue-thrust is
not as good as for a simple tongue-thrust, since there are two
neuromuscular problems: the abnormal occlusal reflex and the
abnormal swallow. Check carefully by palpation the mandibular
elevators during the swallow (Chapter 10). In the complex tongue-
thrust they do not contract, and the mandible is stabilized by tongue
and infra-mandibular muscle contractions. It is possible to have a
complex tongue-thrust but no open bite if the tongue is positioned
evenly atop all teeth during the swallow. The patient's attention,
must be brought to the problem and the difficult prognosis ex-
plained carefully at the start of therapy. The patient should know,
at the start of treatment, t~~t much of the responsibility for suc-
cessfW. therapy lies with Himself or herself.
Contrary to popular practice, it is advisable to treat the oc-
clusion first. When the orthodontic treatment is in its retentive
stages, careful occlusal equilibration is completed. The muscle
training then begun is similar to that for a simple tongue-thrust,
with minor modifications. (I) When teaching the patient to swallow
properly, great emphasis must be placed on keeping the teeth
together, and step I of the treatment usually is prolonged. (2) It
is always necessary to use step 3, for considerable time must be
taken to reinforce the newly learned reflexes. A maxillary lingual

FIG 18-55.
Cast of patient with treated complex tongue-thrust. A and 8, intra-
oral views at the beginning of treatment. C and D, the soft tissue of
the face before treatment. E-G, occlusal views at the end of treat-
ment. This patient was treated orthodontically twice previously before
this correction was obtained. H, occlusal views at the end of retention.
arch wire with short, sharp spurs may be used as a retainer. Even
after the patient has mastered the new swallow and theabnormal
actions of the lip and mentalis muscles are seen no longer, it is
prudent to leave the lingual arch wire in place: complex tongue-
thrusts are tenaciously retained activities. Our present state of
knowledge does not allow a correction of all cases of complex
tongue-thrust. Until we are wiser concerning these matters, it is
important to do meticulous tooth positioning, and careful equili-
Orthodontic- Techniques 549
Note the persistence of the mamelons on the lower incisors, indi-
cating that even yet there are not full occlusal 'stops in the incisor
region. I and J, facial soft tissue views at the end of treatment. Note
some improvement in the.posture of the lips at rest.
-,
bration followed by persistent myotherapy. Despite the clinician's
best efforts, partial relapse may be seen in some cases (Fig 18-
55).
3) Retained Infantile Swallow.-Retained infantile swallow
is defined as the undue persistence of the infantile swallow well
past the normal time for its departure. Very few people have a
retained infantile swallow; those who do ordinarily occlude on just
550 Treatment
FIG 18-56.
Severe open bite. A, open bite resulting from retained infantile swal-
low. Usually the teeth occlude on one molar in each quadrant. This
patient was treated by a very competent orthodontist and underwent
full edgewise therapy; the photograph was taken 1 month after re-
moval of the retainers. B, open bite due to a skeletal morphologic
pattern-the "long face syndrome." Treatment was solely orthodontic.
one molar in each quadrant (Fig 18-56). They also demonstrate
strong contractions of the facial muscles during swallowing, The
tongue protrudes markedly, and it is held between all of the teeth
during the initial stages of the swallow. Persons with retained
infantile swallows do not have expresive faces, since the muscles
of the seventh cranial nerve are being used for the massive effort
of stabilizing the mandible and not fOr the delicate facile move-
ments of facial expresion. They also have serious difficulties in
mastication and may have a low gag threshold. The retained in-
fantile swallow must be differentiated from the open bite associated
with disproportionately long· anterior face height-the so-called
"long face" syndrome. In the latter, primarily a severe skeletal
dysplasia, the tongue adapts to the disharmonious morphology in
a more passive way simply to effect an anterior seal during the
swallow and the swallow is usually completed with the teeth to-
gether (Fig 18-56,B). Undue anterior facial height is a skeletal
dysplasia which may require both orthodontics and orthognathic
surgery: the retained infantile swallow is a problem in abnormal
neuromuscular development. Little is known concerning the exact
etiology of this severe problem, b~~ should these patients lose their
teeth, satisfactory denture prosthesis is difficult. The prognosis for
correction of the retained infantile swallow is poor. Fortunately,
the true retained infantile swallow is rare.
4. Abnormal Tongue Posture
The continuous effects of abnormal tongue posture may pro-
duce more open bites than the more obvious tongue thrusts. There
are two forms of the protracted tongue posture: (1) the end~genous
and (2) the acquired. During the arrival of the teeth, the tongue
normally changes its posture and comes to rest inside the encircling
dentition. Some children have an inherently abnormal tongue pos-
ture and the tip of the tongue persists in lying between the incisors.
Fortunately, the great majority of the endogenous protracted pos-
ture problems are not unesthetlc and there is stability of the incisor
relationship even though a mild open bite is seen (Fig 18-57,A).
On rare occasions, serious open bites have been present from the
first stages of eruption (Fig 18-57,B).
The acquired protracted tongue posture is a more simple mat-
ter, 'since it usually results from chronic pharyngitis, tonsillitis, or
other nasorespiratory disturbance. It may be prudent to refer the
patient to an otolaryngologist before starting the orthodontic ther-
apy for as long as the precipitating cause is present, the tongue
will posture itself forward and any positioning of the incisors may
be unstable. Sometimes the nasopharyngeal condition no longer
exists but the tongue remains ina forwarq position. The posture
in those circumstances usually can be induced to change by the
simple expedient of attaching sharp spurs to a bonded anterior
sectional lingual wire or"airectly to the'teeth.
- An adaptive tongue posture is sometimes seen when the max-
illa is narrower than the mandible. Since the tongue must aid in
the encircling seal to complete the swallow, it may adapt a posture
atop the lower teeth. When rapid palatal expansion is completed
and posterior intercuspation is correct, a normal posture usually
returns. Posterior open bites are more often postural problems than
"lateral tongue-thrusts".
To summarize, there are two clinically significant problems
in abnormal tongue posture: (1) the endogenous protracted tongue

FIG 18-57.
Open bite resulting from abnormal tongue posture. A, a Class 11,
Division 1 malocclusion with the patient 2 years out of retention. Note
the return of a very mild open bite. This patient was treated twice
more, with the occlusion returning each time to this relationship. B,
a severe open bite caused by abnormality of tongue posture. There
was no marked tongue-thrust on swallowing; rather, the tongue re-
mained in this position most of the time.
posture, for which the prognosis is pOor and around which the
occlusion must be built; and (2) the acquired protracted tongue
posture, which usually is correctable after the precipitating causes
have been corrected.
5. Lip-Sucking and Lip-Biting
These habits are seen most frequently with an excessive over-
jet and/or overbite. In Class IT, Division 1 cases, the lip habits
frequently are severe and their treatment should not be started until
the incisors have been positioned correctly. SQIIle lip habits are
then self-correcting, but the hyperactive mentalis muscle remains.
The modified oral shield shown iJl Fig 18-41 is useful.
6. Fingernail-Biting
Nail-biting ordinarily is not seen until after a child is 3 or 4
years of age. Psychologists think it a reflection of anxiety or
personality maladjustment. The habit reaches its peak incidence
during the teens. Children who bite their nails may have maloc-
clusion, but no specific malocclusion is pathognomonic of nail-
biting.
Orthodontic Techniques 551
H. OCCLUSAL EQUILIBRATION
(OCCLUSAL ADJUSTMENT)
Occlusal equilibration (occlusal adjustment) is the systematic
reshaping of the occlusal anatomy of teeth to minimize the role
of occlusal disharmonies (interferences) in reflexly determined
mandibular occlusal positions.
Occlusal equilibration is done for quite different reasons dur-
ing active facial growth and occlusal development than in adult-
hood. Balanced function is a desired factor in normal occlusal
development, since functional crossbite or functional Class Il or
III malocclusions may, in time, create important skeletal compli-
cations and temporomandibular dysfunction (see Chapter 15).
1. Equilibration in the Primary Dentition
Equilibrative procedures serve different purposes in the pri-
mary and mixed dentitions than in the permanent: the techniques
for treatment differ, too. Before attempting any equilibration, re-
read pertinent sections of Chapters 10 and 11. Cases treated by
this procedure are illustrated in Chapter 15.
The following articl~s and instruments are needed for equil-
ibration in the primary de'ntition:
a) Articulation paper.
b) Diamond points.
c) Diamond disk.
/
d) Record casts.
It is useful to try the equilibrative procedure on casts before
attempting it in the mouth. Casts oriented in the ideal occlusal
position (see Chapter 11) may be marked with articulation paper
and the plaster scraped away to simulate tooth grinding. Written
records kept of the surfaces ground and the order of the grinding
will be of value when one is actually doing the grinding in the
mouth. Remember where the interferences are most likely to appear
(Fig 18-58).
The Procedure is as follows:
a) Teach the child to tap the teeth together, with the midlines
coinciding. Since this is the occlusal position they are reflexly
avoiding, learning it requires some guidance from the dentist. Place
your thumbs beneath the mandible on either side, grasping it firmly
while touching the gingivae in the cuspid region with the index
fingers (Fig 18-59). Gently move the mandible to the desired
position while giving verbal suggestions and tactile signals with
the fingers on the gingivae. The initial occlusal interferences to
be ground now will be seen clearly (Fig 18-60).
c) Mark the midline interferences with articulating paper (Fig
1.8-61)., ~.
, ;.d) Grind out the midline ipterferooces, which are usually
found first in the cuspids and later in the molars (Fig 18-62).
e) Teach the child to protrude his or her jaw with the midlines
together and the teeth touching. This may be done by placing your
index finger against the gingivae at the mandibular midline and
asking the child to follow with his or her jaw as you gently with-
draw your finger (Fig 18-63). The reason for this check of pro-
trusive interferences is shown in Figure 18-64.
f) Mark the protrusive interferences with articulation paper.
g) Grind away the protrusive interferences.
552 Treatment

FIG 18-58.
A·1, the usual site of cuspid interference in the primary dentition. to the transverse ridge. B-2, the usual areas of interference and
A-2, the area usually removed on the lingual of the maxillary cuspid. " . grinding on the marrdibular second primary molar. B-3, the typical
A-3, the area usually ground on the mandibular primary cuspid.• relationship of the primary s!lcond molars when there is occlusal
A-4, the corrected primary cuspid relationship. B-1, the usual areas interference. B-4, the usual areas of interference on the mandibular
ground on the maxillary second primary molar. Note the relationship first primary molar.

FIG 18-59.
Teaching the patient to tap his or her teeth together and the midlines
coincident.
h) Apply topical fluoride to all surfaces that were ground.
Typical effects on the functional aspects of a Class II or Class
III malocclusion are shown in Figure 18-65.
2. Equilibration in the Mixed Dentition
Proceed in the mixed dentition as in the primary, grinding
only primary teeth. Any permanent teeth that are interfering should"
not be ground but be moved with appliances. Since their position
is likely to change many times before final adult occlusion is
established, the areas ground might be needed later as occlusal
stops.
3. Equilibration in the Permanent Dentition
The reasons for equilibration of the occlusion as presented in
most textbooks of occlusion. periodontics, or restorative dentistry
rarely embrace the orthodontic perspective, since the problems of
stabilizing a deteriorating adult dentition ravaged by disease and
loss of teeth are in the minds of the writer. Equilibration of an
orthodontic correction of a malocclusion in a healthy adolescent
or young adult is undertaken with a quite different rationale, namely,
to maximize favorable occlusal and alveolar adaptations to the
expected developmental and functional changes which occur nat-
urally with time. Occlusal equilibration is one of the most im-
portant techniques to assure stabilization of an orthodontically
corrected occlusion (see Chapter 13).
\
\
)
FIG 18-60.
A, typical interferences that appear when midlines are coincident, B, an atypical unilateral interference with the mlOllnes togemer.
Orthodo,!tic Techniques 553
a) Rationale'
Reasons for occlusal equilibration of the orthodonticaIly treated
occlusion include:
a) To stabilize the corrected occlusion.
b) To alter favorably abnormal swallowing and other reflexes
(Fig 18-66).
c) To provide a favorable functional environment for further
developmental changes.
d) To supply artificial wear to those occlusal surfaces, which,
in the malocclusion state, were not worn or were worn abnormally.
e) To minimize occlusal slides prompted by occlusal inter-
ferences, a principal cause of mandibular incisal crowding during
retention (Fig 18-67).
What follows is the barest outline, for I have presumed the
reader is familiar with the rudiments of procedures used routinely
in periodontics and restorative dentistry: if one is not, see Sug-
gested Readings at the end of this chapter.
Equilibration is no substitute for meticulous positioning of
teeth. It can, however, minimize the muscle's response to those
occlusal interferences, which cannot be removed with mechano-
therapy.
In difficult cases, or if one is inexperienced in this procedure,
begin by mounting casts with a face bow bite registration on an
adjustable articulator. Then follow these steps, scraping away the
occlusal interferences of the plaster teeth with a small knife, until
the desired result appears. Note in writing the sequence of occlusal
grinding on each tooth surface for reference later when actually
doing the equilibration on the patient.
b) Procedure
a) If a cusp is making premature contact in the retruded contact
position, the opposing groove or incline should be ground if the
cusp interferes in only one or two functional key positions (Fig
18-68).
b) The prematurely contacting cusps in the retruded contact
position should be ground if there is interference in all of the three
key positions (Fig 18-69).
c) A forward slide into occlusion should be corrected by
grinding on the interfering mesioclusal inclines of the upper teeth
or the distoclusal inclines of the lower teeth. Occlusal stops should
be maintained for .premolars and molars without loss of vertical
dimension (Fig 18-70).
d) A lateral slide into occlusion should be corrected by wid-
ening of the central fossa at the level of the occlusal stop (Fig 18-
71).
e) If the lateral slide on the contacting teeth is away from the
midline, grind as shown in Fig 18-72.
554 Treatment

FIG 18-61.
Marking the interferences with articulation paper when the midlines
are together. A, the correct position of the articulation paper, illus-
trated on casts. 8, typical positions of midline interferences. Note
that the markings persist on the lingual slopes of the buccal cusps o·

in the upper arch. In a normal occlusion, these markings would be

in the central fossae.

FIG 18-62.
Method of grinding the midline interferences. A, primary cuspid, lat-
eral view. Note the areas of grinding and the change in relationship
achieved by that grinding. 8, primary molar. The method is similar
to that for the cuspid.

