sr Om Prakash KharbandaPreface Acknowledgements Contributors Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 PTT ORD Rett ConCd Consequences of malocclusion and benefits of orthodontic treatment + Consequences of malocclusion * Benefits of orthodontic treatment « immediate benefits * Long-term benefts » Limitations of arthadontic treatment + Aesthetic dentisry procedures complementary t0 cexthodontics Psychological implications of malocclusion and orthodontic treatment + Psychological implications of malocclusion « Psychological factors motivating patient to seek orth- ‘dlontic treatment « Motivational factors in adults» Orthognathic surgery patients ® Functional factors * Malocelusion associated with dentotacial deformities # Cleft lip and palate * Maiocclusion due to trauma Epidemiology of malocclusion and orthodontic treatment needs «Secular rendsin malocclusion prevalence « Prevalence of malocclusion in North America and Canada + Prevalence of malocclusion in Europe + Prevalence of malocclusion in South Arica * China and ‘Mongoloid races « Prevalence of malocclusion in india * Malocclusion in south India ® Malocclusion in, ‘orth India * Malooclusion in Indian tribals ¢ Summary f malocclusion in india ° Orthodontic treatment needs of india Classification and method of recording malocclusion + Recognition of malocclusion Historical review « Classification of malocclusion # Intra-arch malocclu sion Interarch malocclusion « Systems of classification * Angle's concept af malocclusion # Simon's, Classtication and ‘canine law'« Brtish incisor classification * Ackerman and Profit classification * Katz premolar classification « Classification in primary dentition Recording the severity of malocclusion: orthodontic indices + Qualitative methods of recording malocclusion # Quantitative methods of recording malocclusion * Occlusal index Treatment priory index (TP!) + Handicapping malocclusion assessment rocors + Index of enhodontic treatment needs (IOTN) « Limitations of IOTN + Peer assessment rating ® Index. ‘of complexity, outcome, and need (ICON) * ABO discrepancy index Growth of the craniofacial complex «+ Prenatal development» Genetic control of craniofacial embryogenesis * Concepts of skeletal growth * Concept of mechanotransduction « Methods of studying physical grawth « Postnatal growth * Growth of nasomaxilary complex Growth of the mandible + Growth trends « Timing of craniofacial skeletal, {growth « Clinical implications Altered orofacial functions on development of face and occlusion + Orofacialunctions and craniofacial development Transition from infantile swallow to mature swallow + Pathophysiology of habits « Sucking habits» Classification of orofacial habits * Prevalence of orofacial 13 46 55Chatper 8 Chapter 10 Chapter 11 Chapter 12 Chapter 13, Tabs « Non-nutiive sucking habits * Types of thumb sucking » Effects of digit sucking on oral Styctures « interception of habit * Tongue thrusting, swallowing habit or eelained infantio swan 4, Causes of tongue thrusting « Diagnosis of tongue thrusiing swallow «Interception and team nia tongue thrusting + Mouth breathing habit Effects of oral breathing » Clinica features Degree of mouth breathing * Orthodontic implications Bruxism + Aetiology Clinical featuree s Tetons Biology of orthodontic tooth movement salute of orthodontic tooth movement» Orthodontic and orthopaedic tooth mavement « Phases of {ooth movement « Optimal orthodontic forces * Tissue reactions to orthodontic forces « Poneto, tigament remodeling histological ndings «Pathways of tooth movment Arachidone acidic tes prostaglandins and leukotrienes + Mechanical strain as frst moseonger = Curtent view of coh Cdontic tooth movement Immediate early genes (IEGs) expression « Pain and mobilly wi enocsec ticappliances Clinical evaluation prten' history «Clinical assessment ofa child wih a potential for malocclusion Locking for signs of Patent maloccusion in a three-year-old child: characteristics of face and vention at 3.6 yea $,Cr0ss abnormalities of face form + Primate spaces « Signs of potential malodelusion just belong ‘ruption of permanentincisors * Cinical assessment ofa chid wth developing or established melnence ‘f child during mixed dentition stage « Examination of face * Dynarn SBilattne maxilary octusal plane Functional examination including TMY « Tenderness on palpation 4 Bange of motion « Trauma and distocation Speech and malocclusion « Parts of speech « Ancoxe, Iment of speech in relation to malocclusion and dental anomalies « Clinical examination of Gris see ‘Sufpected deleterious habit(s) * Clinical assessment of an adult seeking orthodontic treatwont 5 staoral examination + Examination of soft issues of oral cavity © Examination of oral host od Periodontium * Examination o dentition andl acciusion Analysis of diagnostic records 7 Mimum set ot records needed for a detailed orthodontic case analysis « Orthodontic study models Fseyluation of study models * 2. Analysis of study models « Step by step procedure fer use of probabilly tables * 2. E models or digital models « Facial photographs ® 1 Photographs for forcteal Sri Cephalometric evaluation (cephalogram-lateral view) « Gthopantomogram (panoramic adios, raphy of the maxila and mandible) * Analysis of diagnostic records for assessing growin « Porc gTaath velocity * Chronological age* Skeletal maturation « Cervcal vertebrae maturation index (va) {Dental age * Facial growth spurts « PA view cephaiograms « Recent advancements i oft agnostic aids * Stereophotagrarmmetry* Technetium scan * 3D GT and cone berm CT Introduction to cephalometrics: historical perspectives and methods ‘istorical perspective «First cephalostat © 2Dto 3D cephalometrics * Cephalometric noms * Boon. Bash growth study # Burlington growth study for craniofacial growth « Cephalometlc apparaice {7 eacthalder «Image receptr system » Radiographic apparas Types of cephalogram according ‘2 