How to Overcome Malocclusion and achieve perfect smile Part

How to Overcome Malocclusion and achieve perfect smile Part – 3

Introduction

Treatment approaches for Class II malocclusion include non-extraction and extraction approaches. Non-extraction involves moving maxillary teeth distally, while extraction involves removing premolars. Growth modification, camouflage, and surgical correction are current treatment approaches. Growth modification uses appliances to alter skeletal relationships, while camouflage aims to disguise skeletal problems by repositioning teeth. Surgical correction involves procedures like mandibular advancement and maxillary impaction. Class III malocclusion should be treated early to prevent worsening. Myofunctional appliances, chin cup therapy, and face mask therapy are common treatments. Fixed appliances can be used in the mixed-dentition stage. Risks of orthodontic treatment include pain, gingival inflammation, demineralization, and root resorption. The Index of Orthodontic Treatment Needs is used to determine the severity of malocclusion and the need for treatment. Malocclusion does not correct itself naturally and usually requires intervention.

Treatment approaches to Class II Malocclusion

There are 2 alterations for the treatment of a dental class II malocclusion.
Non-extraction approach involving distal movement of maxillary teeth.
Extraction approach involving unilateral or bilateral dental extraction.

Non-extraction approach:
If a class II dental relationship is caused by mesial drift of maxillary permanent molars due to premature loss or small maxillary primary molars, the maxillary permanent molars may be moved distally to achieve a normal class I relationship.
Extraction approach:
The space is obtained by extracting the maxillary I or II premolar. Current treatment approaches:
1. Growth modification
2. Camouflage
3. Surgical correction

2.1 Growth modification

The goal is to alter unacceptable skeletal relationship by modifying the patients remaining facial growth.
3 types of orthodontic appliances are used

1. Extra oral force appliance: Head gear
2. Functional appliance
3. Inter-arch elastic traction

2.1.2 Functional appliances:

The functional appliances are designed to position the mandible downward & forward to stimulate the mandibular growth.
Types of Functional Appliances:
- Removable tooth-borne appliances: activator, bionator, twin block appliances.
- Removable tissue-borne appliances: Frankels appliance or Functional Regulator.
- Fixed tooth-borne appliances: Herbst appliance.

2.1.3 Inter-arch elastic traction

Inter-arch traction from the anterior part of the mandibular arch to the posterior part of the mandibular arch is commonly referred to as class II elastics.
It delivers the anterior force to the mandibular teeth & posterior force to the maxillary teeth, so it results in protraction of mandibular teeth & retraction of maxillary teeth.
It also causes some extrusion of mandibular molars & maxillary incisors that accompanies anteroposterior changes.

2.2 Camouflage

Orthodontic camouflage is a viable alternative for the treatment of mild-to-moderate skeletal discrepancies in the maxillary structures.

The therapeutic objective is to correct the malocclusion while trying to disguise the skeletal problem.

Goal:

To disguise the unacceptable skeletal relationship by orthodontically repositioning of teeth in the jaws.
It causes the protraction of the mandibular teeth and the retraction of the maxillary teeth.
The appropriate patients are older adolescents

Two types:

1) Camouflage without extraction

2) Camouflage with extraction

Camouflage without extraction

It is indicated when space is present in the dental arches.
Non-extraction treatment for retracting the maxillary dentition and protracting the mandibular dentition to eliminate overjet and achieve normal posterior occlusion.
Once the space has been gained, the remainder of the fixed appliance is placed, & alignment & levelling are completed before space closure.

Camouflage with Extraction:

Extraction of max. Premolars are indicated to gain sufficient space.
If there is no crowding or protrusion, there is no need for extraction.
The limitation of this approach is to extract the max II molars & mandibular I or II premolars.
Once the extraction has been completed, we have to place a fixed orthodontic appliance to correct the protrusion.

2.3 Surgical Correction

Divided into 5 categories:

