Jyotsna Rao - QRS 4th Year - Orthodontics - WWW - Thedentalhub.org - in

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PART I
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Topic 1 Introduction to orthodontics
Commonly asked questions
Long essays:
1. Define orthodontics. Describe aims and science of
orthodontics.
2. What is orthodontia? Describe the various
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sequelae of malocclusion of teeth.
3. Describe briefly the aims, objectives, scope and
limitations of orthodontic treatment. [Same as LE
Q.1]
Short essays:
1. Objectives of orthodontics. [Ref LE Q.1]
Short notes:
1. Aims of orthodontics. [Ref LE Q.1]
2. Jackson's triad. [Ref LE Q.1]
3. Define interceptive and preventive orthodontics.
4. Define orthodontics. [Ref LE Q.1 and Q.2]
5. Adult orthodontics.
6. Contributions of E.H. Angle to orthodontics.
7. Aims and scope of orthodontics. [Same as SN Q.1]
8. Describe Andrew Jackson's triad. [Same as SN Q.2]
9. Give the BSSOdefinition of orthodontics. [Same as
SN Q.4]
Solved answers
Long essays:
Q.1. Define orthodontics. Describe aims and science

of orthodontics.
Ans.
{SNQ.4}
• Orthodontics is the study of growth and development
of the masticatory apparatus and the prevention and
treatment of abnormalities of this development.
• According to British Society of Orthodontics (BSSO),
'Orthodontics includes the study of growth and
development of the jaws and face particularly, and
the body generally, as influencing the position of the
teeth; the study of action and reaction of internal
and external influences on the development and the
prevention and correction of arrested and perverted
development'.
Aims of orthodontic treatment are as follows:
i. All branches of dentistry have one common aim, the
establishment of as good an occlusion as possible, not
only in the functional but also in the aesthetic sense.
ii. The aim of orthodontics is to achieve a functional and
aesthetically harmonious occlusion by altering
permanently the positions of natural teeth.
This is accomplished by the careful stimulation of
alveolar bone tissue to alter its shape, and support
the teeth in a more favourable position.
{SN Q.1}
iii. The goal of modern orthodontics is to create the
best possible occlusal relationship within the
framework of acceptable facial aesthetics and
stability of the occlusion.
iv. It may be said that orthodontics seeks the following:
a. To intercept departures from normal
development of the masticatory organs.
b. To restore conditions to normal development at
the earliest when required.
c. To establish as good an occlusion as possible in
both functional and aesthetic sense.
v. It is important that in order to achieve the
results, we do not interfere with normal
function more than is required. The use of
appliances should be kept to the minimum
possible to attain the desired result lest they
interfere with normal growth changes and
produce further abnormality.
vi. It has been found (Gardiner, 1956) that at least
50°/o of all schoolchildren may benefit from
orthodontic treatment, and dental surgeons, in
general family practice, are often requested by
parents to provide such treatment.
Objectives of orthodontic treatment are as follows (
Fig. 1.1 ):
AestheUc harmony
Functional efficiency Structural balance

FIG. 1.1 Jackson's Triad.
(SN Q.2 and SE Q.1)

{(The objectives of orthodontic treatment are briefly
summarized by Jackson into the following three
headings:
i. Functional efficiency
ii. Structural balance
iii. Aesthetic harmony
All the above three objectives put together are popularly
known as Jackson's triad.
i. Establishing functional efficiency:
Correction of malocclusion eliminates all the
unfavourable sequelae of malocclusion and
thereby restoring the functional efficiency of the
masticatory apparatus.
ii. Restoring structural balance:
Achieving structural balance between the hard and
soft tissues maintains stability of the corrected
malocclusion.
Failure to achieve structural balance will lead to
relapse or loss of correction achieved.
iii. Aesthetic harmony:
The prime objective of orthodontic treatment is the
improvement of facial aesthetics and is the single
most common reason for the patients to approach
an orthodontist.)}
Q.2. What is orthodontia? Describe the various

sequelae of malocclusion of teeth.
Ans.
{SNQ.4}
• Orthodontics is the study of growth and development
of the masticatory apparatus and the prevention and
treatment of abnormalities of this development.
The various problems or sequelae of malocclusion are
as follows:
i. Psychological and social problems.
ii. Poor appearance.
iii. Interference with normal growth and development
like crossbites causing asymmetry and influences of
overbite and overjet.
iv. Improper or abnormal muscle function like
hyperactive mentalis, hypoactive upper lip, increased
buccinator pressures, tongue thrust and associated
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,
iv. Improper or abnormal muscle function like
hyperactive mentalis, hypoactive upper lip, increased
buccinator pressures, tongue thrust and associated
muscle habits like lip biting, nail biting, finger
sucking, etc.
v. Abnormal deglutition.
vi. Mouth breathing.
vii. Improper mastication.
viii. Speech defects.
ix. Increased caries activity.
x. Predisposition to periodontal disease.
xi. Temporomandibular joint problems.

xii. Impacted and unerupted teeth leading to
pathologies like cysts and damage to other teeth.
xiii. Risk of truma/accidents.
xiv. Prosthetic rehabilitation complications.
i. Psychological and social problems:
• Irregular and protruding teeth have a negative
impact on a patient's psychology.
• Children with malocclusion become introvert and
their social behaviour is immature, e.g.
introversion or self-consciousness and response to
nicknames like 'Bugs bunny', 'Buckteeth', etc.
ii. Poor appearance:
• Poor appearance due to malocclusion forms
hinderance to the child's performance in school as
well as in other extracurricular activities like
games.
• Preventive or interceptive measures should be
attempted to correct malocclusion if it is detected
in early stages of child development.
iii. Interference with growth and development:
• Perverted perioral muscle activity due to abnormal
finger-sucking habit could cause morphological
and functional changes to dentition.
• Common effect of abnormal perioral muscle
activity is development of posterior crossbites.
• Many a time, functional aberrations will lead to
unilateral crossbite, which, in turn, will cause
facial asymmetry.
• Flattening of mandibular anteriors may be caused
due to increased deep bite and abnormal lip
posture.
• Anterior occlusal interferences will cause pseudo-
class III.
iv. Abnormal muscle function:
• Abnormal muscle activity could be contributing to
malocclusion.
• In the case of lip trap, cushioning of lower lip
behind the proclined upper incisors will aggravate
proclination.
v. Improper deglutition:
Many malocclusions result in abnormal functioning
of stomatognathic system like improper
deglutition.
vi. Mouth breathing:
Malocclusions, such as increased overjet, can result
in mouth breathing, usually correction of
increased overjet can make lip closure possible,
establishing anterior oral seal and making nasal
breathing possible.
vii. Improper mastication:
Malaligned teeth change the pattern of chewing,
which can lead to temporomandibular joint (TMJ)
problems, periodontal problems, etc.
viii. Speech defects:
• Malocclusion affects the speech pattern of
individuals.
• Effect of cleft lip: Speech problem in cleft lip patients
are due to velopharyngeal incompetence, naso-oral
communication, abnormal tongue posture and
function and lip tissue inadequacy.
ix. Increased predilection to caries and periodontal
diseases:
• Irregular teeth make self-cleansing of oral cavity
less effective and may lead to increased
susceptibility to caries and periodontal diseases.
• Loss of proper contact between teeth and abnormal
axial inclinations could lead to uneven distribution
of functional stresses, which, in turn, can lead to
periodontal problems.
x. Temporomandibular joint disorders:
Malocclusion causes temporomandibular joint
problems like clicking, crepitus, pain and
dysfunction.
xi. Malocclusion and trauma
One of the most common problems associated with
class II div 1 malocclusion is high risk of trauma to
maxillary anterior teeth.
xii. Impacted and unerupted tooth:
• Impacted teeth may interfere with eruption of
successor or neighbouring tooth and may also
cause resorption of the roots of adjacent tooth.
• Possibility of development of pathologies like cysts
due to impacted/unerupted tooth is most likely.
xiii. Prosthetic rehabilitation problems
• Supra eruption of tooth into opposing edentulous
area, and tipping of teeth into adjacent edentulous
area cause space problems for prosthetic
rehabilitation.
Q.3. Describe briefly the aims, objectives, scope and

limitations of orthodontic treatment.
Ans.
[Same as LE Q.1]
Short essays:
Q.1. Objectives of orthodontics.

Ans.
[Ref LE Q.1]
Short notes:
Q.1. Aims of orthodontics.

Ans.
[Ref LE Q.1]
Q.2. Jackson's triad.

Ans.
[Ref LE Q.1]
Q.3. Define interceptive and preventive

orthodontics.
Ans.
i. According to Graber, interceptive orthodontics is 'that
phase of the science and art of orthodontics employed
to recognize and eliminate potential irregularities in
the developing dentofacial complex'.
ii. Graber defined preventive orthodontics as the action
taken to preserve the integrity of what appears to be
the normal occlusion at a specific time.
Q.4. Define orthodontics.

Ans.
[Ref LE Q.1 and Q.2]
Q.5. Adult orthodontics.

Ans.
i. Orthodontic treatment of adults is known as adult
orthodontics.
ii. Orthodontic treatment for adults is broadly classified
into two types:
a. Adjunctive orthodontic treatment
b. Comprehensive orthodontic treatment
(a) Adjunctive orthodontic treatment procedure is
carried out to facilitate other dental procedures
to control disease and restore function.
Example: Uprighting of molars, forced eruption,
crossbite correction, diastema closure, etc.
(b) Comprehensive orthodontic treatment is
essential treatment procedure carried out in
children for correction of malocclusion.
Response to orthodontic force is slightly slower
in adults as compared to children.
Q.6. Contributions of E.H. Angle to orthodontics.

Ans.
Edward H. Angle is considered as the 'father of modern
orthodontics' for his numerous contributions to the
speciality of orthodontics, which are as follows:
i. Publication of book on orthodontics in 1887
ii. Concept of occlusion in orthodontics
iii. Hypothesis of 'Key of Occlusion'
iv. Classification of malocclusion
v. Various appliances like:
• Angle's E-arch
• Pin and tube
• Ribbon arch appliance
• Edge-wise appliance.
Q. 7. Aims and scope of orthodontics.

Ans.
[Same as SN Q.1]
Q.8. Describe Andrew Jackson's triad.

Ans.
[Same as SN Q.2]
Q.9. Give the BSSO definition of orthodontics.