FIG 18-63.
Teaching the patient to protrude his or her jaw with the midlines
coincident. The index finger is pushed against the gingivae in the
region of the lower central incisor, 'and the patient is instructed to
advance the mandible, following the finger.
 Orthodontic Techniques 555

FIG 18-65.
AP correction of functional malocclusion. A, primary cuspids. 8, pri-
mary molars.

FIG 18-64.
The reasons for checking and grinding the protrusive intenerences.
These casts were taken after the midline interferences had been
ground. By advancing the lower cast a very small amount (note that
the incisors are not yet end to end), a typical interference is seen
between the maxillary cuspid and the mesial marginal ridge of the
mandibular first primary molar. Another interference seen frequently
is between the lingual cusp of the maxillary first primary molar and
the mesial marginal ridge of the mandibular second primary molar.

I, I
I I•••••
. ' I I -0#.' I I I I f .
.......•..• I
..•....•.•.•, "
.•...•...•.•.•.•.•.•...•.. Before '. ~quJ/ibrot/~n
I
.....••••..•••..•.........•••............••................•..
......•..........•....•..••....•••....•....•............•..
•.••.•.•.•..............
.•...•..•..•.•.•.•...•.•......•••.•.•

After EqUJ/ibrofion I I
................................................
II
""
I I I
I'"'''' """
Unconscious (Saliva)

Unconscious (Bolus)

Command (Saliva)

Unconsciaus (Saliva)

Unconscious (Bolus)

Command '(Saliva)

Cammand (H~)

"""",) t,,,th oport 0 5 10 15 20 25

_ te6th together Number of Subjects (Total 28)
FIG 18-66.
The effect of occlusal equilibration on the swallow relex.
556 Treatment

A
o .25 .50 .75 1.0 L25 1.5 1.75 2.0 2.25 2.5 2.75
1.42
P-A slid@ at @nd of tr@atm@nt

Lat@ral slid@ at @nd of tr@atm@nt

.45
V@rtical slid@ at @nd of tr@atm@nt

P-A slid@ 1 y@ar aft@r r@t@ntion

Incisal crowding 1 y@ar aft@r r@t@ntion

usual Eiiil
Comparison of r@lapsf symptoms using and n@w _ r@t@ntion plans.

B .'
3.5

30
2.5

20
FIG 18-67.
A and e, the effects of occlusal equilibration on "slides" into occlusion 10
and mandibular incisal crowding.
5
---
6mos Iyr

Mean "Slide": Old Retention Program

--- Mean "Slide":

Mean Incisal
New Retention Program
Crowding: Old Retention Program
Mean Incisa I Crowding: New Retention Program

FIG 18-68.
A, working. e, usual occlusal position. C, balancing.
 Orthodontic Techniques 557

FIG 18-69.
A, working. B, usual occlusal position. C, balancing.

J) As a final step, remove any minor interferences that may

remain between the retruded contact position and the ideal occlusal
position.

REFERENCES
FIG 18-70.
A, usual occlusal position. B, retruded contact position.
fJ Adjust the working side on the guiding inclines, including
the incisal edges and the buccal cusps of the upper teeth and the
lingual cusps of the lower teeth (Fig 18-73).
g) Adjust for protrusive contact on the incisal edges of the
upper teeth, except in unusual cases.
, h) Do whole grinding on only one of two interfering cusps
or inclines if they both serve as occlusal stops.
i) If a cusp or incline that interferes in balance is out of
occlusion in the usual position, grind on that cusp or incline.
1. Ahlgren J: Mechanisms of mastication. Acta Odontal Scand
1966; 24 (suppl): 44.
2. Ahlgren J: The neurophysiologic principles of the Andresen
method of functional jaw orthopedics. A critical analysis
and new hypothesis. Swed Dent J 1970; 63:1-9.
3. Andresen V: Beitrag zur Retention, Z Zahnaevztl Orthop
1910; 3:121.
4. Andresen V: Ueber das sogenannte "norwegische System
der Funktions-Kiefer-Orthopadie," Dtsch Zahnaerztl Woch-
enschr 1936; 39:235,283.
5. Auf der Mauv HJ: Electromyographie recordings of the lat-
eral pterygoid muscle in activator treatment of Class 11, di-
vision 1 malocclusion cases. Eur J Orthop 1980; 2;161-
171.
6. Balters W: Krafteinwirkung oder formgestaltende Reiszset-
zung? Zahnarztl Welt 1952; 7:437-441.
7. Balters W: Reflexmechanismus und Funktiona-blauf.
Fortschr Kieferorthop 1955; 16:325-327.
8. Bimler HP: Die elastischen Gebissformer. Zahnarztl Welt
1950; 11:315-319.

FIG 18-71.
A, usual occlusal position. B, retruded contact position. C, same after grinding.
I
558 Treatment
FIG 18-72.
A, usual occlusal position. S, retruded contact position. C, same after grinding .
FIG 18-73.
Working side interference.
9. Demisch A: Langzeitbeobachtungen uber die Stabilitat der
Okklusion nafh Distalbisstherapie mit dem Berner Aktiva-
tor. Schweiz Mschr Zahnheilk 1980; 90:867-880.
10. Demisch A: Herren' s dentofacial orthopedics. In Graber
TM, Neuman BF (eds), Removable Orthodontic Appli-
ances, 2nd ed. WB Saunders Co, Philadelphia, 1984.
11. Frankel R: The theoretical concept underlying treatment
with function correctors. Trans Eur Orthod Soc 1966; 233-
250.
12. Frankel R: Biomechanical aspects of the form/function rela-
tionship in craniofacial morphogenesis: A clinician's ap-
proach in McNamara JA Jr, Ribbens KA, Howe RP (eds),
Clinical Alteration of the Growing Face, monograph 14.
Craniofacial Growth Series. Ann Arbor, Mich, Center for
Human Growth and Development, University of Michigan,
1983.
13. Frankel R, Frankel C: A functional approach to treatment
of skeletal open bite. Am J Orthod 1983; 84:54.
14. Graber LW: Chin cup therapy for mandibular prognathism.
Am J Orthod 1977; 72(1):23-41.
15. Graf EJ: Funktionelle Krafte bei bimaxillaren Regulations-
apparaturen, doctoral thesis. Univ of Bern, 1962.
16. Harvold E: The Activator in Interceptive Orthodontics. St
Louis, CV Mosby Co, 1974.
17. Herbst E: Dreissigjahrige Erfahrungen mit dem Retentions-
Scharnier. Zahnartliche Rundschau 1934; 43:1515-1524,
1563-1568, 1611-1616.
18. Janson I: Skeletal and dentoalveolar changes in patients
.'
treated with a bionator during prepubertal and pubertal
growth in McNamara JA Jr, Ribbens KA, Howe RP (eds)
Clinical Alterations of the Growing Face, monograph 14.
Craniofacial Growth Series, Ann Arbor, Mich, Center for
Human Growth and Development, University of Michigan,
1983.
19 .. Kingsley NW: Oral Deformities. New York, D Appleton &
Co, 1880.
20. McNamara JA: Neuromuscular and skeletal adaptations to
altered function in the orofacial region. Am J Orthod 1973;
64:579.
21. McNamara JA: Functional determinants of craniofacial size
and shape. Eur J Orthod 1980; 2:131.
22. McNamara J A, Carlson D:Quantitatjve analysis of TMJ
adaptations to protrusive function. Am J Orthod 1979;
76:593-611.
23. McNamara JA, Hivton RJ, Hoffman DL: Histologic analy-
'; sis of temporomandibular joint adaptation to protrusive
function in young adult rhesus monkeys. Am J Orthord
1982; 82:288.
24. Pancherz H: Long-term effects of activator (Andresen appli-
ance) treatment. Odontol Rev (suppl) 1976;27:35.
25. Robin R: Observation sur un nouvel appareil de redresse-
ment, 1902; Rev Stomatol 9:423.
26. Rogers AP: Exercises for the development of the muscles
of the face, with a view to increase their functional activity.
Dent Cosmos 1918; 60:857-876.
27. Sander FG: Zur Frage der Biomechanik des Aktivators-Ent-

wicklung und Erprobung neuer Untersuchungsmethoden,
Wiesbaden, Estdeutscher, 1980.
28. Sander FG: The effects of functional appliances and Class
ITelastics on masticatory patterns, in McNamara JA Jr,
Ribbens KA, Howe RP (eds), Clinical Aherations of the
Growing Face, monograph 14. Craniofacial Growth Series,
Ann Arbor, Mich, Human Growth and Development, Uni-
versity of Michigan, 1983.
29. Solow B, Tallgren A: Head posture and craniofacial mor-
phology. Am] Phys Anthropol1976; 44:417-436.
30. Solow B, Tallgren A: Dentoalveolar morphology in relation
to craniocervical posture, Angle Orthod 1977; 47:157-164.
31. Woodside DG: The Harvold-Woodside activator, in Graber
TM, Neuman B (oos), Removable Orthodontics, 2nd ed.
Philadelphia, WB Saunders Co, 1984.
SUGGESTED READINGS
C-4: Edqewise Mechanisms
1. Lindquist IT: The Edgewise Appliance, in Graber TM,
Swain BF (eds), Orthodontics: Current Principles and
Techniques, St Louis, C V Mosby, 1985, pp 565-639.
2. Ricketts RM, Bench RW, Gugino CF, et al: Bioprogressive
Therapy, Denver, Rocky Mountain Orthodontics, 1979.
3. Roth R: Treatment mechanics for the straightwire appli-
ance, in Graber TM Swain BF (eds), Orthodontics: Current
Principles and Techniques, St Louis, CV Mosby Co, 1985,
pp 665-716.
4. Thurow RC: Edgewise Orthodontics, 4th ed. St Louis, CV
Mosby Co, 1982.
5. Tweed CH: Clinical Orthodontics, 2 vols. St Louis, CV
Mosby Co, 1966.
C-5: Light-Wire Appliances
1. Begg PR, Kesling PC: Begg Orthodontic Theory and Tech-
nique, 3rd ed. Philadelphia, WB Saunders Co, 1977.
2. Thompson WJ: Modem Begg: A combination of Begg and
straightwire appliances and techniques in Graber TM,
Swain BF (eds), Orthondontics: Current Principles and
Techniques, St. Louis, CV Mosby, 1985, pp 717-789.
C-6: Other Fixed Appliances
1. Fastlicht, J: The Universal Orthodontic Technique. Phila-
delphia, WB Saunders Co, 1972.
D-I-a: Extra-oral Traction Devices
Head Gears
1. Bowden DEl: Theoretical considerations of headgear ther-
apy: A literature review. Part 1. Mechanical principles, Br
] Orthod 1978; 5:145-152; Part 2. Clinical response and
usage. Br] Orthod 1978; 5:173-181.
2. Hershey HG, Haughton CW; Burstone CJ: Unilateral face-
bows: A theoretical and laboratory analysis, Am ] Orthod
1981; 79:229-249.
3. Jacobson A: A key to the understanding of extraoral forces.
Am] Orthod 1979; 75:361-386.
4. Worms FW, Isaacson RJ, Speidel TM: A concept and clas-
sification of centers of rotation and extraoral force systems.
Angle Orthod 1973; 43:384-401.
Face Masks
1. Petit H: Adaptation following accelerated facial-mask ther-
apy in McNamara JA Jr, Ribbens KA, Howe RP (eds),
Orthodontic Techniques 559
Clinical Alteration of the Growing Face, monograph 14.
Craniofacial Growth Series. Ann Arbor, Mich, Center for
Human Growth and Development, University of Michigan,
1983, pp 253-289.
Chin Cups
1. Graber LW: The alterability of mandibular growth, in
McNamara JA Jr (eds), Determinants of Mandibular Form
and Growth, monograph 4. Craniofacial Growth Series.
Ann Arbor, Mich, Center for Human Growth and Develop-
ment, University of Michigan, 1975.
2. Thilander B: Chin-cup treatment for Angle Class III maloc-
clusions. Trans Eur Orthod Soc 1965; 41:311-327.
D-I-b: Lip Bumpers
1. Bjerregaard J, Bundgaard AM, Melsen B: The effect of the
mandibular lip bumper and maxillary bite plate on tooth
movement, occlusion, and space conditions in the lower
dental arch. Eur] Orthod 1983; 84:147-155.
D-I-c: Active Plates
1. The active plate in Graber TM, Neuman B (eds), Remov-
able Orthodontic Appliances, 2nd ed., Philadelphia, WB
Saunders Co, 1984, pp 12-53.
E-2: Vestibular Appliances
1. The use of muscle forces by simple orthodontic appliances,
in Graber TM, Neuman B (eds), Removable Orthodontic
Appliances, 2nd ed., Philadelphia, WB Saunders Co, 1984.
E-3: Functional Jaw Orthopedic Appliances
Books
1. Graber TM, Neumann B: Removable Orthodontic Appli-
ances, 2nd ed., Philadelphia, WB Saunders, 1984.
2. Graber TM, Rakoski T, Petrovic AG: Dentofacial Or-
thopedics with Functional Appliances, St Louis, CV Mosby
Co, 1985.
3. Harvold EP: The Activator in Interceptive Orthodontics, St
Louis, CV Mosby Co, 1974.
Articles or Chapters
Activators
1. Graber TM: The Activator: Use and modifications, in Gra-
ber TM, Neumann B (eds), Removable Orthodontic Appli-
ances, 2nd ed., Philadelphia, WB Saunders Co, 1984; pp
198-243.
2. Reey RW, Eastwood A: Passive activator: Case selection,
treatment response and corrective mechanics. Am] Orthod
1978; 73:378-409.
3. Woodside 00: The Harvold-Woodside activator, in Graber
. TM, Neumann B (e;ds),Removable Orthodontic Appliances,
, ~.2nd ed., Philadelphia, WB Saunders Co, 1984; pp 244-
310.
Bionators
1. The Bionator, in Graber TM, Neumann B (eds), Removable
Orthodontic Appliances, 2nd ed., Philadelphia, WE Saun-
ders Co, 1984; pp 357-375.
Frankel Function Regulator
1. The Frankel Function Regulator, in Graber TM, Neumann
B (eds), Removable Orthodontic Appliances, 2nd ed., Phil-
adelphia, WB Saunders Co, 1984; pp 520-573.
560 Treatment

2. McNamara JA Jr, Huge S: The Frankel appliance. Am J Herbst appliance treatment: A cephalometric investigation.
Orthod 1981; 80:478-495. Am J Orthod 198282:104-113.