1) Mandibular advancement

2) Mandibular total sub apical advancement

3) Maxillary impaction

4) Anterior maxillary subapical setback

5) Combined surgery

Mandibular advancement:
- Indicated in mandibular deficiency.
- Intra oral Ramus Osteotomy or Sagittal Split
- It is a method for advancing the mandible.
- L” or “C” osteotomy is preferred.
- Orthodontic treatment required to prepare a patient for mandibular advancement includes tooth alignment, determining the final vertical anteroposterior incisor positions, and ensuring interarch compatibility.
Mandibular total sub apical advancement:
- Used to advance the mandibular dento alveolus.
- Indications:-
  - Short, lower face height
  - Excessive lower bite
- Goal:-
  Correcting the anteroposterior occlusal discrepancy and eliminating excessive overjet will advance the entire dento-alveolar segment.
Maxillary Impaction:
- It is indicated for vertical max excess
- Bone is removed at osteotomy site to permit superior re-positioning of maxilla
- As the maxilla moves up, the mandible rotates upward and forward around the condylar axis, correcting the anteroposterior occlusal discrepancy.
Anterior Max Sub-apical Setback:
- It is indicated if max excess is limited to anteroposterior dimension with no associated max vertical and transverse skeletal problems.
- The treatment goal is to use the max I pre-molar space to surgically retract the max anterior teeth while maintaining a class III molar relationship and achieving a class I canine relationship while reducing overjet.
Combined surgical approaches:
- It is not uncommon to require a combination of max and mandibular surgeries to adequately address the malocclusion
- In this situation, a mandibular advancement is required in addition to the max impaction to complete the anteroposterior correction.

Class II, Div. 2, is treated by:

Reduction in incisal overbite.
Alteration of incisal inclination.
The deep overbite is reduced by using anterior bite planes or fixed appliances with anchor bends or reverse curves of spee.
The incisor inclination often necessitates the use of torquing springs to move the upper incisor roots lingually & the crowns buccally.

Management of Class III Malocclusion

It should be recognised & treated early due to the following reasons:

Early interception reduces the severity of the developing malocclusion.
Class III malocclusion, characterised by anterior cross-bite, often results in retarded maxillary growth due to the locking of the maxilla within the mandible.
The occlusal forces on the mandibular incisors exerted by the maxillary incisors in cross-bites encourage the continued forward growth of the mandible, further worsening the pre-normalcy.

Interception during growth:
- To avoid skeletal malocclusion, Class III malocclusion with an underlying skeletal malrelationship must be detected early in development.
- Aim: To improve the skeletal discrepancy, thereby providing a more favourable environment for future growth.
- It also helps to eliminate or reduce the chances of orthognathic surgeries in the future.
- Myofunctional appliances: The Frankel III appliance can be used to intercept a class III malocclusion due to maxillary skeletal retrusion.
- Chin cup therapy is used in the treatment of Class III malocclusion with a protrusive mandible & normal maxilla.
- Face mask therapy: also known as REVERSE PULL HEADGEARS. Used to treat mild to moderate skeletal Class III malocclusion caused by a retrognathic maxilla and hypodivergent mandible.

Treatment using Fixed Appliances:

Best done in mixed dentition, before the eruption of permanent canines.
In patients with mild to moderate class III skeletal pattern, a combination of retroclination of lower incisors & proclination of upper incisors may be required.
Class III intermaxillary elastic traction from the lower labial segment to the upper molars can also be used to move the upper arch forwards & lower arch backwards.
However, care is required to avoid extrusion of molars, which will reduce overbite.

3. Treatment of anterior crossbite:

Mild anterior cross-bite can be treated using lower anterior inclined planes or removable appliances incorporating screws designed for anterior expansion.

4. Treatment of posterior crossbite:

Class III malocclusion is frequently associated with posterior crossbite.
It can be treated through rapid maxillary expansion.

5. The Role of Extractions:

Class III malocclusion, which is characterised by mild mandibular prognathism and lower arch crowding, can be treated by extracting the lower first premolars and then using fixed mechanotherapy.
This is an orthodontic concealment of the underlying skeletal malocclusion.

6. Treatment of severe Class III malocclusion:

Severe class III malocclusion after growth completion is treated with surgical and corrective procedures.
Class III maxillary deficiency is treated with maxillary advancement procedures such as a leFort I osteotomy.
Mandibular prognathism causes Class III malocclusions, which are treated with mandibular setback procedures.

7. Treatment of Pseudo-Class III Malocclusion:

Occlusal prematurity-induced pseudoclass III malocclusion improves after the cause is removed.

Risks of Orthodontic Treatment

Pain and discomfort:

This is one of the most commonly occurring adverse effects; after having an orthodontic brace fitted and adjusted, patients will normally feel some pain or discomfort. Also, you can experience rubbing and ulcers on the cheeks from the appliance while first getting used to the brace or from long wires, which can occur as the teeth move into the correct position.

Gingival inflammation (red swollen gums):

Most patients will experience some gingival inflammation when wearing fixed appliances. This is usually easily reversible once the braces are removed, but it is best to avoid it happening in the first place. Poor oral hygiene can cause permanent damage to the teeth, also leading to the potential risk of periodontal disease and gingival recession. Active periodontal disease must be treated and stabilised before orthodontic treatment.

Demineralisation and Caries (brown, white marks & holes in the teeth)

Demineralisation and caries are also common risks of orthodontic treatment with both fixed and removable appliances. Maintaining good oral hygiene, getting diet advice and attending your regular dental check-ups can help to prevent this.