Ans.
[Same as SN Q.4]
Topic 2 General principles and
concepts of growth
Long essays:
1. Define growth and development. Mention the
various theories of growth and write in detail

functional matrix hypothesis.
2. Define growth and enumerate various theories of
bone growth.
3. Enumerate the various methods of measuring
growth. Discuss the clinical importance of the
knowledge of growth and development in
orthodontics.
4. Define growth. Discuss briefly clinical application
of knowledge of growth and development in
orthodontics.
5. Enumerate the various theories of growth. Explain
in detail the functional matrix theory. [Same as LE
Q.1]
6. Enumerate various theories of growth. Describe
functional matrix theory of Moss. [Same as LE Q.1]
7. Enumerate theories of bone growth. [Same as LE
Q.1]
8. What are the methods of measuring growth?
Discuss the importance of the knowledge of
growth and development in orthodontics. [Same
as LE Q.3]
Short essays:
1. Growth spurts.
2. Methods of gathering growth data.
3. Discuss drift and displacement with examples.
4. Functional matrix theory.
5. Neurotrophism.
6. scammon's curve. [Ref LE Q.4]
7. Safety valve mechanism.
8. Endochondral and intramembranous bone
formation.
9. Growth site versus growth centre.
10. Expanding V principle. [Ref LE Q.2]
11. Growth spurts and two clinical importances.
[Same as SE Q.1]
12. Pubertal growth spurts. [Same as SE Q.1]
13. Methods of studying growth. [Same as SE Q.2]
14. What are growth studies? [Same as SE Q.2]
15. Functional matrix theory of growth and
development. [Same as SE Q.4]
16. Explain differential growth and Scammon's
growth curve. [Same as SE Q.6]
17. Cephalocaudal gradient of growth. [Same as SE
Q.6]
18. Define and distinguish between 'growth centre'
and 'growth site' with examples. [Same as SE Q.9]
Short notes:
1. Growth spurts. [Ref SE Q.1]
2. Growth sites. [Ref SE Q.9]
3. Growth curve.
4. Capsular matrix.
5. Functional matrix theory.
6. Methods of measuring/studying growth. [Ref LE
Q.3]
7. Twin studies.
8. Neurotrophism.
9. Types of bone growth movements. [Ref SE Q.3]
10. Growth trends.
11. Growth centres.
12. Differential growth.
13. Methods of gathering growth data.
14. Enumerate the peak periods of postnatal growth.
[Same as SN Q.1]
15. Enumerate various theories of growth. [Ref LE
Q.1]
16. Growth spurts and two clinical importances.
[Same as SN Q.1]
17. Prepubertal growth spurt. [Same as SN Q.1]
18. Scammon's growth curves. [Same as SN Q.3]
19. Enumerate the various tissues for which
Scammon's growth curves are plotted. [Same as
SN Q.3]
20. Cortical drift. [Same as SN Q.9]
Solved answers
Long essays:
Q.1. Define growth and development. Mention the

various theories of growth and write in detail
functional matrix hypothesis.
Ans.
{SN Q.15}
Based on the expression of intrinsic genetic
potential, various theories of craniofacial growth
are as follows:
i. Genetic theory by Brodie
ii. Sutural dominance theory by Sicher
iii. Cartilaginous theory by Scott
iv. Functional matrix theory by Melvin Moss
v. Von Limborgh's theory
Other concepts/theories related to craniofacial
growth are as follows:
i. Hunter and Enlow's growth equivalent concept
ii. Petrovic's cybernetic theory
Functional matrix theory (Melvin Moss)
• The functional matrix concept attempts to
comprehend the relation between form and
function.
• Functional matrix hypothesis was put forward by
Melvin Moss based on the work of Van der Klaauw.
Simply stated, the theory is as follows: 'There is no
direct genetic influence on the size, shape or
position of skeletal tissues, only the initiation of
ossification. All skeletogenic activities are
primarily based upon the functional matrices'.
According to original version of functional
matrix hypothesis:
• Head is a composite structure __. Operationally
consisting of number of relatively independent
functions.
For example: digestion, respiration, vision,
olfaction and speech equilibrium and neural
integration
• Each function is carried out by a group of soft
tissues, which are supported and protected by
related skeletal elements.
• Soft tissues + skeletal elements related to single
function are known as functional cranial
component.
Associated with one single

function totally alJ the
I
i. Skeletal element' are ii. oft Li sue are known
known as keletal unit. as functional matrix.
• It was demonstrated that the origin, growth and

maintenance of a skeletal unit depend almost
exclusively upon its functional matrix.
1968- updated version of Melvin Moss hypothesis:
• Functional matrix hypothesis claims that the origin,
form, position, growth and maintenance of all
skeletal tissues and organs are always secondary,
compensatory and necessary responses to
chronologically and morphologically prior events
or processes that occur in specifically related
nonskeletal tissues, organs or functional spaces.
• Each of the independent functions in craniofacial
region are carried out by functional cranial
component (it consists of all tissues + organs +
spaces and skeletal parts necessary to carry out a
given function).
Functional cranial component

is divided into
I
Functional matrix Skeletal unit
comprises compn es
t t
All the ti sue , Skeletal ti ue related to
organ and funciioning specific function
spaces as a whole matrix
Skeletal unit: Comprising bone, cartilage and tendinous

tissue. It is nothing but all skeletal tissues associated
with a single function.
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Functional matrix
It consists of muscles + glands + nerves+ vessels + fat
+ teeth and functioning spaces.
Functional Matrix
Periosteal matrix Capsular matrix

It includes muscles + Example: Neurocranial
blood vessels + nerves + capsule and orotacial
glands etc. capsule.
They act directly and They act indirectly and

actively upon their related passively on their related
skeletal units, bring about skeletal units producing a
transformation in their size secondary compensatory
and shape by bone translation in space.
deposition and resorption.
Capsular Matrix
Neurocranial capsule Orofacial capsule

Is made up of skin connective Surrounds and protects
tissue, aponeurotic layer, loose the
connective layer, periosteum, oronasopharyngeal
base of the skull and two layers spaces which
of duramatter which surrounds constitute the
Capsular Matrix
N eurocranial capsule Orofacial capsule

Is made up of skin connective Surrounds and protects
tissue, aponeurotic layer, loose the
connective layer, periosteum, oronasopharyngeal
base of the skull and two layers spaces which
of duramatter which surrounds constitute the
and protects neurocranial orofacial capsular
capsular functional matrix, matrix. The growth of
which is the brain + facial skull is
leptomeninges + CSF. influenced by volume

and patency of these
spaces.
• Each of the neurocranial capsule and orofacial

capsule is an envelope which contains series of
functional cranial components (i.e. skeletal units +
functional matrix), which as a whole is
sandwiched between two covering layers.
• The alterations in special position of skeletal units
are brought about by the expansion of these
capsules within which the respective bones arise
and grow, and are maintained.
• The skeletal units are passively and secondarily
moved in space as their enveloping capsule is
expanded. This kind of translative growth is not
brought about by deposition and resorption.
Clinical implications of functional matrix theory
• Orthodontic corrections of teeth are done either by
intraoral and/or extraoral appliances. The force
application by these appliances tends to alter the
functional matrix.
• Alteration in periosteal functional matrix produces
changes in microskeletal unit, i.e. alveolar bone,
while the alteration of capsular functional matrix
produces changes in macroskeletal unit, i.e. jaws.
Q.2. Define growth and enumerate various theories

of bone growth.
Ans.
Growth has been defined by various clinicians in
different ways, as follows.
According to:
J.S. Huxley: 'The self-multiplication of living substance'.
Krogman: 'Increase in size, change in proportion and
progressive complexity'.
Todd: 'An increase in size'.
Meridith: 'Entire series of sequential anatomic and
physiological changes taking place from the beginning
of prenatal life to senility'.
Moyers: 'Quantitative aspect of biological development
per unit of time'.
Moss: 'Change in any morphological parameter which is
measurable'.
Based on the expression of intrinsic genetic
potential, various theories of craniofacial growth are
as follows:
i. Genetic theory by Brodie
ii. Sutural dominance theory by Sicher
iii. Cartilaginous theory by Scott
iv. Functional matrix theory by Melvin Moss
v. Von Limborgh's theory
i. Hunter and Enlow's growth equivalent concept
ii. Petrovic's cybernetic theory
i. Genetic theory
• This is one of the earliest theories put forward
by Brodie in 1941.
• Brodie stated simply that all growth is
controlled by genes, and is planned.
This theory is more of an assumption and is not
proved.
• Primary genetic control determines only
certain features and does not have complete
influence over all growth.
ii. Sicher's sutural dominance theory/Sicher's
hypothesis/Sutural theory
• Sutural dominance theory was put forward by
Sicher. According to him, bone growth within
the various craniofacial units is the result of
growth taking place in sutures.
• According to Sicher, the growth of skull tissue is
controlled by its own genetic potential.
According to him, all bone-forming elements, like
cartilage, sutures and periosteum, are growth
centres.
• This theory is also known as the sutural
dominance theory because proliferation of
connective tissue and its replacement by
bone in the suture is considered to be the
primary event.
• Growth taking place in the sutures which
connect maxillary complex to the cranium
causes downward movement of the midface.
Drawbacks of sutural theory:
• Any unusual pressure on suture initiates
bone resorption and not bone's deposition,
as bone is a tension adapted tissue.
• Sutures do not act as primary growth centres.
Growth in the sutural area is a secondary
response to functional needs.
• Evidence in favour of secondary role of
sutural growth is more.
• Based on various experimental studies, it was
shown that extirpation or removal of facial
sutures had no effect on the growth of
skeleton.
iii. Cartilaginous theory
• Cartilaginous theory is also known as Scott's
hypothesis/nasal septal theory and is put
forward by James Scott.
• This theory is based on the principle that
intrinsic growth-controlling factors are
present in cartilage and periosteum.
• According to Scott, cartilaginous sites
throughout the skull are primary growth
centres and growth of cartilage in nasal
septum provides force that displaces maxilla
downwards and forward. Nasal septum is
considered to be the major contributor in
maxillary growth.
• In mandible, condylar cartilage is considered to
be the growth centre present bilaterally with
the horse-shoe-shape mandible in-between.
Experimental evidences inf av our of this theory are
as follows:
• Removal of nasalseptal cartilage in rats and
rabbits resulted in deficient snout of these
animals.
• Transplantation of a part of epiphyseal plate
and synchondroses to a different location
results in continued growth in the new
location, which indicates innate growth
potential of the cartilage.
• Nasal septum also shows innate growth
potential on being transplanted to a
different location.
iv. Functional matrix theory (Melvin Moss)
• The functional matrix concept attempts to
comprehend the relation between form and
function.
• Functional matrix hypothesis was put
forward by Melvin Moss based on the work
of Van der Klaauw. Simply stated, the theory
is as follows: 'There is no direct genetic
influence on the size, shape or position of
skeletal tissues, only the initiation of
ossification. All skeletogenic activity is
primarily based upon the functional
matrices'.
• Head is a composite structure. Each function
is carried out by a group of soft tissues,
which are supported and protected by
• Soft tissues + skeletal elements related to
single function are known as functional
cranial component.
-
Associated with one single
function totally all the
I
i. SkeletaJ element are ii. Soft ti ues are known
known as skeletal unit. as functional.
• It was demonstrated that the origin growth and

maintenance of the skeletal unit depend
almost exclusively on its functional matrix.
1968 - updated version of Melvin Moss' hypothesis:
• Functional matrix hypothesis claims that the
origin, form, position, growth and
maintenance of all skeletal tissues and organs
are always secondary compensatory and
necessary responses to chronologically and
morphologically prior events or processes that
occur in specifically related nonskeletal
tissues, organs or functional spaces.
• Each of the independent functions in
craniofacial region are carried out by
functional cranial component, which consists
of all tissues + organs + spaces and skeletal
parts necessary to carry out a given function.
v. Von Limborgh 's theory
• In 1970, Von Limborgh put forward a multi-
factorial theory.
• He explains the process of growth and
development in a view that combines all three
existing theories: functional matrix theory,
sutural theory by Sicher and genetic theory.
• According to Von Limborgh, five factors that
control the growth are as follows:
i. Intrinsic genetic factors - These are genetic
control of the skeletal units themselves.
ii. Local epigenetic factors - Bone growth is
determined by genetic control originating
from adjacent structures like brain and
eyes.
iii. General epigenetic factors - These are
genetic factors determining growth from
distant structures, e.g. sex hormones and
growth hormones.
iv. Local environmental factors - Nongenetic
factors from local external environment,
e.g. habits, muscle force.
v. General environmental factors -
Nongenetic general environment factors,
e.g. nutrition and O 2•
Views expressed by Von limborgh can be
summarized as follows:
• Chondrocranial and desmocranial growth are
controlled by intrinsic genetic factors.
• Cartilaginous parts of skull are considered as
growth centres.
• Sutural and periosteal growth is additionally
governed by local nongenetic environmental
infamies.
• Sutural growth is controlled by influences
originating from skull cartilages + other
• Sutural growth is controlled by influences
originating from skull cartilages + other
adjacent skull structures.
• Periosteal growth to a large extent depends on
growth of adjacent structures.
[SE Q.10]
{Hunter and Enlow's growth equivalent concept:
According to Enlow's expanding 'V' principle:
• Many facial bones or parts of bone have a 'V'-
shaped pattern of growth. In these bones the