G. Correction of Deleterious Oral Habits

Bimler Appliance
I. Bimler HP: The Bimler Appliance in Graber TM, Neumann I. Hanson ML: Oral myofunctional therapy. Am J Orthod
1978; 73:59-67.
B (eds), Removable Orthodontic Appliances, 2pd ed., Phil-
adelphia, WB Saunders Co, 1984, pp 410-519.
H. Occlusal Equilibration (Occlusal Adjustment)
I. Ramjford SP, Ash MM Jr: Occlusal adjustment of natural
Herbst Appliance teeth, chapter 13, in Occlusion, 3rd ed. Philadelphia, WB
1. Pancherz H: The mechanism of Class IT correction in Saunders Co, 1983.

.
"

-.
-.•....
Index
A well-treated cases, records of,
Ackerman-Proffit classification
system, 191
Acrylic
inclined plane extension in
lingual crossbite, 418
regainer, split-saddle, 527
space maintainer, multiple,
530
Activators, 539
casts and, 539
cephalography of, 538-539
for Class 11, type D-2 maloc-
clusion, 453
classic, 538
derivatives of, 539
fit inside mouth, 534
open-front, 540
before trimming, 538
af:er wear, 538
Adaptation: mechanisms
Adolescence
malrelationships during, lat-
eral, 447-450
periodontitis during, 447
treatment during (see Adoles-
cent treatment)
Adolescent treatment, 432-471
advantages of, 434
difficulties with, 434
goals
arch form, 435
axial inclinations, 435
compromises, 435
definition of, 434-435
dental,435
esthetics, 435
functional, 435
incisal relations, 435
midlines, 435
occlusal, 435
skeletal, 434
sofHissue profile, 435
spacing, 435
problems
clinical, 440-468
singular to the young adult,
442-447
result assessment, 435-440
understanding, 434
reinforced, 309 elastic, 539
436-438 simple, 309 fixed,518-524
Adult, 472-510 single, 309 principles of biomechanics
cephalometry, 473 stationary, 309 in, 310-313
treatment, 472-510 Angle system: of malocclusion functional (see Appliance, re-
with good oral health (see classification, 186-188 movable, loose below)
Treatment, of adults with Angulations: developmental in gross disharmony between
changes in, 129 osseous bases, 397
good oral health)
Ankylosis Herbst, 541, 543
treatment plan for, 473-475
molar
Affective states: and postural hybrids, 541-542
first permanent mandibular,
position, 86 jaw
447
Age (see also Appliances, re-
permanent, 391 movable, loose below)
equivalence, 16
primary, 390 definition, 535
overbite and, 126
Airway: upper, reflexes, 76 permanent teeth, 391 forces in, 308-313
during adolescence, 446-
Alar musculature: and mouth- indications, 535
447
breathing, 207 types, 535-539
Aligners: spring, anterior, 526 of primary teeth, 107-108, uses, 535
388-391
Alimentray tract: reflexes, 76 light-wire, 522
Anomalies
Alveolar in maloccusion
craniofacial, 426
bone (see Bone, alveolar) Class 11, 400
of, 142 craniofacial growth and, 53
crest, 256 with periodontal disease
of crown shape, 355-356 and tooth loss in adult,
development guidance in
Class 11 malocclusion, face, origin of, 22-26 478-479
399-400 of incisor, maxillary central, myodynamic, 539
357
process, 63 palatal expansion, 520
of primary teeth, 107
in appliances, removable passive, 529-531
of shape
loose, 533-534 perversions, 541-542
during adolescence, 442
in Class 11 malocclusion, Quad Helix, 397
400 during adolescence, varia-
removable, attached, 524-531
tions, 442
result assessment, 440 removable, loose, 531-542
crown, 355-356
Anchorage action modes, 532
miscellaneous, 356
cervical, 309 alveolar processes in, 533-
of teeth, 228
classification, 309 534
Appliance
compound, 309 background, 531-535
acrylic, removable, for up-
concepts of, 309-310 craniofacial skeleton in,
righting molar in adult,
control of, 309 534
480-481
cranial, 309 definition, 531
'•. Activator (see Activator)
extra-oral, 309 dentition in, 533-534
• active, 524-428
facial, 309 Barrer, 526 history, 531-532
intermaxillary, 309 Bionator, 540 muscles in, 532-533
intra-maxillary, 309 bonded, in situ, 517 purposes, 531
intra-oral, 309 bracketed, in molar upright- role of timing in interven-
in malocclusion with perio- ing, 481 tion, 535
dontal disease and tooth for crossbite, dental, 396 Schwartz, 525
loss in adult, 479 Crozat, 526, 529 space-regaining, 525-526
muscular, 309 in dentoalveolar contraction, for sucking correction, 546
occipital, 309 397 of thumb, 544
primary, 309 design in molar uprighting traction, extra-oral, 524-525
reciprocal, 309 treatment plan, 482 twin-wire, 522
561
 "

562 Index

Appliance (cont.) contraction of, 397 space maintainer, 520 developmental, 9

universal, 524 in mixed dentition analysis, Bandup: arch, twin, 522 molecular, 9
vacuum-formed, 526 238 Barrer appliance, 526 Biomechanics: principles in
vestibular, 535 in orthognathic surgery with Basicranium, 54-56 fixed orthodontic appli-
construction, 535 orthodGntic treatment, compensatory mechanisms, ances, 310-313
description, 535 497 56-57 Bionator appliance, 540
Arborization perimeter maintenance, 361- functions, 54-55 Birth injuries: and malocclusion,
applied to actual cases, exam- 363 growth, 55-56 151
ples, 336-337 regaining space in, 363- issues concerning, theoretical Birth order: and growth, 12
of Class II malocclusion dur- 364 and clinical, 56-57 Bite
ing adolescence, 454 prenatal shape, 104 timing of growth, 56 crossbite (see Crossbite)
to segregate various treatment relationship of the three Basion, 258 deep, 422-426
protocols, 333 arches, 121, 228 Behavioral development, 10 during adolescence, 464,
Arch space available in mandible Bicanine 467-468
asymmetries, dividers to esti- by dental age, 127 mandibular, width changes, cephalometry of, 425
mate, 396 Archwire 122 complex, 467-468
bandup, twin, 522 helices in, 313 maxillary, width changes in, definition, 422-423
bracket, twin, 522 "light," 313 123 diagnosis, 423-426
contraction, maxillary, pro- lingual,518-519 Bicuspid in periodontic patient, 493
ducing functional cross- attachments for, 519 brackets for, 517-518 simple, during adolescence,
bite, 393 description, 518-519 eruption (see Eruption, 464
dental fixed, 519 bicuspid) simple, during adolescence,
circumference, 123-124 loop, 519 first diagnosis, 464
depth, 123 modifications, 519 loss of, treatment, 351 simple, during adolescence,
dimensional changes in, Porter, 519 transposition, 387 treatment, 464-466
121-126 Quad-Helix, 519, 520 second simple, with labioversion
dimensional changes in removable, 519 of maxillary incisors,
congenitally missing, mov-
young adult, 141 loops in, 313 489-492
ing mandibular first mo-
length, 123 Arteries: carotid, in fetus, 29 lars in, 352 simple, vertical problems in
perimeter, 123-124 Articulare, 258 anterior region and, 489
delayed development, 349
perimeter changes, 124 Articulation: speech, mini-test skeletal, 467-468
eruption of, premature, 383
of,213 skeletal, with Class II mal-
perimeter changes due to impaction, 388
caries and tooth loss, Articulatory valving: place and occlusion in adult, 476
loss of, treatment, 353
125 manner of, 213 treatment, 426
mandibular, abnormally
perimeter, uses of, 126- Attachments open (see Open bite)
shaped, 356
128 for archwire, lingual, 519 overbite (see Overbite)
mandibular, blocked-out,
primary, development, 108 bonding, 517-518 160 planes, 529
Attitude flat, maxillary, for adult,
primary, dimensions of mandibular, congenitally
of adult toward orthodontic 479
arch, 108 missing, 349
quadrants, prenatal, 103 treatment, 473 wax on maxillary cast, 245
mandibular, congenitally
width, 122-123 evaluation in cursory ortho- -wing radiography, 222
missing, treatment, 350-
dimensions, 240-241 dontic examination, 169- 351 Bolton Analysis, 232-233
170 Bolton Tooth Ratio Analysis,
asymmetries and tooth po- mandibular, congenitally
Auricular development: im- 229
sition, 241 missing, treatment, prog-
changes in, 240-241 proper, 24 Bonding attachments, 517-518
nosis, 351
Axiversion, 189 Bone
changes, expected, 240 mandibular, shape varia- alveolar
changes in, growth and tions, 356
deposition of new layers,
treatment causing, 125 B mandibular, size variations, 315
form 356
Bands after hyalinization, 319
during adolescence, 435 unerupted, probability tables character and orthodontic
in mal occlusion Class II, cementation of, 517 for size prediction, 237
tooth movement, 319-
398-399 molar \yi~th changes in, 123 -, ~. 320
leveling mechanics in incisal attachments for, 517 Bimaxillary
, deposition, 44
overbite, 492 correctly contoured, 516 dental protrusion, 466-467
developing bony structures at
malrelationships formation, 515-517 dentoalveolar protrusion, 467 4 years, 138
gross disharmony between maxillary, fitting of, 516 prognathism during adoles- formation
osseous bases, 397 preformed cence, 466, 467 endochrondral, 39
lateral, 391-397 with attached brackets, 517 protrusions, 418-420, 466- intramembranous, 39-42
lateral, differential diagno- examples of, 516 467
growth
sis, 391-396 fitting, 517 dental,420 displacement, 47, 48
mandibular, in mixed denti- separation of teeth before, Biologic activities: classes of al- drift, 47-48
tion analysis, 236-238 515 terations in, 7 endochondral, 40
maxillary method,515-516 Biology fields, 44-46

in mandible, 60
mechanisms of, 44-48
movement, 47-48
rudiments of, 39-48
study, comparative anat-
omy, 43
study, implants for, 43
study methods, 42-44
study with natural markers,
43-44
study, radioisotopes in, 42-
43
study, vital staining in, 42
in malocclusion, 149-150
marker, tetracycline as (in
monkey),42
movement, 9
remodeling, 45-47
resorption, 44
ridge, interradicular, 316
sphenoid, cephalometry of,
251, 254
wall
depository, 314-315
resorptive, 314
zygomatic, cephalometry
251, 254
Brackets
arch, twin, 522
attached, preformed bands
with, 517
for bicuspids, 517-518
for cuspids, 517-518
edgewise, basic, 521
for incisors, 517-518
light-wire, 522
universal, 523
Brain: anterior, lack of develop-
ment, 23
Branchial arches: period of or-
ganization of, 19-20
Branchial fistula, 24
Breath: deep, in examination
respiration, 207
Breathers
mouth (see Mouth-,
breathing)
Breathing
method, evaluation, 171
mirror, steel, to check, 208
nasal, differential diagnosis,
207
mouth (see Mouth-,
breathing)
Bruxism, 81
forces of, 308
Buccal tubes, 517
Buccoversion, 189
Bumpers: lip, 525, 526
Bypassing, 313
c identical means with differ-
Calcification
interrelationships with erup-
tion, 112-114
of permanent teeth, 111-112
of primary teeth, 106
standard~ for teeth, 226
of stylomandibular ligament,
206
Cap: sliding, 522
Caries
arch perimeter maintenance
and primary teeth, 361
causing arch perimeter
changes, 125
malocclusion and, 159
Carotid artery: in fetus, 29
Cartilage: condylar, role of, 61
Casts
Activators and, 539
of Class n, Division I maloc-
clusion, 193
diagnostic, 222
good set of, 223
of malocclusion, with perio-
dontal disease and tooth
loss, 475
of, diagnostic setup, 475
record, 475
maxillary, bite wax placed
on, 245
in molar uprighting, 48\
record, 182, 513
stody, good set of, 514
in tongue-thrusting after treat-
ment, 549
Cementation: of bands, 517
Central tendency: measures of,
13
Cephalography
of Activators, 538-539
of cranial base, 63
lateral, 222-226
of malocclusion
of
Class 1II, 194
with periodontal disease
- and tooth loss, 475
oblique, 222
Cephalometer: patient in, 251
Cephalometry, 247-305
of adults, 473
analysis
counterpart analysis ratios,
263
counterpart analysis ratios,
dental horizontal and
vertical, 263
counterpart analysis ratios,
skeletal horizontal and
vertical, 263
counterpart, simplified,
definition, 263
flow chart for, basic, 265
ent variances, 264
Index 563
misuses of, 282-283 two mandibular registra-
requisites of, 264 tions of same growth
requisites of individual change, 262
measures in, 263-264 history, 250
anatomic dimensions in, re- landmarks
gional, 296 bilateral, 258
anatomic structures in, 251- classification, 256
254 description of, 256-258
AP distances, 288-292 illustration, 257
AP distances, graphs of, 289 reliability of, 256
assumptions, 281-282 validity of, 256
adequacy of one or two limitations of, 281-283
planar projections, 282 lines, 258-259
occlusal position, 281 of malocclusion
orientation of the transme- Class n, 270-273
atal axis, 281-282 Class n, combining hori-
symmetry, 281 zontal and vertical, 271-
configurations in, 262 272
constants, 260 Class n, distribution of,
craniofacial constants in, 272
296-301 Class n, flow chart for dis-
curves in, 255-256 crimination of, 270
in space, 256 Class n, horizontal type,
in deep bite, 425 270-271
deformation, 260, 262-263 Class n, horizontal types,
in triangles, general assess- diagnosis, arborization
ment of, 280-281 for, 273
for description, 249 Class n, horizontal types,
comparison with ideals, diagnosis, decision tree
249 for, 273
comparison with self, 249 Class n, horizontal types,
comparison with standards, identification of, 272-
249 273
for diagnosis, 249 Class n, tracings, 276
displacement, 260, 263 Class n, type A, 270
equipment for, 250-251 Class n, type B, 270
facial height in (see Face, Class n, type C, 270
height) Class n, type D, 270-271
fallacy Class n, type E, 271
of false precision, 282 Class n, type F, 270
of the "ideal," 282 Class n, types I through 5,
of ignoring the patient, 282 271
of superpositioning, 282 Class n, vertical type, 271
of using chronologic age, Class n, vertical types,
282 identification of, 273
flow chart for, 265 Class n, Z-score chart, 274
form
Class 1II, 273-278, 412
change, 260 Class 1II, analysis, exam-
difference in form, 262 ples of, 278
persistence of form through Class 1II, analysis of incisal
time, 262 adaptation, 277-278
Class 1II, analysis, profile,
tensors to show fonI,l. dif-
277
-, ference, 281 -.-
variations in, 265-268 Class Ill, analysis, vertical,
277
future of, 283
geometric methods, 255-263 Class Ill, archetypes, 278
basic elements, 255-258 Class Ill, flow chart for,
277
of growth, 260-262
analysis of morphology, Class Ill, method, 277-278
288 269-270 Class Ill, variations in
constants, 261 form, 277
measures, 261 Class Ill, visualizing treat-
measures along constant ment objectives, 278-
rays, 299 279
564 lrulex