patlentcrientaton + Patient positioning for recorcing a cepnalogram * Techrigue of laking ophalogram » Indications and uses of cophalograms ® Features ofa good cephalogram* Location G@ anatomical structures on a cephalogram Unexpected findings on a cenhalogram Furdameriac oh cephalometric analysis e Cephalometric norm e Studies on cephalometic norms in India Nacsa ‘cephalogram * Cephalometric analysis * Definitions of cephalometric landmarks « Lancinene aa Cranial base * Landmarks on mandible * Landmarks on manila « Dental landmarks Downs’ analysis * Basis of Downs’ analysis * Skeletal pattem + Denture pattern # Population groups Steiner's analy: + auical use of reference planes and parameters * S-N plane substituted FH plane NA and NB Blanes Skeletal analysis + Dental analysis © Soft issue analysis « Steiner's none ler melons ‘interpretation and comments Steiner chevrons/sicks * Cephalometric superimposition Inerre tations and Summary 124 152 167 172Chapter 14 Chapter 15 Chapter 16 Chapter 17 Chapter 18 Chapter 19 Chapter 20 Seo) Chapter 21 Chapter 22 Chapter 23 Chapter 24 oo Tweed’s analysis + Development ofthe diagnostic facial rangle « Cephalometric valuosefoct decision fo treat extraction or non-extraction « FMA and its relationship with IMPA * Head plate coraction + Tweed norms for Indians Ricketts’ analysis ‘+ Robert Murray Ricketts + Ricketts cephalometric analysis « Skeletal landmarks + Basic reference planes + Eleven factor summary analys's mensions of face and Sassouni analysis + Venicallinear dimensions and ratio of face « Sassouni's radiographic cephalometric analysis ¢ Planes * Jarabak ratio of anterior and posterior facial heights (facial height ratio—FHR) « Signs of vertical ‘grown rotation Soft tissue analysis of face + Need for sot tissue analysis « Methods of obtaining soft issue profile on a cephalogram * General appraigal of soft tissue protle « Cephalometric analysis «Indian norms PA cephalometric analysis += PA cephalometric analysis * Set-up for PA cephalametry « Evaluation of PA cephalogram # Some important landmarks used in PA cephalogram « Planes in PA cephalogram « Grummons analysis ‘Ricketts analysis * Maxilomandibular ciffarentia values and ratio « Limitations of PA cephalometry Computerised and digital cephalometrics “= Computerised and clgital cephalometrics « Computerised cephalometics vs digital ephalometrics ‘= Acquisition of digital image + Limitations of conventional cephalometric analysis * Computerised cephalometrios: advantages * Advantages of digital computed radiography (CR) and direct digital radiography (ddF) + Cephaiometrics without X-rays « Digital cephalomety « Computed radiography (CA) «Direct cigtal radiography (ddA) * CR caphalometrics « Design characteristics of photostimulable phosphor cassettes Errors in cephalometrics + Limitations of a cephalogram « Errors during making a cephalogram « Errors during X-ray tracing *Erors of cephalometric landmark identification ye Woe Components of contemporary fixed orthodontic appliance + Components o fixed orthodontic appliance « rackets Bracket material» Bracket base * Bracket ody and slo » The wings # Power arm » Bracket ID + Seltigaing brackets + Aesthetic brackets * aslo brackets « Ceramic brackets» Futuristic bracket design * Limitations of curent bracket Systems « Treatment customization «Intraoral orhodonte accessories « Orthodontic bands + Orth dontic wires » Col springs Orthodontic archwires: material and their properties «= Wire dimensions # Evolution of archwites from past to present « Stainless steel wires # Cabaltchrome Uwies # Nickel-ttanium wires «B-Titanium wires « a-ttanium wires « Nickel ree stainless steel and TMA Wires © Dual lex archnires « Supercable wire # Turbo wire or braided nickel-ttanium rectangular wire ‘Variable modulus orthodontics « Variable transformation temperature « Aesthetic wires « Archforms {nd preformed archwires « Effects of oral enviranment on properties of orthodontic archwires Rubber and synthetic elastics and elastic accessories in orthodontics + Rubber and synthetic elasics Elastics bands « Stocage and dispensing of elastics «Instructions on ring of elastics » Complications of use of natura atex elastics Force decay ® Elastomeric acces- sories Elastic chains (power chains) « Ligation of archwire to brackets with elastic module ‘Anchorage in orthodontic practice + Anchorage * Anchorage loss # Anchorage sources for removable appliance # Anchorage for fixed appliance « Factors affecting anchorage requirements « Treatment planning 7 181 186 194 204 213 221 227 238 254 261Chapter 25 Chapter 26 Chapter 27 Chapter 28 eee Alternative anchorage through temporary anchorage device (TAD) + Alternative anchorage ¢ Historical perspective « Defrition and classification «incications forthe use Cl temporary anchorage devices « Limitations of temporary anchorage device « Complications * Case report «Treatment options Principles of biomechanics and appliance design Basics of biomechanics Types oftooth movement «Analysis of common force systems produced by orthodontic appliances » Inrinsc characterises of materials « Basic propertcs of otnodetie wae * Orthodontic archuire materials + Characteristics of ideal appliance « Application &f procrplee acl Properties Role of removable appliances in contemporary orthodontics {Removable applisnoos (RA) + History of removable appliance indications of removable appliances * Acjvaniages¢ Limitations and disadvantages «Treatment effectiveness Haley apohance era nc plate ¢ Crozat appliance + Components ofa Hawley type temiovabe appliance + Slens hr arplones fabrication and cirical management Laboratory requisition and appliance design © Applarce coke, fy and activation «Bite plane «Activation ofthe acive wire components «Sula ef PA Tcvany to pectic concitons« Bite opening and unlocking the mandible * Correction of antoror prociootes * Class I division 2 malocclusion « Correction of ectopic