Pulpal hyperaemia (Increased blood flow)

Some level of pulpal hyperaemia and inflammation can be expected during orthodontic tooth movement. Such changes are reversible and cause no long-term problems. But In teeth that have had previously trauma, the blood supply may already be compromised, with a greater risk of loss of vitality. Patients with a history of, or signs of, previous trauma are always warned about the risk of loss of vitality.

Root resorption

This is unavoidable when moving teeth with orthodontic treatment and will occur in all patients. However, these changes to the roots are usually insignificant; a small amount of resorption should not affect the long-term health of the teeth.

Tooth movement (relapse)

After orthodontic treatment, you will need to wear retainers to avoid relapse. Retainers are a lifelong commitment. Diastemas (spaces), rotations (twisted), and increased overjets (teeth sticking out) all have a high potential for relapse due to teeth wanting to return to where they come from and soft tissue factors, e.g. the lips and tongue position.

Treatment time

An estimate of treatment length will always be given but can never be accurate as factors such a speed of tooth movement or patient factors like breaking the appliance or not attending appointments can delay treatment.

Extensive root resorption

This rarely occurs but it can happen, which can affect the health of the teeth. There are no reliable predictive factors; in some cases, patients whose teeth have abnormal root form (root shape), the distance the teeth move, treatment time and heavy forces may have an increased risk or damage from other teeth in your mouth. However, extensive resorption can occur unexpectedly due to unpredictable individual susceptibility.

Enamel trauma

This can occur during treatment due to wear from brackets on the lower teeth. This is a particular problem with ceramic brackets and why patients are advised against having them on the lower teeth.

Ankylosis (tooth fused to the bone; will not move)

Ankylosis of a tooth due to trauma or other unknown factors may prevent the eruption of an unerupted or impacted tooth.

Index Of Orthodontic Treatment Needs(IOTN)

The IOTN is the Index of Orthodontic Treatment N
It’s a very important aspect of orthodontics and proves the main method used to objectively determine whether a patient actually needs orthodontic treatment.
It must be noted that the IOTN looks at the NEED for treatment but doesn’t consider how complex the treatment will prove to be.

The IOTN is divided into two components:

Dental Health Component (DHC)
Aesthetic Component (AC)

IOTN: Dental Health Component (DHC)

The Dental Health Component is used to determine the nature and severity of a patient’s malocclusion. It is a graded system from 1 to 5 (5 being the most severe) and the aim is to identify the worst aspect of the patient’s malocclusion. It is also a hierarchical scale, which gives priority to some problems over others. The acronym used for this is:

Missing
Overjet
Crossbites
Displacements
Overbite

Generally, the following rules apply:

Grade 1—virtually perfect
Grade 2: minor irregularities, including a slight overjet or open bite
Grade 3: greater irregularities, including a greater overjet, open bites, deep bites and bigger displacements
Grade 4: severe irregularities, including a large overjet, large reverse overjets affecting speech and large displacements
Grade 5: extreme irregularities which need treatment, including impacted teeth (such as ectopic canines) and severe hypodontia
The IOTN 5i is a very useful grade to know as it involves impacted teeth, excluding third molars, and is very commonly used.
It is the DHC which primarily decides if a patient needs treatment. An IOTN of 4 or 5 permits an individual to have treatment under the NHS. Usually, with a score of 4, the AC is also considered.

IOTN: Aesthetic Component (AC)
The Aesthetic Component is useful in a number of ways. It is made up of 10 colour photographs, which go from 1 (best appearance) to 10 (‘worst’ appearance). It is essentially looking at a patient’s level of ‘dental attractiveness’.
The clinician attempts to match the patient to one of the images based on their malocclusions. Obviously, this may prove to be quite subjective. However, the AC can also be used to show patients that their malocclusion may not be as bad as they believe.
When there are borderline cases based on the DHC (Grade 3), then the AC is considered. If the AC is 6 or more, then generally the patient will receive treatment.

Ques: Is Malocclusion bad?

Having malocclusion—when your upper and lower teeth don’t line up—can affect everything from your dental health to your mental health. Left untreated, malocclusion increases the chance you’ll develop cavities or gum disease. People with malocclusion often struggle with self-esteem and social anxiety. Fortunately, it’s never too late for treatment.

Ques: Can malocclusion be treated?

Yes, malocclusion can be treated. It is usually treated with orthodontics or braces. Some more serious malocclusion might require surgery.

Ques: Can malocclusion fix itself?

It is important to note that epidemiological studies indicate that regardless of the type of malocclusion, it will not correct itself naturally with time and growth. In fact, most dental and skeletal malocclusion problems found in children tend to worsen over time without specialist intervention.

How to Overcome Malocclusion and Achieve a Perfect Smile Part-1

Malocclusion: its causes, symptoms, treatments, and more. Learn how this common dental condition affects bite alignment and oral health.

Learn more