Cephalometry (cont.) description of, 256-258 cup, 459, 525 concepts, current, 50-51
of mandible, 251, 255 distance between points, for extra-oral traction, 526 concepts, functional, 49
mandibular position in, ef- 260 Chondrocranium: development concepts, genetic, 48-49
fects on profile, 267 external, 256 of,31 controlled alteration of,
of maxilla, 251, 255 implants,~256 Class (see under Malocclusion) 322-324
measurement intersection of constructed Classification: definition, 168 controlling factors in, 51-
how do we measure? 260 lines, 256 . Cleft 53
what do we do with meas- intersection of edges of lip, complete, 24 controlling factors in, dis-
ures? 263 regression, 256 lip and nose, 23 ruptive factors, 53
what do we measure? 260 at intersection of images, mandibular, 26 controlling factors in,
of morphology, 262 256 palate, unilateral, 427 "function," 52
analysis, basic, 265 pairs of points defining Condylar cartilage: role of, 61 controlling factors in, natu-
analysis, basic, illustration lengths of line segments, Condylion, 258 ral,51-53
of,266 260 Congenitally missing .teeth (see craniofacial anomalies in,
analysis, basis of, 265 sphenoethmoidal, 258 Teeth, congenitally 53
I
analysis for diagnosis, 265 triples of points, 260 missing) ethnic differences in, 67 J.
analysis, growth, 266-267, true anatomic, 256 Contraction, 189 general body growth and,
269-270 for prediction, 249 dentoalveolar, 396-397 52
analysis, method, 265 problems in, 281-283 appliances for, 397 genetic "theory" of, 50
analysis for prediction of projection case analysis, 396 genetics ill, 51
morphology, 268-269 lateral, 251 mandibular, 397 hypotheses, 48-51
analysis, profile, 267-268 lateral, typical, 252 mandibular, unilateral or hypotheses, Moss, 50
analysis, profile, illustra- oblique, 251, 253 bilateral, during adoles- hypotheses, Petrovic's, 50
tion, 268 posteroanterior, 251, 252, cence, 450 hypotheses, Scott's, 50
analysis, purposes of, 265 258-259 maxillary, bilateral, during hypotheses, servosystem,
50
analysis for screening, 265 posteroanterior, bilateral adolescence, 450
structures, 258 maxillary, unilateral, dur- hypotheses, Sicher's, 50
analysis of symmetry, 268
ing adolescence, 450 hypotheses, sutural domi-
analysis, vertical, 265-267 posteroanterior, midline
nance, 50
analysis, vertical, func- structures, 258 of maxillary arch, 397
malfunctions in, 53
tional,267 purposes of, 249-250 Couple, 311
mandible and, 324
analysis, vertical, illustra- radiographic, 43 Cranial
neurotrophism in, 52-53
tion,267 regression surfaces, edges of, anchorage, 309
overall pattern of, 67
evaluation of, 265-268 256 base
principles, diagrammatic
of malocclusion (see mal- size, 260-262 anterior, 292, 296, 298
representation, 46
occlusion above) of skull of child, 253 cephalograms of, serial, 63 racial differences in, 67
numeric methods, 259-260 of sphenoid bone, 251, 254 in Class I1 malocclusion, temporomandibular joint
why use numbers? 259- superpositioning in, 262 398 and, 324
260 taking cephalogram, conven- growth sites in, 55 skeleton
obtaining cephalogram, 250- tions in, 251 floor, 296 analysis of, 247-305
251 tracing, 254 periosteal surfaces in, 55 development, interaction
of open bite, 424 techniques, 255 vault, 54 with orofacial muscles,
simple, during adolescence, transversals of surfaces, 256 compensatory mechanisms 94
465 for treatment planning, 249 and growth, 54 early treatment, goals for,
for orthodontic treatment for treatment result evalua- functions, 54 347
evaluation, 279 tion, 250 .growth,54 growth of, 37-72
general effects, 279 understanding the cephalo- issues concerning, theoreti- growth of, regional, 53-67
mandible, 279 gram, 263-281 cal and clinical, 54 growth of, role in ortho-
dontics, 38-39
mandible, changes, 280 using the cephalogram, 263- timing of growth, 54
maxilla, 279 281 Craniofacial in re:novable appliance,
loose, 534
maxilla, changes, 280 of zygomatic bone, 251, 254 anomalies, 426
Cranium
regional effects, 279 Cervical anchorage, 309 craniofacial growth and, 53
(See also Cranial)
after orthognathic surgery, Cervical cyst, 24 'ch,anges in fetus, third to~'
at birth, 35
503 tervical sinus: failure of com- •. ninth months, 34
'Crista galli, 258
in orthognathic surgery with plete obliteration, 24 constants in cephalometry, Crossbite, 423
orthodontic treatment, Cervical traction, 525 296-301
anterior, simple, 418, 419
497 Chain: elastomeric, 518 dysplasia, diagrammatic rep- acrylic inclined plane ex-
pattern, 260 Children resentation, 496 tension in, 418
discussion of, 262 skull, cephalometry of, 253 growth during adolescence, 463-
plane, 258-259 3-year-old, malocclusion traits "adult," 67-68 464
point(s) in, 110 changing concepts acting as during adolescence, diag-
change in distance between Chin paradigms, 49 nosis, 463-464
points, 260 asymmetry after orthodontic concepts in, changing, 48- during adolescence, treat-
classification, 256 treatment, 500-501 51 ment, 464
 Index 565

diagnosis, 418 interference in primary denti- development, genetic fields transitional (see mixed above)
treatment, 418 tion, 552 influencing, 121 Dentoalveolar
buccal, 189 loss of, treatment, 351 Dentin: forming tissues, ar- contraction (see Contraction,
definition, 189 malposition in malocclusion rangement of, 102 dentoalveolar)
dental CIlISs 11, 398 Dentition diagnosis of lateral malrela-
appliances for, 396 maxillary analysis, 221-246 tionships during adoles-
case analysis, 396 ectopic eruption, 386 development of, 99-146 cence, 448
treatment, 396 ectopic with impaction, 387 in young adult, 140-141 protrusion, bimaxillary, 467
dental type, 150,419 eruption direction, 350 diagnostic data for, 222-226 tissue reactions, 315-317
dentoalveolar contraction (see impaction, 387-388 early treatment of, goals for, pressure side, 316
Contraction, impaction during adoles- 347 tension and, 317
dentoalveolar) cence (see below ) effects
Development, 1-164
functional, 150, 392 impaction, treatment, 389 of mandibular growth on, behavioral, 10
arch contraction producing, labioversion, with spacing 66 of chondrocranium, 31
maxillary, 393 between incisors, 161 of nasomaxillary complex concepts of, basic, 6-17
. of incisor, maxillary, 418 moving mesially to serve as growth on, 59-60 of craniofacial skeleton, inter-
lateral, locked, diagnostic lateral incisor, 441 of temporomandibular joint action with orofacial
setup prior to, 487 transposition, 387 growth on, 66 muscles, 94
lingual, 189 maxillary, impaction during exchange, two patterns of, defects of unknown origin in
molar loss causing, mandibu- adolescence, 445-446 109
malbcculsion, 151
lar first primary, 161 background, 445 interaction with orofacial
definition, 9
muscular, 150, 392 diagnosis, 445 muscles, 94
delay of second bicuspids,
of primary dentition, equili- orthodontic movement, mixed
349
bration and Porter lingual 445-446
analysis of, 179, 235-240 of dentition, 99-146
appliance for, 393 surgical exposure, 445-446 analysis, form for, 236 in young adult, 140-141
single-tooth, in periodontics transplantation, autogenous, analysis, illustrative case to
in adult, 488 446 ectopic, in permanent teeth,
show application of, 239 118
skeletal (see Dysplasia, treatment, 445
analysis, modifications, face, maximal, period of, 22
skeletal) moving to serve as lateral in- . 238-240
treatment with space supervi- cisor, 349 of facial muscles, 32-34
analysis, problems with,
sion, 391 occlusion, result assessment, of lip, upper, 21
240
Crowding 439 mandible, 32
equilibration in, 553
during adolescence, 442-447 permanent, maxillary, of masticatory muscles, 34
method for localization of
complex, during adolescence, blocked-out, 160 of maxillary complex, 31
space needs in, 238
443-445 primary, loss of, arch perime- nasal fin, 21
occlusal change patterns in, nostril floor, 21
definition, 443 ter maintenance in, 362 130
diagnosis, 443 removal in equilibration, 552 of occlusion, 99-146
occlusal changes in, 128-
treatment, 443-445 unerupted, probability tables J31
primary, 108-111
simple, during adolescence, for size prediction, 237 in young adult, 140-141
period of, 126-140
442 Cyst of oral structures, 26-31
problems singular to, 360-
definition, 442 cervical, 24 summary, 35
391
diagnosis, 442-443 thyroglossal, 26 palate
at 9 years, 139
treatment, 443 bony, 31-32
permanent, 119-121
Crown normal,28
D equilibration in (see Equili-
conical, as supernumerary perioral region, 2Q-22
bration, in permanent
tooth, 354 Data of permanent teeth, 111-121
dentition)
diameter, mesiodistal, perma- cross-sectional, II prenatal dental, 100-105
mesiodistal crown diame-
nent dentition, 176 principles of, 8
advantages of, II ters, 176
shape anomalies, 355-356 of salivary gland, 30-31
disadvantages of, II mesiodistal diameters of,
Crozat appliance, 526, 529 study methods, 10-11
derived, 10 120
Crystallization: of hemoglobin of teeth, 30
direct, 10 prenatal beginnings, 100-104
in hyalinized zone, 318 temporomandibular joint, 32,
growth (see Growth, data) spatial patterns, IO~~ 105
Cup (see Chin cup) "
33
,. longitudinal, 10 • primary
Curve of Spee: during adoles- themes of, 8
cence, 435 advantages of, 10-11 cuspid interference in, 552
disadvantages of, II equilibration in, 551-553 complexity, changing, 8
Cuspid
overlapping, II radiography of (see under shifts from competent to
brackets for, 517-518
semi longitudinal , 11 Radiography) fixation, 8
eruption (see Eruption,
cuspid) DE space: changes in, 160 relationship to developing shifts from dependent to in-
excellent vertical position Decision tree (see Arborization) bony structures at 4 dependent, 8
after serial extraction, Deep bite (see Bite, deep) years, 138 timing of, 16
380 Dental in removable appliance, of tongue, 26
impaction (see Impaction, arch (see Arch) loose, 533-534 diagram of, 26
. cuspid) casts (see Casts) at 6 years, 139 Developmental biology, 9
566 Index

Developmental events, 7-8 Elastics, 518 alteration due to pathology in sequence of, 228
Developmental signs: divisions Elastomeric chain, 518 primary molar, 116 alterations in, 383-385
of,9-1O Electromyography bicuspid, 135-140 disturbances of permanent
Diagnosis of facultative muscles, 82 mandible, 135-140 teeth, 162
definition, 168 of mandible~ wide open posi- maxilla, 140 examination of, 175
effect of etiologic classifica- tion, 94 cuspid, 135-140 symbolization of, 177
tion of malocclusion on, of obligate muscles, 82 mandible, 135-140 of succedaneous teeth, 113
189-191 of orofacial muscles, 77-78 maxilla, 140 variations in sequence of
Diagnostic setup: for space of swallowing, 210 delayed, 385 eruptions, 162
management, 233-235 Embryo during adolescence, 445- Esthetics
Diastema face developing in, 20 447 during adolescence, 435
fibroma causing, 159 sketches of, 19 difficulties, 383-386 in adult, 473
midline Emotion: and postural position, ectopic, 385-386 facial, result assessment,
closure of, 474 86 of cuspid, maxillary, 386 439-440
.treatment in adult, 479 Enamel forming tissues; ar- of cuspid, maxillary, with in orthgnathic surgery with
Differentiation: definition, 9 rangement of, 102 impaction, 387 orthodontic treatment,
Digital sucking (see Sucking) Endocrine disorders: and maloc- of incisor, mandibular, 386 497, 503
Distal step protocol, 368-373 clusion, 157 molar, first, permanent, Ethmocephaly simplex, 23
Distocclusion (see Malocclu- Endodontics: in malocclusion maxillary, 384, 385-386 Ethmoid registration, 300
sion, Class 11) with periodontal disease guidance in mal occlusion Ethnicity: cranjofacial growth
Distoversion, 189 and tooth loss in adult, Class 1I, 399-400 and,67
Divider method: for measuring 478 idiopathic failure of teeth to Evolutionary changes: long-
from medium raphe to Enlow's method: to study erupt, 383 term, 7
estimate asymmetries of ground bone sections, 44 incisor, 135 Examination: intra-oral, 222
dental arch, 396 Equation, orthodontic, 148-149 l~teral, 360 Examination, orthodontic, cur-
Diirer: anatomic drawings from, elaborated, 149 mandible, 135 sory, 167-182
250 Equilibration, 551-557 maxilla, 135 appearance evaluation, 169- I
..•.
Dysostosis: mandibulofacial, 25 balancing, 556-557 interrelationships with calcifi- 170
Dysplasia in crossbite of primary denti- cation, 112-114 attitude evaluation in, 169-
craniofacial, diagrammatic tion, 393 molar, first, 131-135 170
representation, 496 cuspid removal in, 552 mandible, 131-135 available space evaluation,
ectodermal, congenitally functional malocclusion, AP maxilla, 135 178
missing teeth in, 348 correction, 555 permanent, 136 definition, 168
skeletal, 149, 392, 396 grinding in, 557-558 molar, second, 140 before the exam, 169
classification, 495-496 incisal crowding and, 556 of permanent teeth, 112-117 flow chart of, 168
with mandibular insuffi- interferences form for, 181
bodily growth and, 117-
ciency, 394-395 118 head position for, improper,
marking of, 554
open bite and, 214 171
midline, grinding method, ectopic development in,
open bite due to, 422 , 554 118 health evaluation, 169-170
vertical in Class 11 malocclu- instruments for, 169
midlines in, 553 factors affecting, 114-117
sion, 398 factors determining tooth questionnaire to be filled out
protrusive, reasons for
by patient or patient's
checking and grinding, position, 118-119
555 parent, 168
E factors regulating, 114-117
soft-tissue profile examina-
in mixed dentition, 553 normal order of, 117
tion, 171
Ear: in Pierre Robin syndrome, molar grinding in, 552 sequence of, 117 Exercise
25 in permanent dentition, 553- sequence, favorable, 118
growth and, 12
Early treatment (see Treatment, 557 sex differences in, 117
myotherapeutic (see Myother-
early) procedure, 553-557 stages of, 118
apeutic exercises)
Ectodermal dysplasia: missing rationale, 553 timing, 117
Exerciser: Nuk Sauger, 545
teeth in, 348 in primary dentition, 551-553 variability in, 117 Extraction
Ectopic development: in perma- retruded contact position, position of teeth, examination in malocclusion with perio-
nent teeth, 118 557-558 " . of, 175 "~. dontal disease and tooth
Ectopic eruption (see Eruption, "slides" into occlusion and, pr~eocious, of primary teeth, loss, 479
ectopic) 556 106
molar, second
Edgewise bracket, 521 swallow reflex and, 555 predicting emergence, 226- in orthodontic treatment,
Edgewise mechanism, 521 tapping teeth together in, 553 228 444
Edgewise treatment: full, for teaching patient to protrude tables of development, 226 typical effect of, 382
Class 11, type 0-2 mal- jaw with midlines coinci- Wainright's rule for, 226- premature, of primary teeth,
occlusion, 453 dent, 554 228 152
Elastic Equilibrium theory: of forces premature, 383-385 serial
appliance, 539 within masticatory sys- of bicuspid, second, 383 cephalography showing
through-the-bite, diagram of, tem, 307-308 of primary teeth, 106 vertical position of cus-
396 Eruption, 226-228 root ratios and, crown, 227 pids in, 380
 Index 567