growth movements and enlargement occur
towards the wide ends of the 'V' as a result of
differential deposition and selective resorption
of bone.
• Bone deposition occurs on the inner side of the
wide end of 'V' and bone resorption on the outer
surface. Deposition also takes place at the ends
of two arms of the 'V' resulting in growth
movement towards the ends.
• In a number of regions, such as the base of the
mandible, ends of long bones, mandibular body,
palate etc., the 'V' pattern of the growth occurs.}
Q.3. Enumerate the various methods of measuring

growth. Discuss the clinical importance of the
knowledge of growth and development in
orthodontics.
Ans.
{SN Q.6}
Various methods of measuring growth are as follows:
A. Proffit's classification
Proffit's classification
I
Measurement approaches Experimental approaches
i. Anthropometry i. Vital staining
ii. Craniometry ii. Radioactive tracer
iii. Cephalometry iii. Autoradiography
iv. Arcial growth iv. Implant radiography
v. Logarithmic spiral
vi. Finite element analysis
B. Moyer's classification is of the following types:

i. Quantitative
ii. Observations
iii. Rating and ranking
iv. Opinions
The quantitative method of measuring growth is
again of the following types:
Direct
l
Indirect Combiner ion
measurements measurements
i. Anthropometry i. Study casts i. Radiography

+ implant.
ii. Craniometry ii. Radiographs ii. Radiograph +
memphy ics bands
iii. Vital staining iii. Photographs iii. Auroradiography
iv. Implant markers
v . Histochemistry
Various methods of measuring growth in detail are

as follows:
I. Craniometry and anthropometry
• Craniometry is the art of measuring of skulls so
as to discover their specific differences. Precise
measurements can be made with craniometry.
It is a cross-sectional type of study.
• Site, amount and rate of growth cannot be
elicited by craniometry but gives information
about direction of growth to some extent.
• Anthropometry is the measurement of skeletal
dimensions on living individuals. It is a
longitudinal study.
• Anthropometry gives little information about
the amount of growth and to some extent the
rate of growth, whereas it gives relatively
accurate information about the direction of
growth.
Clinical uses
• Cranial and facial index are two important
indices used in orthodontics.
• Index is the ratio of smaller to a larger linear
measurement expressed by means of
percentage.
Maximum cranial breadth

ranial index = x 10
Maximum cranial length
• Maximum cranial breadth 'is the measured

distance between the two most prominent
points on the either side of the head'.
• Maximum cranial length 'is the measured
distance from glabella to opisthocranion, the
most prominent point of the occipital bone in
the midline'.
• The values of cranial index are more for
brachycephalic/short and round head types
and are around 80 to 85, and are less of
around 70- 7 5 for dolichocephalic/long narrow
head types, while for mesocephalic/middle
type, the values are in between the above two
types.
Facial height
Facial i ndcx X 100
Zygomatic breadth
• Facial height is the measured distance from

nasion to gnathion whereas zygomatic breadth
is the distance between two zygomas.
• The values of facial index are more for
leptoprosopic, i.e. high and narrow facial type
90-95; less for euryprosopic, i.e. broad and
round facial type 80-85; and average in
between these two values for mesoprosopic,
i.e. middle type around 85-90.
II. Vital staining
• Vital staining is an experimental method of
measuring growth introduced by John Hunter
in the eighteenth century.
Commonly used dyes for vital staining are as
follows:
• Alizarin S
• Radioactive tracers
• Fluorochrome
• Tetracycline
• Trypan blue
Procedure:
• This technique involves injecting certain dyes
that stain mineralizing tissues and get
incorporated in bones and teeth.
• Animals are sacrificed and tissues are studied
histologically for the manner in which bone
is laid down, site of growth, direction,
duration and amount of growth at different
sites of the bone.
• Disadvantage of this method is that it is not a
longitudinal study; hence repeated data of
the same individual cannot be obtained.
III. Implant radiography
• Use of implant radio graph to study bone
growth was introduced by Professor Bjork in
1969. It is an experimental method for
studying physical bone growth.
Procedure:
• It involves inserting small bits of biologically
inert metal alloys into growing bone, either
mandible or maxilla.
• Very tiny metallic implants, 1.5 mm long and
0.5 mm in diameter made of Tantalumare,
were used.
• Osseo-integrated implants serve as reference
points, and serial cephalometric radiographs
are taken repeatedly over a period of time,
and compared.
Preferable sites of implants in mandible and maxilla
are as fallows:
i. Mandible
• Anterior aspect of symphysis in the midline
below roots.
• Two pins on the right side of body of mandible:
one below first premolar and another below
second premolar or first molar.
• External surface of ram us on the right side at
the level of occlusal surface of molars.
ii. Maxilla
• Hard palate behind deciduous canines.
• After eruption of maxillary incisors, below the
anterior nasal spine.
• Bilaterally, one implant on the either side of
zygomatic process of maxilla.
Junction of hard palate and alveolar process
medial to the first molar.
• Implant radiography gives very accurate
information about site, amount and direction
of growth, while a relatively accurate
information about the rate of growth.
• Drawbacks of this method are that it is a two-
dimensional study of three-dimensional
process and radiation hazard.
Q.4. Define growth. Discuss briefly clinical

application of knowledge of growth and
development in orthodontics.
Ans.
• Growth has been described in so many terms.
Todd defines growth as 'increase in size'.
Krogman: increase in size, change in spatial
proportion over time
Huxley: Self-multiplication of living tissues.
Moss defines growth as any change in morphology
which is within measurable parameters.
Meredith defines growth as the entire series of
anatomic and physiological changes taking place
between the beginning of prenatal life and the
close of senility.
Moyer defines growth as the biological process by
which living matter gets larger.
• Development is defined in simple words as the
'progression towards maturity'.
• According to Melvin Moss, 'Development can be
considered as a continuum of causally related events
from the fertilization of ovum onwards'.
Importance of knowledge of growth and development
in orthodontics is as follows:
Craniofacial growth is a complex phenomenon. A
thorough knowledge of the normal pattern of
growth and normal variations will help in
identifying the problems and also utilize the
normal growth to advantage in treatment.
r1inirn1 i rn rvl i r-ri t i rvn e nf rrrrvu it h nnil d oviolrvnrn owt rnn
- -
Clinical implications of growth and development can
be studied under the foiiowing headings:
i. Growth pattern
ii. Differential growth
iii. Variability
iv. Timing variations
v. Safety valve mechanism
i. Growth pattern
• Definite arrangement of designs in definite
proportional relationship is known as pattern.
In relation to growth, pattern can be defined
as proportional relationship over time.

• The patterns are the controlling or restricting
mechanisms to preserve the integration of
parts of the body under varying conditions.
Differential growth (cephalocaudal growth,
Scammon's growth) and predictability are the
contributors to pattern.
ii. Differentialgrowth
[SE Q.6]
• {Throughout life, human body does not grow at
the same rate, different organs grow at different
rates to a different amount and at different
times, this is known as differential growth.
• The concepts of differential growth are more
clearly understood by two important aspects of
growth:
(a) Cephalocaudal gradient of growth
(b) Scammon's cure of growth
(a) Cephalocaudal gradient of growth
• An axis of increased growth gradient extending
from head towards the feet is called
'cephalocaudal growth'.
• In fetal life, head constitutes 50°/o of the total
body length, while limbs are primitive (30°/o).
At the time of birth, head constitutes 25°/o-30°/o
and there is increased growth of body and
limbs.
In an adult, the head constitutes only 12°/o, while
limbs account to 50°/o. These changes in the
pattern of growth are because of
cephalocaudal gradient.
• Cephalocaudal growth in face:
At the time of birth, jaws and face are less
developed compared to skull. Maxilla being
closer to head grows faster, and the growth is
completed before mandibular growth.
Mandible being away from the brain grows
more and growth completes later than maxilla.
(b) Scammon's cure of growth:
Major tissues of the human body are divided
into four types:
i. Lymphoid tissue
ii. Neural tissue
iii. General tissue
iv. Genital tissue
These different tissues grow at different
times at different rates
i. Lymphoid tissue
Proliferates rapidly in late childhood to
almost 200°/o of adult size. Adaptation to
protect child from infection, by 18 years it
undergoes involution to reach adult size.
ii. Neural tissue
Grows very rapidly and almost reaches
adult size by 6- 7 years of age, after that a
very little growth occurs in neural tissues.
iii. General/visceral + (muscle, bone and
other organs)
They exhibit 'S'-shaped curve of rapid
growth up to 2-3 years of age followed by
slow phase of 3-10 years of age.
Followed by rapid phase of growth after
10th year, terminating by 18-20 years.
iv. Genital tissue (reproductive organs)
Negligible growth until puberty. They grow
rapidly at puberty, reaching adult size,
after which growth ceases.
Effect of Scammon's growth in facial region:
Mandible follows somatic growth pattern. Long-
time growth is seen until about 18-20 years in
males.
Maxilla follows neural growth pattern and growth
ceases earlier; hence skeletal problems of the
maxilla should be treated earlier to mandible.}
iii. Variability in growth
Variability in growth is the law of nature. No two
individuals mimic alike, and no two
individuals grow in the same pattern.
The reasons for variability in growth are as follows:
a. Variation within normal range: evaluated by
Wetzel's grid
b. Variation due to other influences, which include:
i. Heredity
ii. Nutrition
iii. Racial difference
iv. Climate
v. Exercise
vi. Socioeconomic factors
vii. Psychological factors
viii. Size of the family
ix. Hormonal changes
c. Variation due to timing effects:
i. Body build
ii. Sex difference
iii. Growth spurts
a. Variation within normal range:
• Is evaluated by Wetzel's grid.
• The resultant curve obtained by plotting the
height and weight of an individual against
the age over a period of time is compared
with normal range.
• Any unexpected growth pattern changes
should be evaluated and investigated for
growth abnormality.
b. Variation due to other influence areas:
• Heredity: On rate of growth and onset of
menarche, there is genetic control.
• Nutrition: Certain parts of the body may be
affected by malnutrition and they show
retardation of growth.
• Racial differences: Differences in skeletal
maturity are exhibited by different races.
• Climate and seasonal effects: People living in
cold places have more of fat or adipose
tissue.
• Exercise: Increases muscle mass and
physique.
c. Variation due to timing effects:
• Timing variations in growth is nothing but
occurrence of the same events at different
times for different individuals.
iv. Timing variations in growth are due to
following reasons:
i. Body build
ii. Sex difference
iii. Growth spurts
Body build:
Ectomorphic: Late maturing individuals, grow
for a longer period.
Mesomorphic: Individuals exhibiting average
growth period.
Endomorphic: Early maturing individuals
where growth completes much faster.
Sex differences:
• Boys and girls exhibit variation between
onset of menarche and rate of growth.
In girls, there is early onset of menarche,
and growth completes faster than boys of
the same age. In boys, there is delayed
onset of puberty, and growth occurs over a
longer period.
Growth spurts:
• Growth does not take place uniformly at all
times. There seems to be periods when a
sudden acceleration in growth occurs. This
sudden increase in growth is termed growth
spurt.
• The growth spurts can be utilized for growth
modulation treatment.
v. Safety valve mechanism
• Safety valve mechanism is a nature's attempt to
maintain proper occlusion. To compensate for
horizontal growth in mandible, the maxillary
intercanine width serves as a safety valve.
• In mandible, the intercanine width is
completed at 9 years of age in girls and at
around 10 years of age in boys.
• In the maxilla, the intercanine width is
completed by 12 years of age in girls and at 18
years in boys.
• The delay in growth of maxillary intercanine
arch width serves as a 'safety valve' for
pubertal growth spurts in mandible. Maxillary
intercanine width adjusts to the mandibular
dentition as it is brought forward, this is called
'safety valve mechanism'.
Q.5. Enumerate the various theories of growth.