canine « Avoidable complications of BA Invisible removable appliances: alternative orthodontic treatment systems {Historical development « The Invialign® system «Indications for the appliance « Steps and treatment ‘stages with Invisalign® system of clear aligners « Treatment with ClearSimile syetom”™ COaoeone Chapter 294 Steps and treatment stages in contemporary orthodontic treatment « The frst appointment « Diagnostic records * Designing a treatment pian Discussing the planned treatment approach * Active treatment stages Chapter 298 Orthodontic adhesives and bonding techniques Chapter 30 Chapter 31 {Fram banding to bonding * History of bonding orthodontic attachments on teeth «Ideal bonding systems * Advantages of bonding « Disadvantages of bonding « Types of bonding material « Fund ‘mentals of bonding * Etching: the basis of bonding * Bonding technique + Step by step clinical {technique of flawless bonding * Patient evaluation prior to bonding « Instruments required * Dist bonding procedure * Light cure bonding agents Allernatives to acid etching * Bonding with sel etching primer (SEP) » indirect bonding procedure * Bonding on fuorosed teeth * Bonding on uncon. ventional tooth surfaces « Bonding to amalgam and Co-Cr/ NiCr alloys « Bonding to porcelann suraces Preservation of normal occlusion and interception of malocclusion during early mixed dentition + Goals of preventive and interceptive orthodontics * Management and preservation of space * Active space maintainer or space regaining appliance « Resolution of crowding during early mixed denttion. Serial extractions * Historical perspective + Controversies with serial extraction « Benefits and indica, tions of serial extraction» Extreme facial types and serial extraction Stepsin sora extraction « Antoriy ‘Grossbite in deciduous and mixed dentition; ciferontial diagnosis and management « Anterior rosette in decicuous dentition * Therapeutic approach * Anterior crossbite in early mixed dentition * Local Causes of anterior crossbite * Treatment of anterior crossbite of local origin « Retention + Unilateral rossbite with mancibular shit * Dental anomalies and malocclusions during mixed dentiion « Only ‘odontic aspects of supemumerary teeth * Management of supemnumeraries * Hypaconta, Non-extraction treatment * Factors influencing extraction decision + Non-oxtraction cases * Methods to gain space to resolve limited crowding and protrusion * Expansion of upper arch * Non-extraction teatment of antorior Crowaling by interproximal reduction of dentition incications« Proximal recontouring and prevention Of relapse dus to late mandibular crowding * Pracautions and complications « Tachniques« Intraoral ‘molar distaiztion ¢ Objectives « Appliance design and case reports « Post-dstalization « Timings of ‘molar distaization 267 276 289 304 311 317 327 341Chapter 32 Chapter 33 Chapter 34 Chapter 35 Chapter 36 Chapter 37 Chapter 38 Chapter 39 Chapter 40 Chapter 41 eon Class | malocclusion: extraction treatment «+ Class | croweling extraction cases « Treatment sequence + Leveling and alignment «Incisor retraction Class I division 1 malocclusion: features and early intervention of growing maxillary excess + Prevalence «Clinical ndings « Cephalometric findings « Interception of developing classi maloocly- sion Class II division 1 malocclusion: functional appliances «Functional appliances « Historical perspective « Classification of functional appliances e 1. Activator Geldonablock 2. Baiters bionator« 3. Frankl appliance + 4. Twin block appliance * Case selection for functional appliance treatmentof Class Il malacclusion « Age « General rules for bite registration Class Il division 1 malocclusion: fixed functional appliances «= Fixed functional appliances « Rigi fixed functional appliances * Flexible fixed functional appliance (FFFA) « Hybrid fixed functional appliance « Herbst appliance * Appliance design « Bite registration for the Herbet appliance « Appliance fabrication» Clinical manipulation + Cephalometric skeletal and dental ‘changes with Herbst appliance treatment « Splint type appliance * Herbst appliance for non-surgical treatment during early and late aduithood + Mandibular protraction appliance by Filho * Short-term ‘Cephalometric skeletal and dental changes with MPA * Hybrid fixed functional appliances « Mode of correction with FFA, Management of class II malocclusion with fixed appliance «Treatment of class I division 1 malocclusion with xed appliance therapy « Cizss I raiment options ‘osth of choice for extraction « Treatment sequence « Indications of fst premolar extraction inthe ppor arcs only» Occlusion and profile after extraction treatment «Factors affecting sft tissue protle changes Class II division 2 malocclusion or Deckbiss (German) malocclusion « Facial features « Dental features + Cephalometric features » Aetiology * Treatment considerations “Issues with stabilly and retention Class Ill malocclusion in growing patients + Prevalence of skeletal class Ill malocclusion * Aatology + Nature of Class Il! malocclusion and Components of he problem « Eatly indicators of mandibular prognathism + Treatment options in grow- ing children * Interception of malocclusion + Maxillary protraction appliance * Bonded or banded ‘appliance + Retention « Effecis of chin cup and protracton face mask therapy on craniofacial skeleton ‘Age vs, maxllary protraction Orthodontic aspects of impacted teeth « Definition of mpacted tooth « Prevalencefincidence ofimpactions + Maxillary canine * Central incisor = Mandibular canine + Maxilary canine « Diagnosis of an impacted tooth + Ciinical examination { Maxilary central incisor « Maxilary canine « Radiological examination + Treatment considerations for impacted toeth » Observation « inlervention «Relocation of an impacted tooth « Bilateral impacted palatal canines in an adult female Transposition of teeth + Aetiology « Treatment considerations + Case