protocol for gross discrep-
ancy problems, 379
records of patients treated
by, 381-382
Eye: slant in Treacher Coli ins
syndrome, 25
F to upper molars, extra-oral,
Face
anchorage, 309
anomalies, origin of, 22-26
breadth, 292-296
cartilaginous skeleton in em-
bryo, 32
craniofacial (see Craniofacial)
depth, 288-292
measures of, 290-292
developing in embryo, 20
development, maximal, pe-
riod of, 22
dimensions, overall, 284-288
esthelics, results assessment,
439-440
external features, examination
of, 170-172
growth, prenatal, 18-36
height
anterior, 284
anterior lower, 284
anterior upper, 284
growth, graphs of, 287,
288
measures of, 283
posterior, 284
posterior lower, 285
posterior upper, 284
ratio of lower anterior to
total anterior, 286
ratio of posterior mandibu-
lar height to total poste-
rior facial height, 286
ratio of total anterior to to-
tal posterior, 285
vertical distances, 284-288
length, 290-292
mandibular dentoalveolar
effective, 290
mandibular skeletal effec-
tive, 291
maxillary dentoalveolar ef-
fective, 290
examination, morphologic,
198
organization, summary of, 35
orofacial (see Orofacial)
orthopedics, forces in (see
Forces) ,
period of organization of, 19-
26
proportions, changes in, 22
reflexes, 80
in Treacher Collins syndrome,
25
upper, frontal section, in fe-
tus, 21
width, 292-296
bigonial distance, 296
condylion distance, 294
lateral point on condyle
distance, 294
measures of, 292
measures, graphs of, 293
medial point on condyle
distance, 295
molar alveolar crest dis-
tance, upper, 295
molar fossae intersect dis-
tance, 295
zygomatic coronoid inter-
sect distance, 294
Facial Form Analysis, 172
completed, 174
example of, 175
landmarks of, 173
Family
pattern, 16
size and growth, 12
Faucial pillars: examination of"
173
Fetus
carotid arteries in, 29
face in, upper, frontal sec-
tion,21
third to ninth months, 34
craniofacial changes dur-
'ing,34
radiographic changes dur-
ing, 34
summary, 36
Fibroma: causing diastema, 159
Finger-sucking (see Sucking)
Fingernail biting, 551
malocclusion and, 156
anterior component of, 119 treated as vectors, 310
application vertical, parallelogram of,
to dentition during thumb- 312
sucking, 154 Frankel function regulator, 539,
orthodontic, various man- 541
ners, schematic represen- Frankfort Plane, 189, 259
tation, 321 horizontal, 85, 259
Frontozygomatic sutures, 258
313 Fruit drops: sugarless, for
applied, and time to ortho- tongue correction, 548
dontic tooth movement, Functional appliance (see Appli-
321 ance, removable, loose)
of bruxism, 308
definition, 3 IO
G
effect on rigid free body, 3 IO
equivalent systems, 312 Gagging, 82-83
horizontal, parallelogram of, Gears: head, 524-525
312
Genetic
in jaw appliances, 308-313 changes, long-term, 7
in masticatory system, 307- concepts in craniofacial
308 growth, 48-49
abnormal forces, 308 control, ubiquitous, modu-
equilibrium components, lated by environment, 8
308 factors in growth, II
equilibrium theory, 307- fields influencing dental de-
308 velopment, 121
natural forces, inherent, theory in craniofacial growth,
307 50
originating from circumoral Genetics
musculature, 307 in congenitally missing teeth,
originating from muscles of 348
mastication, 307 in craniofacial growth, 51
originating within teeth, in malocclusion, 151
307 Genioplasty, 509
against maxilla Geometric methods in cepha-
anterior, 324 lometry, 255-263
posterior, 323 basic elements, 255-258
transverse, 324 Gingiva
of occlusal dysfunction, 308 diseases in malocclusion, 159
of occlusion (see Occlusion, effects of orthodontic treat-
force) ment on, long-term, 325
orthodontic examination of, 173
control of, 312-313 excessive display, 504
craniofacial growth and, 53 extensive display, 504-508
periodontal responses to, hypertrophy, with incisal mal-
313-322
alignment, 159
selection of, 312-313 result assessment with, 439
tissue responses to, 313- Gingivitis: with hypertrophy and
322 hyperactivity of mentalis
tooth movements and, 311 muscle, 202
strategies for controlling, in Gold wires: to stabilize mandib-
"

maxillary skeletal effective,
290
posterior cranial base effec-
tive, 291
mask, 459, 525, 526
midface (see Midface)
muscles, 74-75
adaptation to altered man-
dibular position, 533
development, 32-34
examination, functional,
198
Fistula clinical practice, 309 ular incisors in ancient
branchial, 24 therapeutically employed Greek skull, 3
thyroglossal, 26 biomechanical, 309 Gonion, 258
Fixation: intermaxillary, 324 classification, 308-309 Growth, 1-164
Flush terminal plane protocol, natural, 308-309 adult physique and, 12
368, 372-373 therapeutically introduced, arch dimension changes due
Food: nature of, in malocclu- 308 to, 125
sion, 152 during thumb sucking, 308 basicranium, 55-56
Foramen rotundum, 258 of tongue-thrusting, 308 birth order and, 12
Force(s), 306-331 on tooth, parallelogram repre- bodily, and eruption of per-
anchorage and (see senting, 312 manent teeth, 117-118
Anchorage) of traumatic occlusion, 308 bone (see Bone, growth)
568 Index

Growth (cont.) clinical, 14 I maxillary, shape variations,

cephalometry of (see Cepha- significance of, 16 355-356
Impaction, 387-391
lometry of growth) variables affecting, 11-12 during adolescence, 445-447 maxillary, size variations,
charts, by stature and weight Gum pads: in newborn, 105 bicuspid, second, 388 355-356
for boys and girls, 170 cuspid, maxillary, 387-388 moving maxillary cuspid
climate in, 12
H with ectopia, 387 mesially to serve as inci-
concepts of, basic, 6-17 treatment, 389 sor, 441
of cranial vault, 54 Habits peg, 479
diagnosis, 387
craniofacial (see Craniofacial in malocclusion, 152-156 molar size diminished, treatment
growth) oral, deleterious, correction second, 388 in adult, 480
of craniofacial skeleton (see of,543-551 second, treatment, 389 malalignment with gingival
Craniofacial skeleton, Hawley retainers, 530 third, mandibular, 387 hypertrophy, 159
growth) Head semi-impacted molar, man- malposition in mal occlusion
data gears, 524-525 dibular second· perma- Class II, 398
evaluation, II force application to molars nent, 446 malrelationships, localized,
gathering methods, 10-11 and,314 Implant during adolescence, 463-
types of, 10 improper position for cursory in bone growth study, 43 465
definition, 8-9 orthodontic examination, in cephalometry, 256 mandibular
evaluation, 16-17 171 Impressions, orthodontic, 513-
questions to be asked, 16- ectopic eruption, 386
support muscles 515
17 loss of, treatment, 354
function, 206 lower, good, 515
reasons for, 16 wires stabilizing in ancient
morphology, 206 upper, good, 515
exercise and, 12 Greek skull, 3
pain of, 206 Incision
face, prenatal, 18-36 tenderness of, 206 inferior, 258 maxillary
in facial height, graphs of, crossbite of, 418
Height superius, 258
287,288 facial (see Face, height) Incisor labioversion (see Labiover-

family size and, 12 mandible (see Mandible, brackets for, 517-518 sion, of incisors,
heredity in, 11 height) central, maxillary maxillary)
illness and, 12 maxilla (see Maxilla, height) anomalously formed, 357 in overbite, and arch leveling
mandible (see Mandible, ramus, 297 loss of, treatment, 351, 353 mechanics, 492
growth) Helices: in arch wires, 313 spacing between incisors, overlap
muscles, orofacial (see Orofa- Hemoglobin: crystallization of, 357,360 excessive vertical, during
cial, muscles, growth) in hyalinized zone, 318 with spade-shaped interos- adolescence, 464
normal, spacing as part of, Herbst appliance, 541, 543 seous tip, 358 with periodontal disease
360 Heredity (see Genetic) cephalometric analysis of in- and tooth loss, 494
normality (see Normality) Histography: of muscle activity, cisal adaptation, 277- severe, 494
76 278
nasomaxillary complex (see "peg lateral," treatment,
Nasomaxillary complex, History: case, form for, 181 crowding and equilibration, 355, 356
556
growth) History: of orthodontics, 3-4 position
nutrition in, 11 Howes' Analysis, 229-233 eruption (see Eruption,
relative to lip and tongue
pattern, 12-13 measurements in, 234 incisor)
lateral posture, 119
clinical implications of, 13 Hyalinization, 317-319 result assessment, 439
contributions to, 12 congenitally absent, mid-
alveolar bone after, 319 primary, and arch perimeter
line spacing in maxilla
definition, 12 crystallization of hemoglobin maintenance, 361
due to, 358
physical, 10 in hyalinized zone, 318 spacing after labioversion of
congenitally missing, 358
plotted in different ways, 14 definition, 318 cuspids, 161
eruption, 360
psychological disturbance elimination of damaged tis- Infant, swallowing in, 92-93
maxillary, during adoles-
and, 12 sues, 318-319 retained, 549-550
cence, 440-442
race and, 12 in intermaxillary suture (in maxillary, congenitally Infradentale, 258
seasonal effects on, 12 monkey),61 missing, treatment, 349- Infraversion, 189
secular trends in, 12 of palate, 323 350 Ingervall's diagram: of postural
skeletal, in Class II malocclu- periodontal ligament after,
" f!1axillary, congenitally- >. position, 85
sion, 399 . 319
"missing, treatment, prog- Instruments: for examination,
socioeconomic factors in, 12 reconstruction of supporting nosis, 350
cursory orthodontic, 169
standards, general, I7 tissues, 319 maxillary, goals for, 440
Intercuspation: ideal, 142
study methods, 10-11 right, 318 maxillary, loss of, treat-
tissue degeneration, 318-319 Intermaxillary anchorage, J09
temporomandibular joint (see ment, 351
Temporomandibular Hyperactivity: of mentalis mus- maxillary, methods for Intermaxillary fixation, 324
joint, growth) cle, and gingivitis, 202 treatment, 440 Intermaxillary suture: hyaliniza-
translation of parts during, in Hypertrophy: of mentalis mus- maxillary, missing, in tion in (in monkey), 61
Class II malocclusion, cle, and gingivitis, 202 adult, 474 Intra-maxillary anchorage, 309
400 Hypophyseal fossa: floor of, maxillary, problems with, Intra-oral
variability in, 13-16 258 440-441 anchorage, 309