Explain in detail the functional matrix theory.
Ans.
[Same as LE Q.1]
Q.6. Enumerate various theories of growth. Describe

functional matrix theory of Moss.
Ans.
[Same as LE Q.1]
Q.7. Enumerate theories of bone growth.

Ans.
[Same as LE Q.1]
Q.8. What are the methods of measuring growth?

Discuss the importance of the knowledge of growth
and development in orthodontics.
Ans.
[Same as LE Q.3]
Short essays:
Q.1. Growth spurts.

Ans.
{SN Q.1}
Growth does not take place uniformly at all times. There
seems to be periods when a sudden acceleration in
growth occurs. This sudden increase in growth is
termed growth spurt.
Etiology: The physiological alteration in hormonal
secretion.
The timing of growth spurts differs in boys and girls.
They are as follows:
A. Just before birth
B. One year after birth
C. Mixed dentition growth spurt (boys 8-11 years and
girls 7-9 years)
D. Prepubertal growth spurt (boys 14-16 years and girls
11-13 years)
Clinical importance:
Knowledge of growth spurts is essential for
successful treatment planning in orthodontics.
• r..rnlhTth rnnrh1l::itinn hlr rni:>::inc nf fnnrtinn::i l
-- --,,.1-··--,
Clinical importance:
Knowledge of growth spurts is essential for
successful treatment planning in orthodontics.
• Growth modulation by means of functional
and orthodontic appliances elicits better
response during growth spurts.
• Surgical correction involving maxilla and mandible
should be carried out only after cessation of growth
spurts.
• During pubertal growth spurts, there is change in
growth direction from vertical to horizontal.
• Periods of maximum growth are suitable for arch

expansion and rapid skeletal expansion procedures.
• Growth spurt period is the best time for interceptive
orthodontic procedures.
Q.2. Methods of gathering growth data.

Ans.
The various growth studies are as follows:
a. Longitudinal studies
b. Cross-sectional studies
c. Semi-longitudinal studies
• This type of study consists of the observations and
measurements pertaining to growth made on a
person or a group of persons at regular intervals
over a prolonged period of time.
• The longitudinal studies are long-term studies
where the same sample is studied by means of
follow-up examination.
Advantages:
• The specific developmental pattern of an
individual can be studied and compared as the
same subjects are followed up over a long
period.
• Developmental variations among individuals
within the sample can be studied.
Disadvantages:
• A long period of time is involved; it often takes
years or decades to complete a study.
• These studies require maintenance of laboratory
research personnel and data storage systems for
a long period of time.
• These can be expensive.
• As these studies are performed over prolonged
periods of time, there is a risk of sample size
reduction due to change of place, or due to other
unforeseen events.
• Cross-sectional studies are carried out by
observation and measurement made of different
samples and studied at different periods.
Advantages:
• These studies are of short duration.
• They are less expensive.
• It is possible to repeat the study in case of any
flaw.
• In these studies, to derive the advantages of
gathering growth data, it is possible to combine
cross-sectional and longitudinal methods.
Types of growth data:
The physical growth can be studied by a number of ways:
i. Opinion
• It is a clever guess of an experienced person
and is the crudest means of studying growth.
• This method of studying growth is not very
scientific and should be avoided when better
methods are available.
ii. Observations
A method of gathering growth-related
information by observation. These are useful
in studying all or none of the phenomena such
as the presence or absence of disease, e.g.
presence or absence of a caries and Class II
molar relation.
iii. Ratings and rankings
Rating makes use of standard, conventionally
accepted scales for classification. Ranking
involves the arrangement of data in an orderly
sequence based on the value.
Whenever it is difficult to quantify a particular
data, it is possible to adopt a method of rating
and ranking.
Quantitative measurements
A scientific approach to study growth is based
on accurate measurements, which are of
three types:
i. Direct data: Direct data are obtained from
measurements that are taken on living
persons or cadavers by means of scales,
measuring tapes or calipers.
ii. Indirect data: Growth measurements
derived from images, photographs,
radiographs or dental casts of a person.
iii. Derived data: The data derived by
comparing two measurements. These two
sets of measurements can be of different
time frames or of two different samples.
Q.3. Discuss drift and displacement with examples.

Ans.
{SN Q.9}
• Drift and displacement are two basic modes of
movements involved during growth. The overall
process of craniofacial enlargement is a combination
of drift and displacement.
Cortical drift
• Growth of most bones occurs due to interplay of
bone deposition and resorption. A combination of
bone deposition and resorption resulting in a
growth movement towards the depositing surface
is called cortical drift.
• If bone deposition and resorption on either side of a
bone are equal, then the thickness of the bone
remains constant.
• If in case more bone is deposited on one side and
less bone resorbed on the opposite side, then the
thickness of the bone increases.
• Drift occurs in all the regions of growing bones,
producing generalized enlargement as well as
relocation of parts.
Displacement
The movement of whole bone as a unit is known as
displacement.
It can be of two types: primary or secondary
a. Primary displacement
If a bone gets displaced as a result of its own
growth, it is known as primary displacement,
e.g. growth of the maxilla at tuberosity region
results in pushing of maxilla against the
cranial base, resulting in the displacement of
maxilla in forward and downward directions.
b. Secondary displacement
If a displacement of bone occurs as a result of
growth and enlargement of adjacent bone, it is
known as secondary displacement.
Examples: Growth of the cranial base results in the
forward and downward displacement of maxilla.
Q.4. Functional matrix theory.
Ans.
Simply stated, the theory is, 'There is no direct
genetic influence on the size, shape or position of
skeletal tissues, only the initiation of ossification. All
skeletogenic activity is primarily based upon the
functional matrices'.
According to original version offunctional matrix
hypothesis:
• Head is a composite structure operationally
consisting of number of relatively independent
functions, e.g. digestion, respiration, vision
and neural integration.
• Each function is carried out by a group of soft
tissues, which are supported and protected by
Soft tissues + skeletal elements related to single
function are known as functional cranial
component.
Functional cranial component

i divided into
I
Functional unit 'kclctal unit
Compri e
+all the tissue
,
+
keletai ti sues related to
organ and functioning pecific function
spaces a · a whole matrix
• It was demonstrated that the origin, growth

and maintenance of skeletal unit depend
almost exclusively on its functional matrix.
Functional matrix:
It consists of muscles + glands + nerves + vessels +
fat + teeth and functioning spaces.
Functional Matrix
Periosteal matrix Capsular matrix

It includes muscles + Example: Neurocranial
blood vessels + nerves + capsule and orotaclat
glands etc. capsule.
They act directly and They act indirectly and

actively upon their related passively on their related
skeletal units, bring about skeletal units producing a
transformation in their size secondary compensatory
and shape by bone translation in space.
Capsular matrix has neurocranial capsule and

orofacial capsule. Each of the neurocranial
capsules and orofacial capsules is an envelope
which contains series of functional cranial
components (i.e. skeletal units + functional
matrix) which as a whole is sandwiched
between two covering layers.
• The alterations in special position of skeletal
units is brought about by the expansion of
these capsules within which the respective
bones arise, grow and are maintained.
• The skeletal units are passively and
secondarily moved in space as their
enveloping capsule is expanded. This kind of
translative growth is not brought about by
Clinical implications offunctional matrix theory:
• The force application by orthodontic
appliances tends to alter the functional
matrix.
• Alteration in periosteal functional matrix
produces changes in microskeletal unit. i.e.
alveolar bone, while the alteration in
capsular functional matrix produces
changes in macroskeletal unit, i.e. jaws.
• •
• The force application by orthodontic
appliances tends to alter the functional
matrix.
• Alteration in periosteal functional matrix
produces changes in microskeletal unit. i.e.
alveolar bone, while the alteration in
capsular functional matrix produces
changes in macroskeletal unit, i.e. jaws.
Q.5. Neurotrophism.
Ans.

• A nonimpulse transmitting neural function that
involves a xoplasmic transport and provides for
long-term interaction between neurons and
innervated tissues and regulates homeostatically the
morphological, compositional and functional
integrity of those tissues is known as neurotrophism.
• Presently, the nature of neurotrophic substances and
the process of their introduction into the target tissue
are unknown.
• The various types of neurotrophic mechanisms are as
follows:
i. Neuroepithelial trophism
ii. Neurovisceral trophism
iii. Neuromuscular trophism
• Neuroepithelial trophism:
There is a neurotrophic control over epithelial
mitosis and synthesis. Certain neurotrophic
substances released by nerve synapses control
normal epithelial growth. If this neurotrophic
process is lacking or deficient, abnormal
epithelial growth, orofacial hypoplasia and
malformation occur.
Example: The presence of taste buds is dependent
upon an intact innervation. The nerves are not
only important for the sensation of taste but also
for healthy growth of taste buds. If the taste buds
are de-innervated, they become atrophic.
• Neuromuscular trophism:
Embryonic myogenesis is independent of neural
innervation and trophic control. The neural
innervation is established approximately at the
myoblast stage of differentiation, without which
further continuation of myogenesis usually does
not occur.
• Neurovisceral trophism:
Visceral organs, like the salivary glands, fat tissue
and other organs, are trophically regulated, at
least in part.
Q.6. Scammon's curve.

Ans.
[Ref LE Q.4]
Q.7. Safety valve mechanism.

Ans.
• Safety valve mechanism is a nature's attempt to
maintain proper occlusion. To compensate for
horizontal growth in mandible, the maxillary
intercanine width serves as a safety valve.
• In mandible, the intercanine width is completed by 9
years of age in girls and at around 10 years of age in
boys.
• In the maxilla, the intercanine width is completed by
the age of 12 years in girls and at 18 years in boys.
• The delay in growth of maxillary intercanine arch
width serves as a 'safety valve' for pubertal growth
spurts in mandible. Maxillary intercanine width
adjusts to the mandibular dentition as it is brought
forward, this is called 'safety valve mechanism'.
Q.8. Endochondral and intramembranous bone

formation.
Ans.
The process of bone formation occurs by two basic
methods, namely:
i. Endochondral bone formation
ii. Intramembranous bone formation
i. Endochondral ossification/cartilaginous
ossification/indirect ossification/endochondral
bone formation
• In this type of osteogenesis, the bone formation is
preceded by the formation of a cartilaginous
model, which is subsequently replaced by bone.
Endochondral bone formation occurs as follows:
• At the site of bone formation, the condensation
of mesenchymal cells takes place and some of
them differentiate into chondroblasts and lay
down hyaline cartilage.
• The cartilage is surrounded by a membrane
called perichondrium, which is highly vascular
and contains osteogenic cells.
• The intercellular substance surrounding the
cartilage cells becomes calcified due to an
enzyme alkaline phosphatase secreted by
cartilage cells.
• The cartilage cells are deprived of nutrition,
leading to their death. This results in the
formation of empty spaces, called primary
areolae.
• The blood vessels and osteogenic cells from
perichondrium invade the calcified
cartilaginous matrix, which is now reduced to
bars or walls due to eating away of calcified
matrix. This leaves large empty spaces
between the walls called secondary areolae.
• The osteogenic cells of perichondrium become
osteoblasts and arrange along the surface of
these bars of calcified matrix and lay down
osteoid, which later becomes calcified to form
lamella of bone.
• The calcified matrix of cartilage acts as a
support for bone formation, and layers of
osteoid are secreted one upon other.
The entire process of endochondral ossification is
continuous and repetitive.
Importance of endochondral ossification
• Cartilage behaves like a soft tissue, and growth
takes place by both interstitial growth and
appositional growth.
• Cartilage can grow in heavy pressure areas, as
it is a pressure-adapted tissue unlike bone, e.g.
cranial base.
• Linear growth takes place allowing lengthening
of bones.
ii. Intramembranous bone formation
• Here, the formation of bone is not preceded by the
formation of a cartilaginous model. Instead, bone
is laid down directly in a fibrous membrane.
The intramembranous bone is formed in the following
manner:
• At the site of bone formation, mesenchymal
cells become aggregated and some of them lay
down bundles of collagen fibres.
• Some mesenchymal cells enlarge and form
osteoblasts, which secrete a gelatinous matrix
called osteoid around collagen fibres.
• The osteoid is converted into bone lamella by
deposition of calcium salts in it, and now the
osteoblasts move away from the lamellae and
a new layer of osteoid is secreted, which also
gets calcified.
• Some of the osteoblasts get entrapped between
two lamellae. These are called osteocytes.
Q.9. Growth site versus growth centre.