reports Ortho-surgical management of skeletal malocclusions « Historical perspective « Pre-surgical orfhadontic treatment « Motivational factors involved in seeking Srthognathie surgery * Case selection for orthognathic surgery * History and clinical evaluation + Extaoral examination « Records and investigations « Cephalometric and computer based prediction fechnology in surgical onhodontic treatment planning ¢ Newer diagnostic aids * Special considerations during surgical veatment planning « Steps involved in an oxthagnathic surgery procedure * Pre: orthodontic preparatory phase « Pre-surgical orthodontic reatment phase + Surgical phase « Post- surgical orthodontic phase » Complications following orthognathic procedures * Complications related to procedures of orthodontic treatment, anaesthesia or surgical procedures 355 363 381 415 440Chapter 42 Chapter 43 Recon Chapter 44 Chapter 45 Chapter 46 Chapter 47 Index Postorthodontic occlusion and immediate Post-deband care {Seats of crthodonti treatment » Occlusion in non-extracton cases * Class |occtusionin extraction Gare and race Seas «Developmental white spots vs onhodontc Geninecnes lesions * Dental hand subject « Post onhodntc extinsic enamel staining White spot lesions (WSL) Maintenance of the outcome results, retention and relapse 7 Mihy retention? * Rules of retention and relapse « Factors Influencing relapse and retention 1 2aGpses in onognathic surgery cases» Relapse in clot cases = Senn appliances + Trutains resses ret» Haey retainer Fixad ingual retainers «Actve steiner eee Protocol * Class Gray Gtenton scheduie« Adjunctive periodontal procedures Io cace ‘orthodontic results * Creunferentaferectomy «Maxilary tenectomy » Aogenous goghen ake Holistic treatment approach in the interdi of cleft lip and palate Invoductons Aen Ble? * Incidence «Embryology and classticaton «Typical aca let « Tagduaton « Abbrevaton of cle types» Cit ofthe hp and ane nee Secondary palate na aay ls Aticiogy of CL Inauterina iagrosisol the cariobecre ree Intorseipl aedios * Pre-surgical Cleft lip * Oslo protocol lisciplinary management (ai pone grit « Primary alveolar bone grafting * Secondary ives ae rafting * Pro-bone graft goneee es Post-bone gat follow-up * Comprehensive orhodontie rate * Distraction oste- ‘onesis Orthognathic surgery « Prosthetic management Orthodontic considerations of interdisciplinary treatment re retdscipinary othadontcs ¢ Objectives onterdiscipinary teatment« Diagnostic set-up * Reais tesenmatt objectives « Po-restorative/pre-orhadontc perodortal cere Conditions commonly teats Grnetcsciplnary care» Missing tethispace managorrentMotergoe oe ‘Fractured teeth + Gingival discropancies « Communication Maxillomandibular distraction osteogenesis 2 Troan of maxilomandioular distraction osteagenosis « Development of intraoral distractors Jeulgilary dstraction osteogenesis « Indications * Contianeiccinne s Advantages of distraction SD eee re othoonahic sugery * Disadvantages «Types erack nao site anduse 1 glataclor designs Anaesthesia» Types of alstracton deuce © Dine st distractor placement sean Ca aPbrORCh «Distaction protocol + Othodonte conlcsratone von Planning and pro. Sarg ce ante eatnent protocols « Pre-istractionorhedontes © Gre ‘management maslionasacton and consolidation « Post-ctracton orodontce © mee Future of "maxilorandiular distraction osteogenesis, Orthodontist’s role in upper airway sleep disorders SOS Tomy Rathonhysiotogy + Common slp csorders« Snring « Sleep ‘apnoea * Symptoms Prone estgatons » Craniofacial anatomy in paions with upren airway sleep disorders « Treat. men‘ protocols * Oral appliances * Applianea fabrication * lace hacen 465 473 491 517 526Ga HPAYP.T Bante o=° OVERVIEW ‘© Psychological implications of malocclusion ‘© Motivational factors in adults © Summary ‘© Psychological factors motivating patient to seek orthodontic treatment ee function and status of oral health. Psychological implications of malocclusion ‘The adverse effects of poor facial aesthetics, motivating a person to seek orthodontic treatment can be broadly divided into: ‘© Low self-esteem and maladjustment © Restriction of social activities ¢ Adverse occupational outcomes. Low self-esteem and maladjustment. The motivation to seck orthodontic treatment is strongly related to an individual's perception of the extent to which their dentofacial appearance deviates from the social norm. The psychosocial handicap imposed by an unaesthetic dental ‘appearance may have a negative impact on the personality, of children who are often subjected to ridicule in the form of teasing, name calling and sometimes even mobbing by their peers.' This mental anguish imposed in carly life may evoke feelings of inadequacy in the child which may well sustain for life, leading to a maladjusted individual, Restriction of social activities. Attractive individuals are believed to have more social appeal and attractiveness. It affects perception of social characteristics like: ‘© Perceived friendliness ‘© Popularity among peers © Academic performance. Adverse occupational outcomes. Malocelusion may become 1 big social handicap, as the affected individual may find it very difficult to smile, talk in public or interact with people. Facial appearance may have important implications in job opportunities, with attractive faces having an edge over the less attractive ones. Hence, malocclusion is closely related to an individual's social performance and well-being. 