examination, 222
feawres, description of, 173-
178
Intrusion, 313
"Invisibles," 526, 529
J after hyalinization,
Jaw
appliance (see Appliances,
jaw)
closure path, 217
ligaments, palpation, 217
movements, 217
'muscles, 75-76, 196-220
palpation, 217
Pierre Robin syndrome, 25
radiography
lateral projections, 222
well taken lateral, 224
reflexes, 80-81
relationships, 216
in newborn, 105
registration of, 242-244
registration in pain or lim-
ited movement, 218
tooth arrangement in, 141
in Treacher Collins syndrome,
25
treatment, functional,
sponse to, 399
Joint (see Temporomandibular
joint)
K Class
Knee spring, 527
L posture, 170-171
Labial frenum: maxillary,
largement, 358
Labioversion, 189
of cuspids, maxillary,
of incisors, maxillary,
418, 463
with deep bite in adult,
489-492
diagnosis, 463
treatment, 463
treatment, 417
Labium frenum
enlargement, 358
malposition, 358
Landmark (see Cephalometry,
landmark)
Lateral malrelationships (see
Malrelationships, lateral)
Learned reflexes, 84
Leeway space
arrayed by original occlusion
and sex, 127
occlusal status, relationships
among, 128
Index 569
Length Macrostomia: in Pierre Robin profile, 185
face (see Face, length) syndrome, 25 retrognathic profile and,
mandible (see Mandible, Malformations (see Anomalies) 185
lengtp) Malnutrition space supervision in, 376-
Ligament(s) craniofacial growth and, 53 378
jaw, palpation, 217 in malocclusion, 162 surgical translation of parts,
periodontal, 320 Malocclusion 400
319 Ackerman-Proffit classifica- syndrome, 191-194
stylomandibular, calcification tion system, 191 traction, extra-oral, re-
of,206 during adolescence, general sponse to treatment, 399
Light wire, 313 characteristics, 434 treatment, early, dental as-
bracket, 522 angle system in, 186-188 ' pects, 401
Lingual archwire (see Archwire, anteroposterior relationships, treatment, early, occlusal
\ lingual) 189 aspects, 40 I
\ Lingual locks, 519 birth injuries and, 151 treatment, early, planning
Lingual sheaths, 517 bone in, 149-150 differential, 401-402
Linguoversion, 189 caries and, 159 treatment, early, rationale
Lip Class I, 186, 187 for, 400-401
-biting, 551 with balance prufile, 185 treatment, early, skeletal
malocclusion and, 156 before and after treatment, morphology in, 400-401
bumpers, 525, 526 192 treatment, general strategies
mandibular, for space su- end-to-end protocol, 368 for, 399-400 .
pervision, 371 flush terminal plane proto- treatment, tactics for, 400
cleft, 23 col, 368 type A (See also under
complete, 24 labioversion in, treatment, Class n during adoles-
color of, 171 417 cence, type A below)
diagnosis, differential, 199- mesial step cases, space su- type A, horizontal, compli-
203 cations of treatment, 403
pervision protocol, 369
functionally abnormal, 199- mesial step protocol, 367- type A, horizontal, treat-
re- 203 368 ment, 402-403
functionally inadequate, 199 type A, traction for, extra-
molar relationship in la-
lower, during swallowing, oral, and space supervi-
bioversion, 415-418
210 sion, 402
syndrome, 192
midlip tissue, lack of devel- type B, 406
treatment in adult, 476
opment,23 type B (See also under
n, 187-188,398-410
normal,200 Class n during adoles-
during adolescence (see be-
"plumpers," 525 cence, type B below)
low)
position, 170-171 type B, horizontal, compli-
alveolar processes in, 400 cations of treatment, 403
appliances for, 400
incisor position and, 119 type B, horizontal, reten-
cephalometry of (see tion in, 403-406
en- normal, 171 Cephalometry, of maloc-
result assessment, 439 type B, horizontal, treat-
clusion, Class Il)
ment' 403-406
strain, 504-508 with deep bite, in adult,
161 type B, horizontal, varia-
-sucking, 551 476
415- tions in, 403
malocclusion and, 156 diagnosis, differential,
type C (See also under
texture of, 171 398-399
Class n during adoles-
treatment, change after, 202 distal step protocol for,
cence, type C below)
upper 368-373
type C, horizontal, compli-
anatomically short, 201 Division I, 187 cations of treatment, 407
development of, 21 Division I, casts of, 193
type C, horizontal, reten-
Lischer's nomenclature, 189 Division 2, 188
tion in, 410
Load: effect of increasing the "functional" features, 399 type C, horizontal, treat-
length of a spring on, homeostatic pattern with me~r, 407-410
312 orthodontic treatment type D, 408-409
Locked molar: mandibular sec- from age eleven, 131 type D (See also under
ond permanent, treat- malpositions in, dental and Class n during adoles-
ment, 446 occlusal, 398 cence, type D below)
Locks: lingual, 519 morphology in, skeletal, type D, horizontal, compli-
Loops: in arch wires, 313 398 cations of treatment, 407
muscle training in, 400 type D, horizontal, reten-
M neuromuscular features, tion in, 407
399,401 type D, horizontal, treat-
Macroglossia: and spacing, 360 orthopedic devices in, 400 ment, 407
570 Index

Malocclusion (cont.) type C, horizontal, tactics, syndrome, 194-195 alignment, anterior, simple
type D, horizontal, varia- suggested, 455 tongue posture in, 204 problems in, 479-480
tions, 407, 410 type D, horizontal, 452- treatment, 416 appliances in, 478-479
type E (See also under 455 treatment, early, general background, 475
Class n during adoles- type D, herizontal, basic strategies, 412 diagnostic procedures, es-
cence, type E below) strategies, 452 treatment, early, rationale sential, 475-478
type E, horizontal, compli- type D, horizontal, compli- for, 412 periapical survey, 475
cations of treatment, 410 cations, 455 treatment, early, tactics for, radiography in, 475
type E, horizontal, reten- type D, horizontal, prob- 412-415 rules for, general, 475
tion in, 410 lems, 455 true, 410 space inadequacy, 485
type E, horizontal, treat- type D, horizontal, reten- vertical analysis, 412 treatment, periodontal, 478
ment, 410 tion, 455 Class III, during adolescence, treatment sequence, 478
type F, 404-405 type D, horizontal, tactics, 455-463 treatment strategies, 475
type F (See also under suggested, 452-455 diagnosis, 457 vertical problems in ante-
Class n during adoles- type D-2, 453-454 strategies, general, 457 rior region, 489
cence, type F below) type E, horizontal, 455 tactics, 457 vertical problems in, com-
type F, horizontal, compli- type E, horizontal, basic treatment, differential, plicated, 493-494
cations of treatment, 403 457-463 physical agents and, 152
strategies, 455
type F, horizontal, treat- type E, horizontal, compli- treatment rationale, 457 posture and, 156
ment, 403 cations, 455 classification, 183-192 prevention of., 345
typical, 194 type E, horizontal, prob- angle, 185 respiratory function disturb-
Z-score chart and arboriza- lems, 455 etiologic, 189-191 ance in, 157-159
tion, 274 type E, horizontal, reten- purposes of, 184 Simon system, 188-189
Class n, during adolescence, tion, 455 system, definition, 184 soft parts in, 151
450-455 systems of, 186-191 systemic diseases in, 156-157
type E, horizontal tactics,
arborization, 454 systems, limitations of, 195 teeth in, 150-151
suggested, 455
background, 450 type F, horizontal, 451 when to classify, 184-186 terminology, 183-192
diagnosis, differential, 450 clinical entities in, 151-162 time factor in, 151
type F, horizontal, basic
rationale for therapy, 450 developmental defects of un- traits in 3-year-old children,
strategy, 451
tactics, 450 known origin in, 151 110
type F, horizontal, records,
treatment, differential, 450 451 early, subleties of, 346-347 trauma causing, 151-152
treatment strategies, 450 endocrine disorders and, 157 prenatal, 151
type F, horizontal, tactics,
type A, horizontal, 450- 451 etiologic sites, primary, 149- treatment, flow of questions
451 151 arising at start of, 333
Class III, 188, 410-415
type A, horizontal, basic tumors and, 159
during adolescence (see be- etiology, swallowing in, 208
strategy for, 451 food in, nature of, 152 vertical relationships, 189
low)
type A, horizontal, compli- functional correction, AP, Malrelationships
cephalography of, 194
cations, 451 555 dental, 392
cephalometry of (see Ce- functional, 392
type A, horizontal, prob- gingival disease in, 159
phalometry, of malocclu-
lems, 451 habits, 152-156 incisal, localized, during ado-
sion, Class III)
type A, horizontal, tactics, lescence, 463-465
diagnosis, differential, 410 heredity in, 151
451 lateral, during adolescence,
midface deficiency, 411, interception of, 345
type B, horizontal, 452 447-450
412 lip-biting in, 156
type B, horizontal, basic diagnosis, 447-448
midface deficiency, early lip-sucking in, 156
strategy, 452 diagnosis, dentoalveolar,
treatment, 414, 415 malnutrition in, 162
type B, horizontal, compli- 448
midface deficiency treat- mastication in, 215
cations, 452 diagnosis, neuromuscular,
ment during adolescence, mediolateral relationships, 448
type B, horizontal, prob- 189
456
lems, 452 diagnosis, skeletal, 447-
molar relationship in, 185, midsagittal plane, 189 448
type B, horizontal, reten-
410 mouth-breathing in, 157
tion, 452 goals, 448
morphologic analysis, 412 nail-biting in, 156 methods, 448
type B, horizontal, super-
. neuromuscular type, 413 oa~opharyngeal diseases ·~ii~ methods, neuromuscular,
posed tracings of, 452
profile analysis, 412 ". 157-159 448
type B, horizontal, tactics,
452 prognathism, mandibular, neuromuscular system in, 149 methods, skeletal, 448
type C, horizontal, 455 411, 412 neutroclusion, 187 problem background, 447
type C, horizontal, basic prognathism, mandibular, in oral habits, deleterious, problem definition, 447
early treatment, 414-415 544 treatment, 448-450
strategies, 455
type C, horizontal, compli- pseudo, 410-415 orbital plane, 189 muscular, 392
cations, 455 pseudo, early treatment of, periodontal disease in, 159 Mandible
type C, horizontal, prob- 412-414 with periodontal disease in anatomic dimensions in, re-
lems, 455 skeletal, 412 ancient Greek skull, 3 gional,296
type C, horizontal, reten- skeletal, mandibular in- with periodontal disease and bone growth in, endochon-
tion, 455 clined plane in, 419 tooth loss, 475-494 dral,60
 study of, 15 -, -., ... .. ~
line, 571
259
craniofacial
ing
distal during
movement
second growth 450
adolescence,
of, 364448-
adolescence, and, in324
Maxilla
lossextraction
363
382
first
line
impaction
Mechanics,
corpus muscles
tenance
Molar
results
mesial
Mask: for
treatment,
distal, in
second
353
adult,
matrix,
contraction,
band
grinding
ing
osseous
Maxillary
Midface forces
eruption
Metals:
correction
end-to-end
loss
Class
367
simultaneous
movement
390
205-206
385
Mastication, 450
backwards,
13
cence,
anterior,
bilateral,
of,
studies, tion
Maturation:
mandible,
first,
fect
evaluation
ism,
malocclusion,
righting,
malposition
system)
permanent
reconstruction,
rotation,
anterior,
height
impaction
inclined,
impaction,
ment
against
measures,
pain
relationship
Massetericloss
anatomic
primary
Mandibulofacial
cephalometry
eruption,
nants
retruded
effect permanent,
unilateral,
during
on
extraction.
impaction, palatal415-418
364
485
205
481 and,
orthodontic
of,
forward,
64
Class
ankylosis,
446
tenderness,
eruption
adolescence,
259
effect
450
64
58-59
crossbite,
midline,
mandibular
osteotomy,
width,
Mesioversion,
Models:upper, (see 310
genitally
posterior,
development,
mesially
lower,
length,
Mastoid
second,asymmetry,
·system,
permanent
mandibular,
forces (see I,
in
maintenance
first,
assessment,
supervision
drift
185,
Class
face,
in
mesial,
adult,
and distal
of,
444
II,
410
459,
81
457 III
307orthodontic
362-363
364
originating
mandibular,
oflength
topically
three
in (see
adolescence,
prognathism
protraction
sive,
posture
examination,
Mesioclusion
Menton,
Mixed and
retruded
wide son
deficiency
bimaxillary
Mesial
with
Measures:
complex, in
497
59
258
three-piece,
m
second
Class
deficiency,joining,
of,
deficiency)
treatment
Ill,
Measurements:
Mean
Maxillomandibular 398
third,
in
65
in
in
of,
disharmony
occlusion,
259
phy 189
uprighting
inclined,
examination,
lar,
59
vision, first)
types
masticatory
processes,
kylosis
ular arch
within
second
againstin
andibular,
(see
step
mandibular of,
open, movement
treatment
movement
439
malocclusion,
482
525,
adult,
483
adult,
391
dentoalveolar,
pathology
fusion
ercises,
Forces,
transilatory,
molar)
in
of,arch
of,
mixed)
gional,
ment, of,
sitions,
available394
perimeter
at,
mandibular)
485
64
285, of,
in
in
maxilla)
482-483
adult,
during
206 543
215
treatment,
492
283
early,297
dimensions,
reflex:
140
89
contact, 296
of,
353-354
adolescence
388 450
typical
expansion359
279 in,
masticatory
equilibration,
variations
285,
with
dentition
Ill)
rect,
(see 161
mesial
permanent,
Impaction,
(in
Band,
(see
Prognathism,
during
treatment
development
of
dibular, 456
pterygoid 298
missing,
rat),
mandibular,
of,94
259
erupting,
force 34
active
myotherapeutic
contact,
morphologic,
bicuspid
10
bilateral,
(see
512-513
Eruption,
relationship,
moving space
of
during
protocol,
freeway
(see and,
526
malocclusion
484and
adoles-
effects
dysostosis,
(in
loss
88 cat),
251,
determi-
of,
space,
from
absent,
142-143
unilateral,
of,
maxillary,
ankylosis
perimeter
of,371system
447 mesially
moving
in
molars
(see in374-375
486
labioversion,
alteration
206
362
definition,448 9389
116
effect 483-
with
drift
Forces,
molar)
90 352
384-
functional,
64
258
system)during
of,ec-
(see
and
Malocclusion,
electromyogra-
intercuspal
509 (see
Prognath-
is
rapid
prognathism
central
Bimaxillary)
anteroposteriorly,
space,
of
with during due
main-
molar
255
in, re-
86
treat-
man-
mo-
super-
mandib- 363
of,
25
of,
449
imper-
an- ac-
552
Force,
caus-
in, in
treat-
dur-
pas-
compari-
space
adolescence,
367-368
tendency,
of,
growth,85
relationship:
midface 31 of,
toof
up-
ex-
Dentition,
con-whenpo-
398
indi- Index
572 Index