Ans.
{SN Q.2}
Differences between growth site and centre are as
follows:
Growth site Growth centre

It is any location or site where It is a location or place
growth takes place where genetically
controlled growth
takes place
It is a region where periosteal or These are the places of
sutural bone formation and ossification with
remodelling resorption tissue-separating force
adaptive to environment take
place
Sites of growth does not continue Centres of growth
to grow when transplanted to continue to grow
another area when transplanted to
another area
They markedly response to Their response to
external influences external influences is
less whereas response
to functional needs is
more
These are the places where They cause growth of the
exaggerated growth takes place major part of the bone
but they do not cause growth of
the whole bone
All growth sites are not growth All growth centres are
centres growth sites
Theories of growth are not based Various theories of
on growth site growth are based on
growth centres
Growth sites do not control the The overall growth of the
overall growth of the bone bone is controlled by
growth centre
Q.10. Expanding V principle.

Ans.
[Ref LE Q.2]
Q.11. Growth spurts and two clinical importances.

Ans.
[Same as SE Q.1]
Q.12. Pubertal growth spurts.

Ans.
[Same as SE Q.1]
Q.13. Methods of studying growth.

Ans.
[Same as SE Q.2]
Q.14. What are growth studies?

Ans.
[Same as SE Q.2]
Q.15. Functional matrix theory of growth and

development.
Ans.
[Same as SE Q.4]
Q.16. Explain differential growth and Scammon's

growth curve.
Ans.
[Same as SE Q.6]
Q.17. Cephalocaudal gradient of growth.

Ans.
[Same as SE Q.6]
Q.17. Cephalocaudal gradient of growth.
Ans.
[Sarne as SE Q.6]
Q.18. Define and distinguish between 'growth centre'

and 'growth site' with examples.
Ans.
[Sarne as SE Q.9]
Short notes:

Q.1. Growth spurts.
Ans.
[Ref SE Q.1]
Q.2. Growth sites.

Ans.
[Ref SE Q.9]
Q.3. Growth curve.

Ans.
Scarnrnon's growth curve indicates that growth rates of
different tissues are different at different ages.
Example: Various tissues for which Scammon's growth
curve is plotted are lymphoid, neural, general or visceral
and genital tissues.
• Lymphoid tissue proliferates rapidly in late childhood
to almost 200°/o of adult size.
By 18 years, it undergoes involution to reach adult
.
size.
• Neural tissue grows very rapidly and almost reaches
adult size by 6-7 years of age and after that a very
little growth occurs in neural tissue.
• General/visceral tissue exhibits 'S'-shaped curve,
which indicates rapid growth up to 2-3 years of age
followed by slow phase between 3 and 10 years of
age, followed again by rapid phase of growth,
occurring after 10th year and terminating by 18-20
years.
• Genital tissue shows negligible growth until puberty.
They grow rapidly at puberty, reaching adult size,
after which growth ceases.
Q.4. Capsular matrix.

Ans.
• Capsular matrix is a component of functional matrix.
It has neurocranial capsule and orofacial capsule.
• Each of the neurocranial capsules and orofacial
capsules is an envelope containing series of
functional cranial components, and, as a whole, is
sandwiched between two covering layers.
• Alterations at special positions of skeletal units is
brought about by the expansion of these capsules
within which the respective bones arise, grow and
are maintained.
• The skeletal units are moved passively and
secondarily in space as their enveloping capsule is
expanded. This kind of translative growth is not
brought about by deposition and resorption.
Q.5. Functional matrix theory.

Ans.
Simply stated, the theory is as follows: 'There is no
direct genetic influence on the size, shape or position
of skeletal tissues, only the initiation of ossification.
All skeletogenic activity is primarily based upon the
functional matrices'.
• Functional cranial component is divided into
functional matrix and skeletal unit.
• Functional matrix comprises all tissues + organs +
functioning spaces as a whole, while skeletal unit
comprises skeletal tissues related to specific function
matrix.
• It was demonstrated that the origin, growth and
maintenance of skeletal unit depend almost
exclusively upon its functional matrix.
• The force application by orthodontic appliances tends
to alter the functional matrix.
• Alteration of periosteal functional matrix produces
changes in microskeletal unit, while alteration in
capsular functional matrix produces changes in
rnacroskeletal unit.
Q.6. Methods of measuring/studying growth.

Ans.
[Ref LE Q.3]
Q.7. Twin studies.

Ans.
• In twin study, twins are compared. Comparing
rnonozygotic twins with dizygotic twins is the best
way to determine the extent of genetic effect on the
malocclusion.
• The heritability of malocclusion can be determined by
comparing the ordinary siblings, rnonozygotic twins
and dizygotic twins.
• In case of rnonozygotic twins, any change in occlusion
or features could be attributed to environmental
factor as both of them have similar DNA, whereas in
dizygotic twins, interplay of genetic and
environmental factors is responsible.
Q.8. Neurotrophism.
Ans.
• A nonirnpulse transmitting neural function that
involves axoplasrnic transport and provides for long-
term interaction between neurons and innervated
tissues that horneostatically regulates the
morphological, compositional and functional
integrity of those tissues is known as neurotrophisrn.
• Presently the nature of neurotrophic substances and
the process of their introduction into the target tissue
is unknown.
• The various types of neurotrophic mechanisms are
i. Neuroepithelial trophisrn
ii. Neurovisceral trophisrn
iii. Neurornuscular trophisrn
Q.9. Types of bone growth movements.

Ans.
[Ref SE Q.3]
Q.10. Growth trends.

Ans.
Three types of growth trends enumerated by Tweed are
as follows:
i. Type A: Maxilla and mandible grow in unison, both
downward and forward. ANB shows no change.
ii. Type B: Maxilla grows more rapidly than mandible.
ANB angle increases.
iii. Type C: Mandible grows faster than maxilla.
Decrease in ANB angle.
These growth trends are helpful in planning retention for
individual orthodontic cases.
Q.11. Growth centres.

Ans.
• Growth centre is a location or place where genetically
controlled growth takes place.
• These are places of ossification with tissue-separating
force and they cause growth of the major part of the
bone.
• Centres of growth continue to grow when
transplanted to another area.
• Their response to external influence is less, whereas
response to functional needs is more.
• All growth centres are growth sites.
• The overall growth of the bone is controlled by a
growth centre.
Q.12. Differential growth.

Ans.
• Throughout life, human body does not grow at the
same rate, and different organs grow at different
rates to a different amount and at different times,
this is known as differential growth.
• The concept of differential growth is more clearly
understood by two important aspects of growth:
a. Cephalocaudal gradient of growth
b. Scarnrnon's cure of growth
a. Cephalocaudal gradient of growth
• An axis of increased growth gradient extending
from head towards the feet is called
'cephalocaudal growth'.
• In fetal life, head constitutes 50°/o of total body
length, while limbs are primitive (30°/o).
At the time of birth, head constitutes 25°/o-30°/o
and there is increased growth of body and limbs.
In an adult, the head constitutes only 12°/o, while
limbs account to 50°/o. These changes in the
pattern of growth are because of cephalocaudal
gradient.
• Scarnrnon's growth curve indicates that growth
rate of different tissues is different at different
ages.
Example: The various tissues for which
Scarnrnon's growth curve is plotted are
lymphoid, neural, general or visceral and
genital tissues.
Q.13. Methods of gathering growth data.

Ans.
Various methods of gathering growth data are as
follows:
The physical growth can be studied by a number of ways:
i. Opinion
ii. Observations
iii. Ratings and rankings
Quantitative measurements:
A scientific approach to study growth is based on
accurate measurements, which are of three types:
i. Direct data
ii. Indirect data
iii. Derived data
Q.14. Enumerate the peak periods of postnatal

growth.
Ans.
[Sarne as SN Q.1]
Q.15. Enumerate various theories of growth.

Ans.
[Ref LE Q.1]
Q.16. Growth spurts and two clinical importances.

Ans.
[Sarne as SN Q.1]
Q.17. Prepubertal growth spurt.

Ans.
[Sarne as SN Q.1]
Q.18. Scammon's growth curves.

Ans.
[Sarne as SN Q.3]
Q.19. Enumerate the various tissues for which

Scammon's growth curves are plotted.
Ans.
[Sarne as SN Q.3]
Q.20. Cortical drift.

Ans.
[Sarne as SN Q.9]
Topic 3 Growth and development of
cranial and facial structures
Long essays:
1. Describe in detail prenatal and postnatal growth
of mandible.