13on Psychological factors motivating patient to seek orthodontic treatment Motivation according to the social cognitive theory, is & dynamic and reciprocal interaction of a triad of three factors: © Personal factors © Behavioural factors © Environment Not all of these factors interact equally. For some, social influences and environment predominate, whereas for others, Personal experiences, feelings and personality traits may play a major role ‘The order and degree to which these factors influence an individual’s motivation and expectation from orthodontic treatment is governed by: © Age © Gender © Socio-economic set-up. However, the degree of psychological distress is not dlitectly proportional to the severity of the dentofacial ‘anomaly. Hence, a rotated lateral incisor or a small median diastema may produce a more negative body image in one person than a gross anomaly in another, Motivating factors differ in different age groups, A factor Which is of utmost importance to a teenager may not be all that significant for an adult in seeking orthodontic treatment, Teenagers find it difficult not to follow the norms and values of their desired reference group. These norms are Strongly influenced by the environment, including the medi Portrayal of an ideal body image. The perception for attractive preference is gradually cated under the influence factors such as; * Self and parental perception of malocclusion © Peer pressure * Severity of malocclusion © Self-esteem © Social class/cultural reasons © Affordability * Availability of specialist orthodontic care Self and parental perception of malocclusion The concem for a deviation or a trait of malocclusion does not direetly correlate with the severity of the problem, A child may be concemed and develop anxiety for a minor tooth deviation Fike rotation or diastema while others may not be concermed for major irregularities. Such perception and concem would be dependent, to large extent on Parents’ perception of malocclusion which may’ get transferred to a child or else a child may develop hisfher ‘wn concems which to some extent may be linked with Secoae awareness and education, besides child's own and priority for well-being and self-image Gosney (1986), in a study among British efi Population referred for orthodontic treatment, oh that some were unaware or relatively unconcerned ah Pronounced malocclusion whereas others showed a Concern over a relatively mild imegulatity. The eo self-image and concern for the deformity may vary change with age. Many children may not seek orthod {reatment in childhood but seek treatment when they {0 adulthood and become aware of its need for sox functional reasons. Parent's satisfaction with their orthodontic treatment be an important consideration in motivation and pen need of orthodontic treatment for their children. Parent’s determinants. Baldwin and Barnes! {hat _mother is usually the mobilising, deciding determining member of the family in terms of for orthodontic treatment. They noted that in such mother usually came from a higher socio-ey background than husband, and may have had on problems of her own in the past. It has been obs father tended to be less involved in the treatment and if father alone was the main f usually for the daughter's treatment, The following factors among parents were responsible for bringing children for orthodontic tet © The parents attempt to resolve problems of their, self-concepts by way of identification with the d and his treatment. ‘They attempt resolution of an insoluble family he Problem by displacement on to the child’ ortho problem and treatment, Feeling of guilt about their own hereditary defor among any of parents, $ View orthodontic treatment as a social status sym Tt has been also observed that children living divorced mother who often develop psycholo shortcomings are often given orthodontic treatment 4 “psychic gift’ in compensation for being deprived father: The presence of these factors would mean that the ‘may be withdrawn from the motivation for treatment orf participation in the decision to seek the treatment. If occurs in a child with a minor malocclusion, the child have no incentive for cooperation during treatment ™ay turn uncooperative. In view of above factors, it is for the dentistorthodontist to know about the pati attitude towards treatment and make sure that patient Possible, becomes member of the treatment team th comprises of the patient, the parent, and the orthodont ‘An uncooperative attitude of the patient can lead to seve Problems during treatment and to unsuccessful resultsfee cased of malocclusion and ortho Peer pressure Peer pressure is perhaps one of the reasons for seeking dental advice. Tt has been well found that many school children may seek advice on need for ‘BRACES! like thei peers. Some school children may consider it as a matter of excitement while others may take “BRACES* as embarrassment, There are differences in perception of wearing “BRACES” in school population and referred population for orthodontic treatment. There may be a general problem in acceptance of BRACES’ in certain class of population while in another it may be a “badge of honour’. Familiarity with appliance may reduce resistance to wear the appliance. However, communication among peers and difficulties with chewing, of food, pain due to appliance breakages, difficulties in speaking, extra efforts in maintenance of oral hygiene and extraction of tooth (teeth) may discourage others for undergoing orthodontic treatment Shaw et al? suggested and it has been my clinical ‘observation too that exposure tothe sight of appliance may actually stimulate demand for similar ‘objects or treatment. ‘The studies on patients’ perception of orthodontic treatment needs and professional assessment of orthodontic, treatment needs do vary. There have been some studies that have used index of orthodontic treatment need (IOTN) as 4 professional ruler to assess the need and patients/parens questionnaire on subjective need. The IOTN has two components: namely dental health component (DHC) and. aesthetic component (AC). The DHC has to be assessed by fa professional who has been calibrated for the same. A study by Shue-Te et al,’ conducted at various orthodontic, offices in San Francisco (California, USA) on patients and. their pretreatment study models, confirmed that aesthetic, component