Molar (cont.) diagnosis, differential, 207 N concepts of, 13-16

mandibular, movement in malocclusion, 157 esthetic, 13
when first molar is lost, Nail-biting, 551
evaluation, sensory, 197-198 evolutionary, 13
353 in newborn, 105-106 malocclusion and, 156
functional, 13
Nasal
mandibular, uprighting in Muscle(s) statistical, 13
adult, 481 (See also Nose)
activity, histography of, 76 Nose
permanent mandibular, alar, and mouth-breathing, breathing, differential diagno-
(See also Nasal)
"locked," treatment of, 207 sis, 207
cleft, 23
446 in anchorage, 309 fin, development of, 21
lack of development, 23
primary, in occlusion, 109 circumoral, in myotherapeutic pit, 24
septal structures, 258
primary, uneven resorption exercises, 543 septum, Scott's hypothesis
Nostril: floor development, 21
of, 139 in crossbite, 392 concerning, 50
Nuk Sauger
third spine
digastric, tendon of (in rab- exerciser, 545
bit),90 anterior, 256
development, 140-141 nipple, 545
early treatment of, goals for, posterior, 258
developmental position var-
347 suture, frontomaxillary, 258 Nutrition: in growth, II
iability, 388
Nasion
impaction during adoles- face (see Face, muscles)
cence, 446 facultative, 82 -sella, 259 o
Nasofrontal suture, 57
impaction, mandibular, 387 electromyographic activity
uprighting, 483 in, 82 Nasomaxillary complex, 57-60 Observations: in growth data, 10
upper groups, 198-206 displacement in, 58 Occipital anchorage, 309
functions, 57 Occlusal adjustment (see
application of force to, 313 head (see Head, support
muscles) growth, 57-58 Equilibration)
head gears in force applica-
amounts and directions, Occlusal equilibration (see
tion to, 314 jaw, 75-76, 196-220
58-59 Equilibration)
uprighting, 480-485 palpation, 217
compensatory mechanisms Occlusal splints, 529-531
in adult, 480-485 length, relationship to ten-
sion, 79 in, 59 Occlusiol!
appliance in, bracketed,
effects on dentition and oc-
481 malrelationships, 392 adaptive mechanisms, 143 .
of mastication (see Mastica- clusion, 59-60 alignment, result assessment,
appliance in, removable
tion, muscles) timing, 59 439
acrylic, 480-481
mentalis vertical, 59
casts in, 481 analysis, 221-246
hypertrophy and hyperac- issues concerning, clinical, 60 of mal occlusion with perio-
complications, 483
tivity of, with gingivitis, periosteal surfaces in, 58 dontal disease and tooth
contraindications, 483
202 Nasomaxillary sutural system, loss, 475-478
diagnostic setup, 482 322-324
modified oral shield to in orthognathic surgery
with mesial translation, 480
train, 537 Nasopharyngeal disease: and with orthodontic treat-
modifications, 483 mal occlusion , 157 -159
neck (see Neck, muscles) ment, 497, 503
in orthognathic surgery, Neck
485 neuromuscular (see appliances in mal occlusion
muscles
.." Neuromuscular) with periodontal disease
problem, 480 function, 206
obligate, 82 and tooth loss in adult,
radiography in, 481 morphology, 206
rationale for, 480 electromyographic activity 478
in, 82 pain of, 206
spring for, 482 centric, 87-88
tenderness of, 206
orbicularis oris, in myothera- change(s)
with transilatory move- strap, 525
ment, 485 peutic exercises, 543 expected, 243
orofacial (see Orofacial, throat angle, obtuse, 504-508
treatment goal, 480 Neonate (see Newborn) patterns in mixed dentition,
muscles) 130
treatment plan, 482 Neural crest, 23
portal, 76 "protrusive" pattern of,
treatment protocol, 482- Neuromuscular
483 pterygoid, 75
diagnosis in lateral malrela- computer plot of, 130
in removable appliance,
with unsuccessful attempt tionships during adoles- in young adult, 141
loose, 532-533
at mesial movement, 487 cence, 448 classification, 178
striated, tension increase in,
width changes in, 123 contact
78 functions, specific, examina-
Molecular biology, 9 " ~ tion of, 206-216 "'~. duration of, 87
temporal, palpation to ascer-
Moment, 310-311 system: in malocclusion, 149 frequency of, 87
tain swallow activity,
Moss' hypothesis: in craniofa- 206 Neurotrophism: in craniofacial cuspid, results assessment,
cial growth, 50 growth, 52-53 439
training in Class II malocclu-
Motivation: of adult for ortho- Neutroclusion, 187 development of, 99-146
sion,400
dontic treatment, 473 Newborn homeostatic patterns "of,
Myodynamic appliance, 539
Motor abilities: evaluation of, gum pads in, 105 131
Myotherapeutic exercises, 542-
197-206 543 jaw relationship, 105 in young adult, 140-141
Mouth limitations, 542 mouth of, 105-106 diagnostic data for, 222-226
(See also Oral) principles, 542-543 tongue posture in, 91 dysfunction, forces of, 308
-breathing procedures, 543 Nipple: Nuk Sauger, 545 early treatment of, goals for,
in alar musculature, 207 purposes, 542 Normality 347
 Index 573

effects status, and relationships tongue-thrust causing, 547 technics (see Technics,
of mandibular growth on, among leeway space, treatment, 421-422 orthodontic)
66 128 Opinion: in growth data, 10 treatment (see Treatment)
of nasomaxillary growth at 10 years, 133 Oral Orthodontics
on, 59-60 at 13 years, 134 (See also Mouth) definition, 3-4
transitional adjustment, pat- habits, deleterious, correction
/ of temporomandibular
growth on, 66
joint
terns, of, 130 of, 543-551
history of, 3-4
purpose of book, 4-5
at 8 years, 133 traumatic, forces of, 308 intraoral (see Intraoral) role of craniofacial skeletal
at 11 years, 134 at 12 years, 134 screens, 535 growth in, 38-39
evaluation, in adult, 473 wear of primary teeth, 152 shields, 535, 536 scope, 4
excursive, lateral, checking Odontoclasts: root resorption by, modified, to train mentalis studying, problems in, 2-3
for occlusal interferences 322 muscle, 537 for dental student, 2-3
in, 180 Odontogenesis structures, development of, for dentist in practice, 3
force bell stage, 102 26-31 use of book, 5
, direction of, 87 bud stage, 102 summary, 35 Orthognathic surgery: historical
magnitude of, 87 cap stage, 102 tactile perception, plastic geo- aspects, 495
functional slide into, extra- initiation of, 100-102 metric figures to test, Orthognathic surgery with or-
oral testing for, 180 sequence patterns, 102-104 198 thodontic treatment
guidances as active or pas- Oligodontia Orbitale, 258 case report&, 497
sive,81 in adult, 485-489 Orofacial management of cases, 495
interferences severe, 490-491 motor skills, evaluation of, referral of cases, 495
with jaw, 217 Open bite(s), 178, 189, 420- 198 selection of patients for, 495
during protrusion, checking 422 muscles, 73-98 sequence of treatments, 496
for, 180 with abnormal tongue pos- adaptation of, 89-94 timing, 496-497
line ture, 205 adaptation to thumb-suck- Orthognathics: molar uprighting
during adolescence, 435 adaptive features, 204 ing, 153 in, 485
functional, 398 during adolescence, 468 analysis, 196-220 Orthopedic
causative features, 204 devices in Class 11 malocclu-
in mixed dentition, changes, electromyography of, 77-
128-131 cephalometry of, 424 78 sion,4oo
models of, 142-143 complex, 421-422 force and, 77 facial, forces in (see Forces)
molars in second, primary, during adolescence, 468 growth of, 89-94 Osteoclast: in resorption of al-
109 tongue-thrust in, 155,212, veolar bone, 314
growth, behavioral, 90-94
at 9 years, 133 548 growth, functional, 90-94 Osteogenesis, 39-42
normal vs. ideal, 142 treatment, 421-422 Osteotomy
growth, structural, 90
definition, 178,420,421 . interaction with craniofacial Le Fort I, 503
plan, results assessment, 439
position, ideal, 243-244 diagnosis, 420-421 skeleton and dentition, maxillary, 497
postnormal (see Malocclu- dysplasia causing, skeletal, 94 three-piece, 509
sion, Class I1) 422 maturation of, 73-98 Overbite, 125-126
pre-normal (see Malocclusion, dysplasia and, skeletal, 214 movement, 77 age and, 126
Class Ill) severe, 550 pressure and, 77 deep, 189
primary simple, 421 study methods, 76-79 excessive (see Bite, deep)
disorders, 110-111 during adolescence, 466 study methods, anatomic, incisal, and arch leveling me-
during adolescence, cepha- 76-77 chanics, 492
development, 108-111
at 5 years, 132 lometric tracing, 465 study methods, behavioral, Overjet, 125-126
neuromuscular considera- during adolescence, diag- 78-79 excessive, 415-418
tions, 108 nosis, 466 measurement method, 177
study methods, functional,
relations in, 108-110 during adolescence, treat- 77-78
radiography of (see under ment, 466 physiology, neuromuscular, p
Radiography) in adult, 492-493 basic concepts, 79-84
relationships anterior, 466 reflexes (see Reflexes, Pain
functional, result assess- anterior, treatment, 421 . orofacial) -.
-.,.". of head support muscles, 206
ment, 439 diagnosis, in adult, 492 Orthodontic jaw relationship registration
future, prediction of, 241- posterior, 466 appliances, fixed, principles in, 218
242 posterior, treatment, 421 of biomechanics in, 310- of muscles of mastication,
ideal, procedure for regis- retention, in adult, 493 313 206
tering, 244 treatment in adult, 493 equation, 148-149 of neck muscles, 206
to soft tissue profile, 199 skeletal, 421-422 elaborated, 149 Palatal line, 259
to teeth, 175-178 during adolescence, 468 examination (see Examina- Palate
results assessment, 439 treatment, 421-422 tion, orthodontic) bony, development, 31-32
"retrusive" pattern of, 131 treatment in adult, 494 forces (see Forces, cleft, unilateral, 427
at 7 years, 132 tongue posture in, 156 orthodontic) closure, 28, 30
at 6 years, 132 tongue posture abnormality impressions (see Impressions, development, normal, 28
stabilization, 326-327 causing, 551 orthodontic) expansion
574 Index
Palate (cont.)
appliance, 520
rapid in bilateral maxillary
corpus deficiency, 449
rapid, in early mixed denti-
tion, 397
fusion, 30
relationship to tongue, 27
separating devices, 521
shelves
formation and elevation of,
27-28
fusion of, 28
widening in Class II maloc-
c1usion, 400
Perception: oral tactile, plastic
geometric figures to test,
198
Periodontal disease
with incisal overlap and tooth
loss, 494
with malocclusion (see Mal-
occlusion, with perio-
dontal disease and tooth
loss)
with mal occlusion in ancient
Greek skull, 3
Periodontal ligament, 320
after hyalinization, 319
Periodontal responses: to ortho-
dontic forces, 313-322
Periodontics
crossbite and, single-tooth,
adult, 488
deep bite and, in adult, 493
Periodontitis: juvenile, 447
Periodontium
charting, in malocclusion with
periodontal disease and
tooth loss, 475
effects of orthodontic treat-
ment on, long-term,
result assessment, 440
Perioral region: development
20-22
Periosteal membranes, 56
Periosteal surfaces
in cranial floor, 55
in cranial vault, 54
in mandible, 63
in nasomaxillary complex, 58
Permanent record (see Record,
permanent)
Petrovic's hypothesis: in crani-
ofacial growth, 50
Phagocytosis, 319
Photograph, 226
extra-oral, correct, 225
Physical growth (see Growth)
Pierre Robin syndrome, 25
Piezoelectric effect, 317
Plan for treatment (see Treat-
ment plan)
Planning (see Treatment, occlusal interferences during, permanent
planning) checking for, 180 case history, 181, 182
Plates, active, 525, 526 "Protrusive" pattern: of occlu- completion of, 182
examples of, 527 sal change, computer record casts, 182
"Plumpers:" ~ip, 525 plot of, 130 radiography, record of, I ffl<
Pogonion, 258 Psychological disturbance: and Redirection: functional, 324
Point (see Cephalometry, point) growth, 12 Reflex(es)
Polymorphisms, 102 Pterygoid airway, upper, 76
Pont's Index, 233 length, and active and passive alimentary tract, 76
Porion, 258 protraction of mandible determinants of mandibular
Porter lingual appliance, 393 (in rat), 90 registration positions,
muscle, 75 84-89
Porter lingual archwire, 519
Position (see Mandible, Pterygomaxillary fissure, 258 facial, 80
position) jaw, 80-81
learned, 84
Positioners (see Teeth,
Q masseteric (in cat), 86
positioners)
orofacial
Posture Quad Helix appliance, 397
Quad-Helix lingual archwire, complex, 81-84
body, examination of, 206
malocclusion and, 156 519,520 simple, 80-81
Quantitative measurements: in swallow, an,d equilibration,
Premolar, second, mandibular
555 .
blocked, providing space for, growth data, 10
489 Questionnaire: for patient or pa- tongue, 81
unlearned, 84
elevation of, 384 tient's parent, 168
Regainers, 525-528
problems during adolescence, acrylic, split-saddle, 527
441 R coil spring, 365
Prenatal
Race examples of, 365-367
facial growth, 18-36 expansion screw, 366
trauma and malocclusion, 151 craniofacial growth and, 67
maxillary plate used for, 367
growth and, 12
Prognathism recurved helical spring, 365
Radiographic cephalometry, 43
bimaxillary, 418-420 removable acrylic, 366
Radiography, 222-226
during adolescence, 466, screw, expansion, 528
bite-wing, 222
467 sliding yoke, 528
of fetus, third to ninth
in mandibular, 411, 502 slingshot, 366, 528
months, 34
discussion of, 412 split saddle, 365, 527
intra-oral periapical survey, vacuum-formed, 529
with midface deficiency, 222
462-463 Relapse, 326-327
jaw theorems concerning, I
with midface deficiency,
projections, lateral, 222
complications, 462 through 10, 326-327
well taken lateral, 224
with midface deficiency, Reliability: of landmark in
of mal occlusion with perio- cephalometry, 256
problems, 462 dontal disease and tooth
with midface deficiency, Remodeling: of bone, 45-47
loss, 475 Resistance: center of, 310
325 records, 462-463 of molar, for uprighting, 481
Resorption
with midface deficiency, occlusal plane projections,
retention, 462-463 of permanent teeth, 141
of, 222,224
of primary teeth, 107
after orthodontic treatment,
in orthognathic surgery with uneven in second primary
500
orthodontic treatment, molar, 139
records of, 458-459 497 Respiration, 207
records, pretreatment, at panoramic, 222 diagn~sis, differential, 207-
start of treatment, prog- example of type of, 224 208
ress records, 460.c.461 periapical, complete set of, examination methods, 207
treatment during adoles- 223 function disturbance and mal-
cence, 457-461 "f2r permanent record, t8i occlusion, 157-159
treatment in adults, 477 Radioisotopes: in study of bone Restorations: in malocclusion
treatment, early, 414-415 growth, 42-43 with periodontal disease
maxillary, 272 Ramus and tooth loss in adult,
Prosthion depth, 291 478
inferior, 258 height, 297 Restriction: functional, 324
superior, 256-258 Rankings: in growth data, 10 Retainers, 531
Protraction, 189 Ratings: in growth data, 10 (See also Regainers)
Protrusions Reconstruction: of mandible, Hawley, 530
bimaxillary, 418-420 492 Retention, 326-327
dental, 420 Record theorems concerning, I
functional, 324 casts, 513 through 10, 326-327
 Index 575