2. Define growth and development. Discuss prenatal
growth of maxilla.
3. Explain how maxilla increases in width, length
and height.
4. Discuss prenatal and postnatal growth of mandible
and its clinical implications in orthodontics.
[Same as LE Q.1]
5. Define growth and development. Explain the
postnatal growth of mandible. [Same as LE Q.1]
6. Explain in detail postnatal growth and
development of maxilla. [Same as LE Q.3]
Short essays:
1. Development of palate.
2. Describe the developmental defects of maxilla.
3. Postnatal growth and development of mandible.
[Ref LE Q.1]
4. Spheno-occipital synchondrosis.
5. Sutural growth of maxilla.
6. Development of tongue.
7. Mechanism of bone growth.
Short notes:
1. Define synchondrosis.
2. Meckel's cartilage.
3. Enumerate the mechanisms of bone growth.
4. Endochondral bone formation.
5. Development of palate.
6. Nasal septal cartilage.
7. Sutural growth of maxilla. [Ref LE Q.3]
8. Butler's field theory.
9. How does infant mandible differ from adult
mandible?
10. Enumerate types of synchondrosis. [Same as SN
Q.1]
Solved answers
Long essays:
Q.1. Describe in detail prenatal and postnatal growth

of mandible.
Ans.
Prenatal growth phases are as follows:
i. Period of ovum (from fertilization to 14th day)
ii. Period of embryo (from 14th to 56h day)
iii. Period of foetus (56th day to birth)
Prenatal growth of mandible:
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[SE Q.3]
{Postnatal growth of mandible:
• Among all the facial bones, the mandible undergoes
the largest amount of postnatal growth, and exhibits
the largest variability in morphology.
• Mandibular growth in the postnatal life shows the
integration of periosteal and capsular matrices of the
functional matrix theory by Moss.
• Capsular matrix involves the oropharyngeal
functional spaces and the mandible grows according
to the functional needs of a particular functional
system. The process of surface remodelling usually
involves the activity of the periosteal matrix, i.e.
muscle fibres.
Mandible at birth:
• Mandible at birth is much smaller in size and varies
in shape from the adult form. The infant mandible
has a short more or less horizontal ramus with
obtuse gonial angle.
• The condyles are low and at the position of the
occlusal plane. The symphyseal suture has not
ossified.
Growth in the first year:
• It involves growth at the syrnphyseal suture and
lateral expansion in the anterior region to
accommodate the erupting anterior teeth.
• The mental foramen is directed at right angle to the
surface of the corpus.
• There is increased bone deposition on the posterior
surface of the ram us of the mandible.
• The infant mandible is suited for the suckling activity
since the condyle and the glenoid fossa is flat, which
helps in the anteroposterior movement of the
mandible.
Mandible in the adult/concept of V principle:
The adult mandible differs from the mandible of an
infant in that
• The ramus is longer and the gonial angle is less
obtuse.
• The bone is larger on the whole and the condyle is
well developed.
• All these changes take place in the growth of the
mandible in the form of an expanding V.
• Because of its horseshoe shape, it is easier to visualize
mandible as a V-shaped bone than the maxilla.
V principle of growth:
According to this principle, growth of mandible in
length, width and height is as follows:
Length:
• The growth of the mandible in length
anteroposteriorly is by the deposition of bone
at the posterior border of the ram us and
resorption at the anterior surface, which helps
to lengthen mandible so that the anterior part
of the ram us is occupied by the posterior part
of the body in the future and accommodates
the developing permanent molars.
• As the articulation of the condyle to the glenoid
fossa is constant, the anterior displacement
causes displacement of the mandible
anteriorly as it grows posteriorly.
• As the mandible grows anteriorly, the opening
of the mental foramen faces backwards so that
the neurovascular bundle leaves the foramen
directed backwards.
• There is corresponding surface remodelling at
the anterior border with deposition in the
posterior surface of the symphysis and
resorption in the superior part of the anterior
surface and deposition in the inferior aspect.
Width:
• There is deposition in the lateral surface of the
ramus and resorption on the lingual surface of
mandible below the mylohyoid ridge. In
contrast, the coronoid process undergoes
apposition at the medial surface and
resorption at the lateral surface. This expands
the mandible like a V.
• The condyle undergoes reduction of bone on
the lateral aspect of neck, and deposition
corresponding to the V principle makes the
condyle longer at the neck.
• Following the V principle, the inter-ramal
distance is efficiently increased by the growth
of mandible, which helps the mandible to keep
pace with the growth of the cranial base.
• The mandible, which is often retrognathic in
the newborn, assumes an orthognathic
relation with the maxilla during adulthood
due to the growth of the bone in length.
• The condylar cartilage contributes little, if any,
to the growth and does not act as primary
growth centre. In patients with ankylosis of
the TM joint, the mandible is found to grow to
normal length.
• The muscular processes of the mandible like
angle, coronoid and condylar processes are
under the influence of the periosteal matrix.
Height:
• Alveolar process height increases well with
eruption of teeth.
• Bone deposition taking place in the lower
border of the mandible also contributes to
increase in the height of the mandible.}
Rotation of mandible:
• Bjork used implants to study the growth
pattern of mandible and found that mandible
undergoes growth rotation. It was found that
although mandible undergoes rotation, the
effects seen are minimal due to external
compensation.
It was concluded that the growth of mandible is
largely influenced by the functional matrices,
and the condylar cartilage has little influence in
its overall growth.
Summary of mandibular growth:
Length increases by:
i. Surface apposition at posterior border of ram us
and resorption at anterior border.
ii. Deposition at bony chin.
iii. Growth at condylar cartilage.
Height increases by:
i. Surface apposition at the alveolar border.
ii. Apposition at the lower border of mandible.
iii. Growth at the condylar cartilage.
u
Height increases by:

i. Surface apposition at the alveolar border.
ii. Apposition at the lower border of mandible.
iii. Growth at the condylar cartilage.
Width increases by:
i. Sutural growth up to 1st year postnatally.
ii. Later surface apposition at the outer surface.
Growth sites in mandible are as follows:
i. Mandibular condyle
ii. Posterior border of ram us
iii. Alveolar process
iv. Lower border of mandible

v. Suture
Q.2. Define growth and development. Discuss

prenatal growth of maxilla.
Ans.
Growth has been defined by various clinicians in different
ways as follows:
According to:
J.S. Huxley- 'The self-multiplication of living
substance'.
Krogman - 'Increase in size, change in proportion
and progressive complexity'.
Todd - 'An increase in size'.
Meridith - 'Entire series of sequential anatomic and
physiologic changes taking place from the
beginning of prenatal life to senility'.
Moyers - 'Quantitative aspect of biologic
development per unit of time'.
Moss - 'Change in any morphological parameter
which is measurable'.
• Development is defined in simple words as,
'progression towards maturity'.
• According to Melvin Moss, 'Development can be
considered as a continuum of causally related
events from the fertilization of ovum
onwards'.
Prenatal growth of maxilla:
• Maxillae, a pair of bones on either side of the
middle third of the face, are formed by
intramembranous bone formation.
• Due to its more cranial location, maxilla is ahead of
mandible in growth generally.
• The cephalocaudal gradient of growth of maxilla
closely follows the neural growth curve in the
Scammon's curves.
Stages of prenatal growth of craniofacial region
are as follows:
• The prenatal craniofacial growth develops in three
stages:
a. The period of the ovum from fertilization till
second week.
b. The period of embryo from 2nd to 8th week.
c. The period of foetus from the 9th week till birth.
• The tissues of the face, both hard and soft
tissues, are of neural crest cell origin, also
called ecto-mesenchymal origin.
• The neural crest cell gives rise to diverse
structures both near the site of its origin and at
the remote sites. In the head and neck region,
the neural crest cells give rise to the facial
processes, the branchial arches and their
cartilages, etc.
Frontonasal process:
• The head begins to take shape at around 21 days
after conception. The migrating neural crest cells
when encounter the lens placode, they form two
streams: The anterior stream of cells forms the
mesenchyme of the frontonasal process and the
posterior stream migrates to form the structures of
the branchial arches.
• Most of the development of the face takes place
between 3rd and 8th week of IUL. At around 4th
week of IUL, the branchial arches begin to develop.
Branchial arches:
• The branchial arches, developing during the late
somite period, are formed from the mesoderm of
the ventral foregut. There are five pairs of
branchial arches, the fifth being transitory.
• The first arch is the mandibular arch and the
second arch is the hyoid arch.
The jaws of the face, i.e. maxilla and mandible, are
derived from the first arch.
• Meanwhile, the frontonasal process of the forebrain
just above the stomodeum develops bilateral
thickenings called nasal placodes. In the middle,
there is invagination of placode to form nasal pits,
on both sides of them there are elevations, which
are medial and lateral nasal processes.
Maxillary process:
• By around the 4th week of IUL, facial process arises
from the first arch, which corresponds to
mandibular processes. Later, ventromedially two
more swellings grow from the mandibular
processes called the maxillary processes.
• By about the 6th week, the processes of the face are
easily discernible. The stomodeum is bound by the
frontonasal process above; the mandibular process
below, and the sides being occupied by the
maxillary processes.
• The maxillary process grows ventromedially
towards the nasal processes.
The maxillary process fuses with the lateral nasal
process and migrates medially to contact the
inferolateral side of the medial nasal process.
• The maxillary and the medial nasal processes are
initially separated by the epithelial nasal fin, which
soon degenerates so that the mesenchyme of the
two processes fuses. The maxillary and
mandibular processes fuse at the sides to form the
cheek tissue.
• The lateral nasal process forms the alae of the nose.
The medial nasal process of both sides fuse to form
the globular process in the middle which gives rise
to the tip of the nose, columella, the philtrurn, the
labial tuberculum of the upper lip, the frenulum
and the entire primary palate.
• The maxillary process forms the alveolus, which
bears teeth distal to the canines and the secondary
palate.
• The area of fusion of the maxillary and mandibular
processes forms the commissural corners of the
mouth. As the two processes grow towards the
fellow of the opposite side, the stomodeum is
narrowed.
Ossification centres of maxilla:
• Maxilla develops by the intramembranous
ossification. A primary ossification centre appears
at about early 8th week at the termination of the
infraorbital nerve just above the canine tooth
lamina. There are two centres for each maxilla.
• Secondary cartilages appear at the end of the 8th
week in the regions of the zygomatic and alveolar
processes that ossify and fuse with the primary
centre.
• Around 8th week, two ossification centres appear in
the region of premaxilla on each side. The centres
rapidly merge with the primary centres and are
overshadowed by the growth of primary centres.
Q.3. Explain how maxilla increases in width, length

and height?
Ans.
Postnatal growth of maxilla:
• The development and growth of maxilla is
completed early compared to the mandible.
• The growth of maxilla, especially in width, follows
closely the neural growth curve more than the
general growth curve in the Scammon's curve.
Growth of maxilla:
Growth of maxilla occurs by the following processes.
A. Displacement or translation:
• Displacement or translation of a bone is the
process by which specific local areas come to
occupy new actual positions in succession as
the entire bone enlarges. It may be active or
.
passive.
• Maxilla is attached to the cranial base; hence,
the growth of the cranial base has a direct
bearing on the nasomaxillary growth.
• A passive or secondary displacement of the
nasomaxillary complex occurs in a downward
and forward direction as the cranial base
grows. This is a secondary type of
displacement; the nasomaxillary complex is
simply moved anteriorly as the middle cranial
fossa grows in that direction.
• It is an important growth mechanism during
the primary dentition period but becomes less
important as growth of cranial base slows
down.
• Active translation takes place when the growth
at the tuberosity of the maxilla pushes the
maxilla forward. A primary type of
displacement is seen in a forward direction
which results in the whole maxilla being
carried anteriorly.
• The amount of this forward displacement
equals the amount of posterior lengthening.
This is a primary type of displacement as the
bone is displaced by its own enlargement.
{SN Q.7}
B. Growth at the sutures by connective tissue
proliferation:
• The maxillae articulate with the surrounding
bones of cranium and cranial base with the
help of the number of sutures like the
zygomaticomaxillary, frontomaxillary,
pterygopalatine and zygomaticotemporal
sutures.
• According to Sicher, growth at these paired
parallel sutures will move the maxilla
downward and forward. It is only secondary
and not a primary mechanism.
• As growth of the surrounding soft tissue occurs,
the maxilla is carried downwards and
forward, leading to the opening up of space at
sutural attachments.·
• New bone is now formed on the either side of
the sutures, leading to the overall increase in
size of bones on either side. Hence, a tension-
related bone formation occurs at the sutures.
C. Remodelling:
• In addition to the growth occurring at the
sutures, simultaneous resorption and
deposition move the surfaces of the maxilla
while maintaining the integrity and basic
shape of the bone.
• Remodelling by bone deposition and resorption
occurs to bring about:
(a) Increase in size
(b) Change in shape of bone
(c) Change in functional relationship
• Maxillary growth matures first in width
followed by the depth and the length. It would
be easier to discuss the growth of maxilla in
the same order.
i. Maxillary width:
• The floor of the orbit faces superiorly,
laterally and anteriorly. Growth proceeds in
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i. Maxillary width:
• The floor of the orbit faces superiorly,
laterally and anteriorly. Growth proceeds in
this direction by deposition and resorption
on the lateral surface of the orbital rim.
• Resorption occurs on the lateral surface of
the orbital rim, leading to lateral movement
of the eye ball. To compensate, there is bone
deposition on the medial rim of the orbit
and
.
on the external surface of the lateral
rim.
• Mid-palatal suture is active till 15 years, but it