was the significant factor for orthodontic, treatment. Social class, availability and affordability. Certain health and cosmeti¢ procedures are more valuable and popular in social classes, which may also be indirectly influenced by affordability as well as availability. Orthodontic treatment or braces may be considered in a group of children in schools, of high socio-economic class as a symbol of prosperity ‘Those not having braces may think they are missing on something and should have it, since they can afford it and also orthodontic specialists are available in their neighbourhood. Severity of malocclusion It is one of the major reasons for seeking orthodontic ‘treatment, particularly “large overjet’ or protruding teeth or severely irregular teeth, A child with severe malocclusion is more likely to seek orthodontic treatment (keeping the ee ‘cooperative patient Psychosocial factors Itcould be related to their greater concem about problemslaestetics ‘Treatment has been intited by the child himsel and decided. by the parents with child being taken into confidence Children wth excellent tamiy rapport Personally traits Usually round 14 years or younger Entusiaste uiging Energetic Set-conled Responsible Detemined Thing Determinedtodo wel Fonthight bing Hard working ‘An uncooperative patient “Those chiron whohavea poor relationship with parents at home and with teachers and peers at schoo! Treatment has boon decided by the parents without child being taken into conidence Childen rom broken families LUsualy around 14 years or above with superior inaigance Hardheaded Independent oot Temperamenial Impatint Often nervous Indvidualstic Soltsufient Intolerant Disregards wishes of others where his decisions are involved Easygoingother governing factors like the socio-e Atfordablity, availabilty of services, parents atitude, ete) than a child with a mild irregularity of teeth, ‘The other factors that may influe forwardly placed teeth can be a School and therefore may generate ey orthodontic treatment. In a study don the roferal po fot Seeking orthodontic treatment and Beatie have show sie eter! paths. Almost all (83%) of the 313 parents ot Sniaren nde age 16 years expressed concern about then Child's teth of which 4856 reported thatthe child has Wan It was the child who first noticed | Overjet and malalignment of teeth teased about in school, need for treatmer being the main reasons for teasing Self-esteem Proportional relationship to the deg, Roots!" stated that the first an effect of dentofacial deformity may chick. The sense of inferiority is a complex, painfuy age ual state characterized by feelings of incompetence, inadequacy and depression in varying degrees, Basically, feelings of inferiority depends on an individual’s comparison pL himself with others. This sense of inferiority dees son become a serious problem until the child enters sehocl, Hoy she is then brought to realize his es others and finds that he/she is n of his/her peers. When the fee of anxiety it produces, id foremost psychological nifests itself as inferiority + mixed With all kinds of peculiar personal traits, may have bet established, rconomic_ status, "ce need for treatment am the social class, awareness and concern. Anterior or use of teasing in the joncem and reason for their study it appeared that some ne in Finland,* parents ate stereotyped because of an Of 473 children were screened for child's dental/facr) In a study by Secord and Backman,” an made to determine whether or not som characteristics related 10 physical attract Consistent stereotypic judgments about the ind Studied the protrusion of the maxillary teeth Tecession of the chin, and alignment of the Personality individual's Appearance, ™ that the primary psycholo of a malocelusion does not result from the ‘thers to the dentofacial iregularity but from the own reaction to the deformity. It has also bee that children with malocclusion often lack love a from their parents and as a result are fru pressed, This may lead to introvert tendenci Gender Although the prevalence of malocciusion is equ males and females, more gitts seem to bo orthodontic treatment than boys. This is the ref the ‘so-called ‘sex stereotyping” wherein the soc higher values and expectations on physical attex in females than males. It has also been found tha are more critical oftheir dental appearance and dix with appearance of their dentition than males" and Eliasi¥ studied psychological effects of mate and the attitudes and opinion about orthodontic te i, tineapore and Sweden population groups, (Fig B). One ofthe significant conclusions was that fe, facial esthetics are perceived differentially by femal 0 a difference in males in Singape inales in Sweden. Ina study, VP Sharma (MDS oat thesis, University of Lucknow, 1972) etal found that Jrere more concerned about their dental defects as con {Oymales. and more concem was observed among indiv belonging to higher socio-economic class Motivational factors in adults Adults seeking orthodont three categories * Those secking treatment with the sole objectiv improvement in their facial attractiveness * Those Seeking treatment because of referral by Beneral dentists for reasons such as prosthock rehabilitation, periodontal discase or traum occlusion. treatment can be group. * Those ‘seeking treatment as a part of orthogna surgery for correction of dentofacial anomalies Adults who seek orthodontic treatment are often s, cal In a study by Riedman, George and Berg evaluate course and outcome of orthodontic treatment Adults from the patients’ and operators’ point of view, ir found that in 75% of adult patiens, dissatisfaction with,Which is the most important feature for facial aesthetic? = Hai Nose 10% i Jaws ene Teeth Face shape oe "= Complexion FSing FSth MSing Msth Which is your reason for having treatment 7 1m Improve chewing 'm Enhance self-confidence Improve dental health ‘= Improve speech 