Retraction, 189 leeway space and, 127 in adult, 478-479 Splint

Retrognathic profile: and Class Shape management, 360-383 diagnostic, 218
. n malocclusion, 185 anomalies (see Anomalies, categories, and symptoms, occlusal, 529-531
Retrognathism: mandibular, 272 shape) 361 repositioning, 539
Retruded contact position, 243 diagnosis, '355 problems, 233-235 Spot welders, 513
"Retrusive" pattern: of occlusal of supernumerary teeth, 354 needs in mixed dentition, lo- Spot welding, 513
development, 131 variations in, 354-356 calization method for, Spring(s)
Roentgenography (see Sheaths: lingual, 517 238
alignery anterior, 526
Radiography) Shields, oral, 535, 536 regainer (see Regainers) auxiliary, 519
Root modified, to train mentalis relationships to tooth size correct positioning, 520
crown ratios, and eruption, muscle, 537 during mixed dentition, effect of increasing the length
227 Sicher's hypothesis: of craniofa- 235-240 of a spring on load, 312
development, 226 cial growth, 50 supervision, 364-373 knee, 527
length Simon system, 188-189 Class I molar relationship, regainer, 527
mean, by chronologic age, Sinus: cervical, failure of com- 370 for uprighting molar, 482
113 plete obliteration, 24 in Class n, 376-378 Standard deviation, 13
at moment of emergence Size (see Teeth, size) with crossbite treatment, Statistical normality, 13
through alveolar crest, Skeletal 391 Stature
113 bases, gross disharmony be- in end-to-end molar rela- of boys, 170
position, result assessment, tween, during adoles- tionship, 374 of girls, 170
439 cence, 450 flush terminal plane proto- study of, IS
resorption, 321-322 crossbite (see Dysplasia, col, 372-377 Strain, 310
by odontoclasts, 322 skeletal) with mandibular lip bumper Strap: neck, 525
orthodontic treatment and, responses to loose removable and maxillary utility Stress: definition, 310
325-326 appliance, 534-535 wire, 371 Subspinale, 256
result assessment, 440 Skeleton, craniofacial (see Cra- molar correction during, Sucking, 152-155,544-546
Rotation, 310 niofacial, skeleton) 371 appliance to correct, 546
center of, 311 Skull: specimen at 8 months, protocol for Class I, 369 clinically significant, 545
of mandible (see Mandible, 138 with traction in Class n intractable, 545-546
rotation of) Sliding cap, 522 type A malocclusion, lip-sucking, 551
Socioeconomic factors: in 402 normal,545
spacing and, 357, 360
s growth,
Soft tissue
12 Spacing, 104, 356-360
subclinically significant, 545
during adolescence, 435, 442
Salivary gland: development, profile between maxillary central in- thumb- (see Thumb-sucking)
30-31 during adolescence, 435 cisors, 357~358, 360 Supernumerary teeth, 121
Sanin-Savara Analysis, 229, 233 in adult, 473 in congenitally missing teeth, during adolescence, 442
result assessment with, 439 356 diagnosis, 354
Schwartz appliance, 525
Science Sold~ring, 512-513 generalized, 360 at midline, 357-358
developmental, divisions of, bracing fingers and hands during adolescence, 442 treatment, 354
9-10 during, 513 localized, 356-357 conical crowns, 354
normal, changes wrought by Space during adolescence, 442 in primary dentition, 354
in arch perimeter, regaining etiology, 356-357 in variations in size and
new paradigms during
scientific revolution, 48 of, 363-364 in permanent tooth prema- shape, 354
Scott's hypothesis: in craniofa- for blocked mandibular sec- ture loss, 356 Supradentale, 256-258
cial growth, 50 ond premolar, 489 sucking and, 357 Supramentale, 258
Screen: oral, 535 gross discrepancy problems, midline Supraversion, 189
Screw: regainer, expansion, 528 373 from incisor congenital ab- Surgery
Self: comparison with, in diagnosis, 373 sence, 358 adjunctive, 326
cephalometry, 249 precautions, 382-383 problems, percentage of craniofacial growth and, 53
Sella, 258 serial extraction protocol cases showing, 357 Sutural membranes, 56
-nasion, 259 in, 379 as part of normal growth, 360 Suture
Semantics: of swallowing, 208- treatment protocol, 373- ., qf small teeth, 360 frontozygomatic, 258
209 382 sucking and, 360 nasal, frontomaxillary, 258
Semi-impacted molar: mandibu- maintainers tongue and, large, 360 Swallow
lar second permanent, band, 520 of unerupted teeth, 356 activity, temporal muscle pal-
446 band and loop, 362 Speech pation to ascertain, 206
Sensory abilities: evaluation of, fixed, technics, 519-521 analysis, 215-216 checking type of, 172
197-206 loop, 520 articulation, mini-test of, 213 evaluation in orthodontic ex-
Sex multiple, 531 orofacial physiology and, 83- amination, 172
differences in eruption of per- multiple, acrylic, 530 84 reflex, and equilibration, 555
manent teeth, 117 in malocclusion with perio- Sphenoethmoidal point, 258 result assessment, 439
emergence of permanent teeth dontal disease and tooth Sphenoid bone: cephalometry retained infantile, 549-550
by, 115 loss, 485 of, 251, 254 tongue-thrust, 155
576 Index
Swallowing, 81-82, 208-215
diagnosis of types, differen-
tial, 209
electromyography of, 210
examination methods, 209-
212
in infant, 92-93
infantile behavior in, retained,
212-215
lip during, lower, 210
in malocclusion etiology, 208
misinformation about, 208
requirements of, 82
semantics of, 208-209
tongue in, 154
tongue-thrust swallow, com-
plex,212
treatment goals, 209-212
Symmetrograph: to determine
asymmetry in dental
arch, 241
T
Technics, orthodontic, 511-560
clinical, basic, 513-518
laboratory, basic, 512-513
Teeth
absence, 356
multiple, during adoles-
cence, 441-442
anomalies, 228
arrangement in jaws, 141
congenitally missing, 348
during adolescence, 440
causes, 348
diagnosis, 348-349
expression of evolutionary
changes in dentition, 348
heredity in, 348
spacing in, 356
treatment, 349-354
development of, 30
analysis, 226-228
stages based on work of
Nolla, I11
enlarging in adult, 479
fields, 104-105
force on, parallelogram repre-
senting, 312
formation, early stages, 101
groups
in malposition, naming,
189
transverse variations, 189
vertical variations, 189
impaction (see Impaction)
large, 355
during adolescence, 442
loss
arch perimeter changes re-
sulting from, 125
with incisal overlap and
periodontal disease, 494
with malocclusion (see
Malocclusion, with peri-
odontal disease and tooth
loss)
treatmentr 351-354
in malocclusion, 150-151
malposed individual, 175
malpositions
naming, 189
orthodontic treatment and,
326
measuring gauge for, 236
missing
congenitally (see Teeth,
congenitally missing)
treatment in adult, 480
movement
in adult, 479
cusp tip before and after
movement, 311
experimental, 315-319
orthodontic (see below)
physiologic, 313-315
tipping, 320
types of, 311-312
movement, orthodontic, 315-
319
applied force and time, 321
character of bone in, 319-
320
factors influencing, 319-
321
force application, 320-324
forces and, 311
physiologic activity, 320
translation, 320-321
number, 228, 348-354
e,xaminationof, 174
problems during adoles-
cence, 440-443
occlusal relationships of,
175-178
permanent
ankylosed, during adoles-
cence, 446-447
calcification of, 111-112
development of, 111-121
emergence, 115
emergence by age, 115
emergence by sex, 115
eruption (see Eruption, of
permanent teeth)
loss of, 162, 351-352
loss during adolescence,
441-442
loss of, multiple, 354
loss of, premature, spacing
in, 356
missing, 120-121
resorption of, 141
size of, 119-120
supernumerary, 121
position(s), 228
arch dimension asymme-
tries and, 241
developmental changes in,
129
positioners, 539-541
construction, 540
limitations, 540-541
teeth setup for construction
of,541
primary, 106-111
ankylosis, 107-108,388-
391
anomalies, 107
calcification of, 106
emergence, differences in
times of, 107
emergence variability in
ages, 106
eruption of, 106
eruption, precocious, 106
formation, average age for
critical events in, 106
loss of, arch perimeter
maintenance in, 361
loss of, multiple, arch pe-
rimeter maintenance in,
363
loss, premature, 159-162
occlusal wear of, 152
resorption, 107
sequence of emergence,
106
shape, 107
size, 107
size, crown, 107
undue retention of, 356-
357
relationships to skeletal sup-
port, 245
separation before bands, 515
method, 515, 516
shape (see Shape)
size, 228-240
analysis of Sanin-Savara,
229
diagnosis, 355
examination of, 174-175
osseous bases in, 355
reduction in adult, 479
relationship to supporting
structure size, 229-235
" .relationships to available
•. space during mixed den-
tition, 235-240
relationships of groups of
teeth, 229
sizes arrayed as deciles,
230-231
supernumerary teeth, 354
variations in, 354-356
variations during adoles-
cence,442
small, 355
during adolescence, 442
spacing of, 360
spacing (see Spacing)
stripping for space for
blocked mandibular sec-
ond premolar, 489
succedaneous, eruption of,
113
supernumerary (see Supernu-
merary teeth)
systemic disturbances and,
107
threshold of receptors sur-
rounding, 87
transpositions (see Transposi-
tions of teeth)
unerupted, spacing, 356
Temporomandibular joint
capsule palpation, 217-218
craniofacial ,growth and, 324
development, 32, 33
dysfunction, 426-427
during adolescence, 468
during adolescence, back-
ground, 468
during adolescence, treat-
ment,468
analysis, 216-218
definition, 426
diagnosis, 426-427
treatment, 427
evaluation in adult, 473
functional relationships of,
study of, 178-181
functions, 66
analysis, 244-245
after orthodontic treatment,
326
growth, 66-67
effects on dentition and oc-
c1usion, 66
issues concerning, clinical
and theoretical, 66-67
mechanisms and sites, 66
guidances
active, 89
passive, 89
result assessment, 440
sounds, 217
Tendon: of digastric muscle (in
rabbit), 90
Tension
active, 79-80
dentoalveolar tissue reactions
and, 317
increase in striated muscle, 78
passive, 79-80
relationship to muscle length,
79
total, 79
Tensors: to show form differ-
ence, 281
Tetracycline: as bone marker (in
monkey),42
 Index 577

Throat cast after, 549 procedures, 348-427 symptomatic, 339

examination of, 173
neck angle, obtuse, 504-508
Thrusting (see Tongue,
-thrusting)
Thumb-sucking, 152-155
correction with appliance, 544
force application to dentition
in, 154
forces during, 308
orofacial muscle adaptation
to, 153
Thyroglossal
..cyst, 26
fistula, 26
Tipping: of teeth, 320
Tongue
correction with sugarless fruit
drops, 548
development of, 26
diagram of, 26
examination of, 173-174
functional, 203
morphologic, 203
large, and spacing, 360
posture, abnormal, 360, 550-
551
differential diagnosis,
205
with open bite, 205
open bite due to, 551
posture and incisor position,
119
posture in malocclusion,
Class Ill, 204
posture in newborn, 91
posture in open bite, 156
posture, variations in, 203
reflexes, 81
relationship to palate, 27
result assessment, 439
in swallowing, 154
tactile signals to, 547
-thrusting, 154-156,546-550
causes, 546
complex, open bite in, 155,
212
complex, open bite due to,
548
diagnosis, 546
forces of, 308
open bite due to, 547
swallow and, complex,
treatment, 546-550
treatment, complex thrust,
548-549
treatment, complex thrust,
treatment, simple thrust,
546-548
visual sigllals to, 547
Tooth (see Teeth)
Torsiversion, 189
Traction
appliance, extra-oral, 524-
525
cervical, 525
extra-oral, 313
chin cup for, 526
in Class 11 malocclusion,
399,400
in Class 11 type A maloc-
clusion, 402
Translation, 310, 313
tooth movement and, 320-
321
Translocation: definition,
Transplantation: of cuspid, max-
illary, in impaction, 446
Transposition of teeth, 386-387
bicuspid, first, 387
cuspid, maxillary, 387
diagnosis, 386
etiology, 386
treatment, 386-387
203-
Transversion, 189
Traumatic occlusion: forces of,
308
Treacher Collins syndrome,
Treatment
adolescent (see Adolescent
treatment)
of adults with good oral
health, 473-475
. attitude in, 473
diagnosis, 473
illustrative cases, 475
motivation of, 473
changes due to, 125
compromise, 339
definition, 168
dimensional changes during,
124-125
diphasic, 334
early, 334, 343-431
benefits of, 346
difficulties in, 346-347
diphasic, 346
goals for, defining, 347
212 goals of, misperceptions of,
346
improper, 346
problems, clinical, 348-
427
rationale for, 345-346 Tubes: buccal, 517
results, assessment of, Tumors: and malocclusion, 159
347-348 Twin-wire appliance, 522-524
satisfactory response to,
definition of, 347
u
treatment planning, 347
understanding, 345-347 Unerupted teeth: spacing, 156
unsatisfactory, manage- Universal appliance, 524
ment, 348 Universal bracket, 523
ideal, 338-339 "U" principle, 45
late, 334
limiting factors in, 340-342 v
of dentist, 341
of individual patient, 340- Vacuum-formed appliance, 526
341 Vacuum-formed regainer, 529
from nature of orthodon- Validity: of landmark in cepha-
tics, 341-342 lometry, 256
paucity of adequate com- Valving: articulatory, place and
9 promising alternative manner of, 213
treatment, 342 Variability, 13-16
with orthognathic surgery (see significance of, 16
Orthognathic surgery Velopharyngeal incompetency,
with orthodontic 83
treatment) Vestibular appliance (see Appli-
palliative, 339 ance, vestibular)
plan
for adult for orthodontic
w
treatment, 473-475
in molar uprighting, 482 Wainright's Rule: to predict
in orthognathic surgery eruption emergence,
25 with orthodontic treat- 226-228
ment, 497 Weights
planning, 332-342 of boys, 170
available space, 334-335 of girls, 170
available treatments, 335 Welders: spot, 513
cephalometry for, 249 Welding: spot, 513
common mistakes in, 342 Wire
definition, 168 archwire (see Archwire)
in early treatment, 347 bending of, 512
in permanent dentition, 340 gold, to stabilize mandibular
in primary dentition, 340 incisors in ancient Greek
in primary dentition, con- skull,3
traindications, 340 "light," 313
problem, discussion of, brackets, 522
333-334 twin-wire appliance, 522-524
selection of cases in gen-
eral practice, 333-339 z
skeletal pattern, 334
summarization of plan, 338 Z-score chart: for Class 11 mal-
timing of, 334 occlusion, 274
.,
in transitional dentition, Zygoma development lack: in
340 Treacher Collins syn-
protocols, arborization to seg- drome, 25
regate various protocols, Zygomatic
333 bone, cephalometry of, 251,
stabilization of, 339 254
successful, 335-339 processes, 258