cannot be generalized. Due to sutural
growth, there is bone fill in the mid-palatal
area and resorption in the lateral aspect.
• The entire wall of the sinus except the mesial
wall undergoes resorption. This results in
increase in size of maxillary sinus.
• In the zygomatic process and the zygomatic
arch, it is more complex. There is deposition
on the posterior and lateral aspects and
resorption on the anterior and medial
surfaces. Thus, the zygomatic bone moves in
a posterior direction.
• The face enlarges in width by bone formation
on the lateral surface of the zygomatic arch
and resorption on its medial surface.
• The nasal part of the maxilla faces in an
anterior, lateral and superior direction. The
growth proceeds in the same direction.
There is surface removal of bone from the
periosteum lining the inner aspect of the
nasal cavity and deposition on the endosteal
surface. This allows the expansion of nasal
cavity.
ii. Anteroposterior/depth
• Zygomatic bone moves posteriorly and
laterally by deposition in the posterior and
lateral surface and resorption in the medial
surface.
• Bone deposition occurs along the posterior
margin of the maxillary tuberosity. This
causes lengthening of the dental arch and
enlargement of the anteroposterior
dimension of the entire maxillary body. This
helps to accommodate the erupting molars.
• The anterior nasal spine prominence
increases due to bone deposition. In
addition, there is resorption from the
periosteal surface of labial cortex. As a
compensatory mechanism, bone deposition
occurs on the endosteal surface of the labial
cortex and periosteal surface of the lingual
cortex, and the maxilla moves forward.
• The zygomatic bone moves in a posterior
direction to keep its relation with the
maxilla. This happens by resorption in the
anterior surface and deposition in the
posterior surface.
iii. Maxillary height
• Bone resorption is seen on the floor of the
nasal cavity. To compensate, there is bone
deposition on the palatal side. Thus, a net
downward shift occurs, leading to increase
in maxillary height.
• As the teeth start erupting, bone deposition
occurs at the alveolar margins. This
increases vertical height of the maxilla and
the depth of the palate. This increase is seen
as long as the teeth erupt. This contributes to
early increase in the height of maxilla and
accounts for about 40°/o increase in the
maxillary height.
Maxillary growth can be summarized as follows:
• Length increases by - Sutural growth and the
surface apposition at maxillary tuberosity.
• Width increases by - Growth at the median palatine
suture and apposition at zygomatic bone.
• Height increases by- Sutural growth, surface
apposition and alveolar growth.
• Growth sites in maxilla:
i. Maxillary tuberosity
ii. Sutures
iii. Alveolar border
iv. Nasal septum
v. Lateral walls
Q.4. Discuss prenatal and postnatal growth of

mandible and its clinical implications in
orthodontics.
Ans.
[Same as LE Q.1]
Q.5. Define growth and development. Explain the

postnatal growth of mandible.
Ans.
[Same as LE Q.1]
Q.6. Explain in detail postnatal growth and

development of maxilla.
Ans.
[Same as LE Q.3]
Short essays:
Q.1. Development of palate.

Ans.
The palate is formed by contributions of the following:
a. Maxillary process
b. Palatal shelves of the maxillary process
c. Frontonasal process
• The frontonasal process gives rise to the
premaxillary region, while the palatal shelves
form the rest of the palate.
• As the palatal shelves grow medially, their union is
prevented by the presence of tongue. Thus, initially
the developing palatal shelves grow vertically
downwards towards the floor of the mouth.
• During the 7th week of intrauterine life,
withdrawal of tongue from palatal shelves aids in
the transformation of their position from vertical
to horizontal direction.
• By 81/2 weeks of intrauterine life, two palatal shelves
are in close approximation with each other which
are initially covered by an epithelial lining. As they
join, the epithelial cells degenerate. The connective
tissues of the palatal shelves intermingle with each
other, resulting in their fusion.
• The entire palate does not contact and fuse at the
same time. Initially, contact occurs in the central
region of the secondary palate posterior to the
premaxilla. From this point, closure occurs both
anteriorly and posteriorly.
• The mesial edges of the palatal processes fuse with
the free lower end of nasal septum, and thus
separate the nasal cavities from each other and the
oral cavity.
• Ossification of the palate occurs from the 8th week
of intrauterine life. The palate ossifies from a
single centre derived from the maxilla. The most
posterior part of the palate does not ossify and it
forms a soft palate. The mid-palatal suture ossifies
by 12-14 years.
• Postnatal growth of palate follows the concept of
expanding 'V' by Enlow. It is a more complex
process. It is one of the best examples of the
expanding V principle.
• Growth at the suture by bone fill-in contributes
more to the increase in width of the palate than
remodelling. The width of the palate also increases
by the growth of the alveolar process, which
diverges out.
• Many bones or parts of the bone are in the form of
V. Bone deposition takes place on the inner side of
V, and resorption takes place on the outer surface.
• If the outer surface of the expanding Vis taken,
then the periosteal surface could be found to be
lined with osteoclasts, and endosteal surface is
found to be lined with osteoblasts.
• In a young child, the maxillary arch and the nasal
floor are very close to the inferior orbital rim. By
deposition on the palatal periosteal surface and
resorption on the nasal floor, the palate comes to
occupy a lower position.
• When viewed in a cross section, the deposition of
the bone occurs along the whole of the periosteal
surface of the palate in such a way that the bone
expands in a lateral direction and also downwards.
• The nasal floor due to resorption increases in
volume and descends down from the level of
infraorbital rim.
• In conjunction with the V principle, half of the
external surface involved in this growth is
depository and the other half is resorptive, thus
half of the bone tissue of the palate is endosteal
and the other half is periosteal.
• The same concept is seen even in the
anteroposterior growth of the palate/midsagittal
section of the palate. There is deposition on the
palatal surface and resorption along the anterior
surface/incisor area and superior surface,
expanding the palate like a V.
Q.2. Describe the developmental defects of maxilla.

Ans.
The developmental defects of maxilla are as follows:
• The most prominent defect in the development of
maxilla is the cleft lip, either unilateral or bilateral.
• The cleft lip can be complete or partial.
• The most common is unilateral cleft lip (1 in 800
births). Bilateral cleft lip is rare and produces a
protuberant, free hanging middle part of the lip.
• The cleft lip occurs due to failure of fusion of
maxillary and medial nasal processes.
• The failure of fusion of medial nasal processes
produces the midline cleft, the 'true hare lip', which
is exceedingly rare.
• Lateral facial cleft or oblique facial cleft is
occasionally seen in the condition of failure of fusion
of lateral nasal process with the maxillary process.
• Cleft lip/palate and other facial clefts develop during
the period of organ formation in the craniofacial
development. This approximates to about 28-55 days
of IUL.
• Overfusion of maxillary and mandibular processes
leads to a small mouth, called microstomia.
Q.3. Postnatal growth and development of the

mandible.
Ans.
[Same as LE Q.1]
Q.4. Spheno-occipital synchondrosis.

Ans.
• 'Synchondroses' are defined as the bands of cartilage
present at the junction of various bones during the
bone formation stage.
• These synchondroses form important growth sites in
the base of skull.
• Cranial base grows by cartilaginous growth in the
Q.4. Spheno-occipital synchondrosis.
Ans.
• 'Synchondroses' are defined as the bands of cartilage
the base of skull.
synchondroses which later gets calcified.
Types of synchondroses:
They are classified into four subtypes:
i. Intersphenoidal synchondroses - occur at birth

ii. Intraoccipital synchondroses - occur at 3-5
years
iii. Spheno-occipital synchondroses - occur at 20
years
iv. Sphenoethmoidal synchondroses - exact age is
not known
Spheno-occipital synchondrosis:
• Spheno-occipital synchondroses are the
cartilaginous junction between the sphenoid
and the occipital bones and are active up to
the age of 12-15 years and become fused by
the age of 20 years.
• It is responsible for most of the lengthening of
cranial base between foramen magnum and
sellaturcica and is the important growth site of
cranial base during childhood.
• Cranial base lengthening is contributed by
elongation of synchondroses in combination
with drift and remodelling.
• As endochondral bone growth occurs at the
spheno-occipital synchondrosis, the sphenoid
and occipital bones move apart. At the same
time, new endochondral bone is laid down in
the medullary region and the cortical bone is
formed in endosteal and periosteal regions.
Thus sphenoid and occipital bones increase in
length and width.
• Cartilage unlike bone is a pressure-adapted
tissue and can grow in heavy pressure areas,
e.g. cranial base.
Clinical implications:
• Spheno-occipital synchondroses are
responsible for most of the lengthening of
cranial base between foramen magnum and
sella turcica.
• It is the major contribution of endochondral
growth till 20 years.
• Elongation of synchondroses in combination
with drift and remodelling contribute to
cranial base lengthening.
Q.5. Sutural growth of maxilla.

Ans.
• The maxilla is connected to the cranium and cranial
base by a number of sutures. These sutures include:
a.Frontonasalsuture
b. Frontomaxillary suture
c. Zygomatico-temporal suture
d. Zygornatico-maxillary suture
e. Pterygo-palatine suture
• These sutures are all oblique and more or less parallel
to each other. This allows the downward and
forward repositioning of maxilla as growth occurs at
these sutures.
• As growth of the surrounding soft tissue occurs, the
maxilla is carried downwards and forward. This
leads to the opening up of space at sutural
attachments.
• New bone is now formed on either side of the suture.
Thus, the overall size of the bones on either side
increases. Hence, a tension-related bone formation
occurs at the sutures.
Q.6. Development of tongue.

Ans.
i. At approximately 4 weeks, the tongue appears in
embryo in the form of two lateral lingual swellings
and one median swelling, the tuberculum impar.
These three swellings originate from the first
pharyngeal arch (Fig. 3.1).
ii. A second median swelling, the copula, or
hypobranchial eminence, is formed by mesoderm of
the second, third, and part of the fourth arch.
iii. A third median swelling, formed by the posterior
part of the fourth arch.
iv. As the lateral swellings increase in size, they
overgrow the tuberculum impar and merge, forming
the anterior two-thirds or body of the tongue, sensory
innervation to this area is by the mandibular branch
of the trigeminal nerve.
v. The posterior part, or root, of the tongue originates
from the second, third, and part of the fourth
pharyngeal arch. The sensory innervation to this part
of the tongue supplied by the glossopharyngeal nerve
indicates that tissue of the third arch overgrows that
of the second.
vi. The extreme posterior part of the tongue is
innervated by the superior laryngeal nerve, reflecting
its development from the fourth arch.
vii. Some of the tongue muscles probably differentiate
in situ, but most are derived from myoblasts
originating in occipital somites. Thus, tongue
musculature is innervated by the hypoglossal nerve.
viii. The general sensory innervation of the tongue is
easy to understand:
• The body is supplied by the trigeminal nerve, the
nerve of the first arch.
• The root is supplied by the glossopharyngeal and
vagus nerves, the nerves of the third and fourth
arches, respectively.
• Special sensory innervation (taste) to the body of
the tongue is provided by the chorda tympani
branch of the facial nerve.
FIG. 3.1Pharyngeal arches involved in

the development of tongue.
Q. 7. Mechanism of bone growth.