'm Enhance facial appearance 1m Attain straight tooth F Sing — Females Singapore M Sing — Males Singapore F Sth — Females Stockholm M Sth — Males Stockholm Fg, 21: Reasons of seeking orthodontic treatment do vary with ethnic and socal factors (Reproduced with permission from Bergman L, Elsi F) ‘dental aesthetics was the prime motive for seeking treatment, Adults are better and more cooperative patients. in maintenance of oral hygiene, wearing of elastics and keeping ‘treatment appointments for, they are self-motivated and have definite objectives in mind. They are also better patients for they spend their own money and decide their own orthodontic treatment. Nattrass and Sandy ” concluded that adults seeking orthodontic treatment can be excellent patients with high motivation and cooperation. Rarely orthodontic treatment of an adult may be imposed by spouse and in such situations the adult patients” behaviour ‘may or may not be the same as the one with self-motivation, ‘Among adult orthodontic patients, a large group may be those referred by general dentist or other dental specialists for interdiseiplinary orthodontic care. Prosthodontics isa common reason of referral which may include either space closure, or uprighting of a tilted molar or space gain for lost space in anterior region. Migration of teeth associated with Periodontal disease in adults with traumatic occlusion is a frequently encountered phenomenon. In such cases, ‘orthodontics may follow periodontal therapy. ‘The orthodontic tooth/tecth movement may also be required for aesthetic dental treatment, and procedures may include intrusiowextrusion of a tooth, shifting of teeth to correct midline problems, create space for veneers/laminates to restore microdontic or small sized lateral incisors. Surgical orthodontic management of dentofacial skeletal deformities is usually deferred till adulthood except in a few situations. Early orthognathic surgery is indicated in cases of extensively growing mandible due 10 condylar hyperplasia, or in children with TMJ ankylosis where condylar cartilage may have to be substituted with costochondral rib graft. Orthognathic surgery patients ‘The adult orthognathic patients display psychological traits ‘and profiles different from others. Cunningham, Gilthorpe ‘and Hunt (2000)" investigated the psychological profile of orthognathic patients prior to starting treatment and compared it with controls. The orthognathic patients displayed higher levels of anxiety and lower body image. ‘The facial image esteem was also found lower but of borderline significance. Williams et al (2005)" studied factors of patients’ motivation for undergoing orthognathic surgery {n 326 patients. The major motivations for having treatment ‘was to have straight teeth (80%). prevent future dental problems (65%), and improve self-confidence (68%). Females sought treatment to improve their self-confidence and smile to improve their social life.Functional factors Many malocclusions are related to poor function and this 's another major drive for seeking orthodontic treatment in ‘many individuals. The functional problems are often caused by malocclusions such as © Class If division 2 © Open bite Severe crowding or displaced anterior teeth * Malocclusion associated with skeletal dentofacial deformities of developmental origin and facial trauma * Congenital defects of face such as cleft lip and palate ‘Traumatic occlusion Many young adults and children who have a reasonably severe problems related with class II division 2 malocclusion who often have a ound squatish face with litte imegularity of maxillary incisors but 100% or more vertical overlap of anterioy teeth. Such a traumatic bite which is deterimental to the health of periodontium which may cause early loss of lower anterior teeth. In other situations, deep bite, if not treated may cause attrition of teeth and therefore by adulthood, the lower anteriors may be significantly worn out. It may not be Possible to provide any rehabilitation of lower anterior teeth due to lack of any clearance for crowns or removable partial denture Articulation of speech Cases with severely crowded, regular incisors and lingually Positioned maxillary incisors may cause difficulty. in Production of linguoalveolar sounds (t, d) Hypodontia/missing teeth cause interdental spacing which ‘may Iead to lateral or forward displacement of tongue luring speech resulting in distortion of sounds. Lingual. alveolar phonemes (e.g. $, Z) followed by lingual palatal Phonemes (J, Sh, Ch) are most affected by spaces in the dental arch, {mn clas IL cases, sibilant and alveolar speech sounds are Most commonly distorted of affected (5, 2, t, d, n, I). In these cases, there is a dificulty in elevating the tongue tip to the alveolar ridge. “Many may not be aware of the cause of speech problems and may end up with speech therapist who may refer such Persons 0 dentistorthodontist. In a study in Melboume Australia, Coyne, Woods and Abrams, researched the community Perceived importance of correcting various dentofacial anomalies. They found that correction of fanetional problems such as ‘difficulty in chewing or SPeaking’ was considered very important. The correction of other factors such as “top teeth which strike out in front", ‘bottom teeth which strike out in front’ or ‘crooked oF ‘rowded front teeth’ was also considered important. They NN AM’ also found a very large percentage of respor considered the need for ‘straight teeth and nice smile important in their lives. Inability to close lips Many others seek orthodontic treatment for reasons 8 inability t0 keep the lips sealed or excessive exposure, These are often adults who are conscious of body image but there are those too who have. ge functional problems Malocelusion associated deformities Others who may seek orthodontic help may be affeete either abnormal growth of the facial skeleton or may s from abnormal faces due to underlying systemic divea ‘genetic disorders. The common causes are Addison's dis {anterior open bite), Mongolism (mandibular prognath and Pierre Robin sequence (mandibular deficiency). Abnormal facial growth in otherwise normal, hea children is often encountered as an abnormally grow {ower jaw ~ mandibular prognathism, which may or hot be accompanied by a flat middle face. Such childte Untreated during childhood may end up as adult pati Nho would require a combination of orthognathic sung and orthodontics for the correction of facial deformitic with dentofa Cleft lip and palate One such category of children are those of cleft lip a Palate where maxillary growth is often restricted in vote transverse and anteroposterior dimensions due to sun Scaring duting repair of cleft of lip and palate. Such chile may also exhibit over growth of the mandible and therefa Would require orthognathic surgery and orthodontics f the correction of facial deformity Malocclusion due to trauma An injury to face during childhood may affect the growt Ot the condylar cartilage. The severity of injury may var from hemorrhage in TMJ to fracture of the condyle. Man Such children particularly in developing countries lik India may remain unattended. These children may ultimate, exhibit restricted mouth opening of varying degrees whic gradually may become more severe leading to comple trismus due to ankylosis of TMJ. The consequences o injury to TMJ manifest in the form of deviated chin to the affected side and consequential facial asymmetry. Facial asymmetry and restricted mouth opening could be a major reason for seeking orthodontic treatment in such children Summary Orthodontists treat dentofacial deformities that interfere With the well-being of patient by virtue of their adverse effect on aesthetics and function, Most patients seck orthodontic treatment with the primary objective of‘improvement in facial appearance’ which may have an ‘effect ‘on their overall personality’. Hence a concept of self-body image is. involved 'A majority of orthodontic patients are young adolescents Wwho are developing human beings and hence are highly emotional and reactive to the environment and ‘circumstances, The orthodontic treatment is quite demanding fn the part of patient not only in terms of extra strain in maintaining oral hygiene, wearing clastics and headgear but also in frequent visits to orthodontist for a long period. ‘The cooperation of patient during treatment is important in determining its length and success. The cooperation or hnon-cooperation is further dependent upon patient's basic personality trait, and orthodontic treatment may further aggravate anxiety of such nervous patients. Hence during the early course of treatment itself, the orthodontist should not only accurately plan the timing of treatment and the choice of mechanotherapy for good and stable results but also understand the patient and his guardians/parents, as 1. Cunningham $3, Feinmann C, tbbetson R. “Disorders of appearance.” In: Feinmann C (Ed): The Mouth, The Face and The Mind, Oxford University Press 1999; 7: 131-56. Gosney MBE, An investigation into some of the factors influencing the desire for orthodontic treatment. Br J Orthod 1086; 13: 87-94 3. Baldwin DC, Bames ML. Some psycho-social factors ‘motivating orthodontic teatment, International Association of Dental Research, 43, Abstract No. 461, 1965, 4, Baldwin DC, Barnes ML. Patterns of motivation in families, secking orthodontic teatment, programs and abstracts of papers, International Association of Dental Research, 44, Abstract No. 421, 1967. 5. Sims MR. Psychological disturbances associated with ‘mutilated malocclusion. J Clin Orthod 1972; 6(6): 341-45 6, Shaw WC, O'Brien KD, Richmond S. Quality contol frthodonties: factors influencing the receipt of female ‘orthodontic teatment. Br Dent J 1991; 170; 66-68. 10. u 2. 20, 2 ‘Shue-Te Yeh M, Koochek AR, Vlaskalic V, Boyd R, Richmond 'S. The relationship of 2 professional occlusal indexes with patients’ perceptions of aesthetics, function, speech, and orthodontic treatment need. Am J Orthod Dentofac Orthop 2000; 118: 421-28 Kilpelainen PY, Phillips C, Tulloch JF. Anterior tooth postion ‘and motivation for early weatment, Angle Onthod. 1993; (633): 171-74 Silverman M. Orthodontics and body image. Penn Dent J 1971; 38(8): 10-15 Roots WR. Consciousness of esthetic defect. Am J Orthod 1949; 35: 57, Roots WR. Face Value, Am J Orthod 1949; 35: 697-703. Secord PF, Backman CW. Malocclusion and psychological factors. J Am Dent Assoc 1959; 59: 931-38 Shaw WC. Factors influencing the desire for orthodontic treatment. Eur J Orthod 1981; 3: 151+ Sheats RD, Me Gorray SP, Keeling SD, Wheeler TT, King GJ. Occlusal traits and perception of orthodontic need in eight grade students. Angle Orthod 1998; 68(2): 107-14. Bergman L, Eliasi F Sociocultural influence on attitudes about orthodontic treatment and treatment need, Institute of Odontology, Karolinska Institute, and Huddinge, Sweden, http://www ki se/odont/cariologiendodonti/978/Lisbeth Bergman Farah Eliasi.paf page 215-244 accessed on 7-1-0. Riedmann T, George T, Berg R. Adult patients’ view of orthodontic weatment outcome compared to professional assessments. J Orofae Orthop 1999; 6X3): 308-20. Nattrass C, Sandy JR, Adult orthodontics ~ a review. Br J Orthod 1995; 22 (4): 331-37. Cunningham SJ, Gilthorpe MS, Hunt NP. Are orthognathic patients different? Eur J Orthod 2000; 22(2):195-202 Williams AC, Shah H, Sandy JR, Travess HC. Patients’ motivations for normal treatment and their experiences of ‘orthodontic preparation for orthognathic surgery. J Orthod 2005; 32(3): 191-202. Coyne R, Woods M, Abrams R, The community and orthodontic eare—part I; Community-percieved importance of correcting various dentofacial, Aus Orthod J 1999; 15: 289- 301 Kharbanda OP. Psychological considerations in orthodontics J Indian Orthod Soe 1984; 17: 13-20.