Ans.
Mechanisms of bone growth:
The growth of any bone follows certain basic
processes like remodelling and growth movements
caused by drifts and displacement.
Remodelling:
• Remodelling is the differential growth activity
necessary for bone shaping. It is not a uniform
process. The process of remodelling is
differential, e.g. if deposition takes place on
the outer/periosteal surface of bone then
resorption takes place in the endosteal surface.
• Remodelling is the basic growth process
providing regional changes in the shape,
dimensions and proportions of bone.
• It also performs regional adjustments in the
bone to the changing functional demands.
Growth movements:
Two types of growth movements occur during the
enlargement of the cranial bones, they are drift
and displacement.
• Drift:
It is the movement of the bone surface caused by
deposition and resorption towards the
depository surface. It is otherwise called
transformation.
• Displacement:
It is the growth of the bone as a whole unit so
that the bone is taken away from its
articulation with other bones. It is otherwise
called translation.
• Displacement is of two kinds:
i. Primary or active:
Where the movement is due to the growth of
the bone itself, e.g. growth of maxilla at
tuberosity region
ii. Secondary displacement:
It is the movement of one bone due to the
growth of other bones or translation
within the capsule. It is passive.
Example: Growth of maxilla due to growth
at the spheno-occipital synchondrosis.
Short notes:
Q.1. Define synchondrosis.

Ans.
• 'Synchondroses' are defined as the bands of cartilages
the base of the skull.
synchondroses which later gets calcified.
Types of synchondroses:
These are classified into four subtypes:
i. Intersphenoidal synchondroses - occur at birth
ii. Intraoccipital synchondroses - occur at 3-5
years
iii. Spheno-occipital synchondroses - occur at 20
years
iv. Sphenoethmoidal synchondroses - exact age is
not known
Q.2. Meckel's cartilage.

Ans.
• The Meckel's cartilage is the cartilage of the first
branchial arch.
• Meckel's cartilage appears bilaterally as cartilaginous
bars, the anterior aspect of these two cartilages
approaches each other near the midline but do not
fuse, while posteriorly they terminate in a bulbous
structure called malleus.
• Malleus and incus are derivatives of Meckel's
cartilage.
• The part of the cartilage extending from the region of
the middle ear to mandible disappears but its sheath
forms the 'anterior ligament of the malleus' and the
'sphenomandibular ligament.'
Q.3. Enumerate the mechanisms of bone growth.

Ans.
Mechanisms of bone growth:
The growth of any bone follows certain basic
processes like remodelling and growth movements.
Remodelling:
• Remodelling is the differential growth activity
necessary for bone shaping. It is not a uniform
process.
• It is the basic growth process providing regional
changes in the shape, dimensions and proportions
-
• It is the basic growth process providing regional
changes in the shape, dimensions and proportions
of bone.
• It also performs regional adjustments in the bone to
the changing functional demands.
Growth movements:
• There are two types of growth movements, namely
(a) Drift
It is the movement of the bone surface caused by
the deposition and resorption towards the
depository surface. It is otherwise called
transformation.

(b) Displacement
It is the growth of the bone as a whole unit so
that the bone is taken away from its
articulation with other bones. It is otherwise
called translation.
• Displacement is of two kinds:
(i) Primary or active displacement
(ii) Secondary displacement
Q.4. Endochondral bone formation.

Ans.
• Endochondral bone is formed in a cartilaginous
model; osteoblasts invade cartilage and replace it.
• The first step during endochondral bone formation is
the differentiation of mesenchymal cells into
chondrocytes. These chondrocytes form a rough
model which is enclosed by perichondral cells.
• Cartilage mass grows by both interstitial growth and
apposition. Cartilage cells hypertrophy and their
matrix begins to get calcified.
• The blood vessels penetrate the cartilage mass from
the perichondrium during this time.
• These penetrating blood vessels carry
undifferentiated mesenchymal cells along with them,
which get converted into osteoblasts.
• Osteoblasts subsequently deposit bone and bone
spicules are formed. Gradually the cartilage mass is
replaced by bone.
• Endochondral bone formation is usually seen in the
areas where there are high levels of compression.
Example: cranial base and movable joints
Q.5. Development of palate.

Ans.
(i) The primary palate is derived from the
intermaxillary segment.
(ii) The main part of the definitive palate is formed by
two shelf-like outgrowths from the maxillary
prominences known as palatine shelves, which
appear in the 6th week of development and are
directed obliquely downward on each side of the
tongue.
(iii) During 7th week, the palatine shelves ascend to
attain a horizontal position above the tongue, and
fuse to form the secondary palate.
(iv) Anteriorly, the shelves fuse with the triangular
primary palate, and the incisive foramen is the
midline landmark between the primary and
secondary plates.
(v) At the same time as the palatine shelves fuse, the
nasal septum grows down and joins with the cephalic
aspect of the newly formed palate.
Q.6. Nasal septal cartilage.

Ans.
• Nasal septum appears to be the primary factor in the
displacement of nasomaxillary complex.
• During prenatal period, nasal septal cartilage lies
behind the cranial base cartilages and is attached in
front and below to premaxillary bone as well as
vomer, and posteriorly to mesethmoid cartilage.
• During postnatal development, perpendicular plate of
ethmoid ossifies from mesethmoid cartilage at birth.
• The perpendicular plate of ethmoid fuses with
cribriform plate of ethmoid at 3 years of age. With
this, the cranial components are fused with the facial
bony elements.
• Anterior part of the nasal septum remains
cartilaginous throughout life.
• After the union of cranial and facial bony
components, the nasal septum has a very little effect
on facial growth.
Q. 7. Sutural growth of maxilla.

Ans.
[Ref LE Q.3]
Q.8. Butler's field theory.

Ans.
• The human dentition is divided into four fields:
incisor, canine, premolar and molar.
• The most distal tooth in each field is more susceptible
to changes or variations, which include absence of
tooth, and variation in size, shape and structure. This
is called 'Butler's field theory'.
Example: Lateral incisors, second premolars and
third molars are the most variable teeth in their
group.
• Canine is the least variable tooth in the arch.
• Butler's field theory does not apply in lower anterior
region, where mandibular central incisor is more
commonly missing than lateral incisor.
Q.9. How does infant mandible differ from adult

mandible?
Ans.
Infant mandible:
The infant mandible has a short, more or less
horizontal ramus with obtuse gonial angle. The
condyles are low and at a position of occlusal
plane.
The adult mandible differs from the mandible of an
infant in that:
• The ramus is longer and the gonial angle is less
obtuse.
• The bone is larger on the whole and the condyle is
well developed.
• All these changes take place in the growth of the
mandible in the form of an expanding V.
Q.10. Enumerate types of synchondrosis.

Ans.
[Same as SN Q.1]
Topic 4 Development of dentition
and occlusion
Long essays:
1. Discuss the development of occlusion and its
significance.

2. Describe the development of dentition and intra-
arch tooth relationships from 6th year to 12th year
of a child's life. [Same as LE Q.1]
3. Define normal occlusion. Describe normal
occlusion in deciduous dentition and its further
development till the age of 12 years. [Same as LE
Q.1]
Short essays:
1. Space of Nance.
2. Describe briefly the development of dentition and
occlusion.
3. Incisal liability.
4. Anthropoid spaces.
5. Transient malocclusions.
6. Andrew's keys to normal occlusion.
7. Ugly duckling stage.
8. Terminal planes. [Ref LE Q.1]
9. Curve of Spee.
10. Gum pads.
11. Leeway space of Nance. [Same as SE Q.1]
12. Physiological spaces. [Same as SE Q.4]
13. Write briefly about Roth's keys of occlusion.
[Same as SE Q.6]
14. Flush terminal plane. [Same as SE Q.8]
Short notes:
1. Gum pads.
2. Primate spaces.
3. Incisor liability. [Ref SE Q.3]
4. Ugly duckling stage. [Ref SE Q.7]
5. Leeway space. [Ref SE Q.1]
6. Distal flush terminal plane. [Ref LE Q.1]
7. Flush terminal plane. [Ref LE Q.1]
8. Theories of eruption.
9. Sequence of eruption of permanent teeth. [Ref LE
Q.1]
10. Transient malocclusion. [Ref SE Q.5]
11. Andrew's keys to normal occlusion. [Ref SE Q.6]
12. Enumerate the stages of eruption of normal
occlusal development.
13. Centric relation.
14. Roth's keys of functional occlusion. [Ref SE Q.6]
15. Premature loss of deciduous teeth.
16. Enumerate the stages of tooth development.
17. Leeway space of Nance. [Same as SN Q.5]
18. Transitional period. [Same as SN Q.10]
19. Enumerate few self-correcting malocclusions.
[Same as SN Q.10]
20. Enumerate Andrew's six keys to normal
occlusion. [Same as SN Q.11]
Solved answers
Long essays:
Q.1. Discuss the development of occlusion and its

significance.
Ans.
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Occlusal development can be divided into the

following periods or stages:
Predental period:
• This period extends from birth to 6 months of age
after birth, i.e. 0-6 months.
• The neonate is without teeth for about 6 months of
life. The alveolar arches of an infant during this
period are known as gum pads.
Features of gum pads are as follows Fig 4.1 :
i. They are pink in colour and firm in consistency
covered by dense layer of fibrous periosteum.
ii. They are horseshoe shaped and develop in the
following two parts:
(a) Labiobuccal portion
(b) Lingual portion
Dental groove:
These two portions are separated by a groove
called the dental groove.
FIG. 4.1 Maxillary gum pad.
Transverse grooves:
iii. The gum pads are divided into 10 segments by
transverse grooves. Each segment consists of one
developing deciduous tooth sac.
Lateral sulcus Fig 4.1 :
iv. The transverse groove between the canine and
first deciduous molar segment is called the lateral
sulcus.
The lateral sulcus of mandibular arch is normally
more distal than that of maxillary arch.
The lateral sulci are useful in judging the interarch
relationship of maxilla and mandible at a very
early stage.
v. Upper and lower gum pads are almost similar to
each other.
Relationship of gum pads:
• When upper and lower gum pads are
approximated, there is a complete overjet all
around, as the upper gum pad is wider and longer
than lower gum pad.
• Mandibular lateral sulci are posterior to maxillary
ones.
• Class II pattern is exhibited as maxillary gum pad
being more prominent.
• Anterior open bite: This infantile open bite is
considered normal. Contact occurs between upper
and lower gum pads in first molar region and a
space exists between them anteriorly, known as
infantile open bite, which helps in sucking.
The Deciduous Dentition Period:
The deciduous dentition period extends from 6
months to 6 years of postnatal life. It starts with
the eruption of deciduous mandibular central
incisors and completes with second deciduous
molars coming into occlusion. The eruption of all
primary teeth is completed by 21/2 - 31/2 years of
age.
The normal features of an ideal occlusion in the
primary dentition are as follows:
i. Spacing of anterior teeth:
Spaces existing between the deciduous teeth,
called physiological or developmental spaces,
are important for normal development of
permanent dentition.
ii. Primate/anthropoid/simian spaces:
These physiological spaces are present
invariably on mesial side of maxillary canines
and distal side of mandibular canines.
As these spaces are commonly seen in primates.
They are known as primate spaces, simian
spaces or anthropoid spaces. These spaces help
in the placement of canine cusps of the
opposing arch.
iii. Shallow overjet and overbite
iv. Ovoid arch form
v. Almost vertical inclination of anterior teeth
vi. Flush terminal plane:
The mesiodistal relation between the distal
surfaces of the upper and lower second
deciduous molars (E) is called the terminal
plane.
A normal feature of deciduous dentition is a
flush terminal plane, where the distal surfaces
of the upper and lower second deciduous
molars are in the same plane.
vii. Deep bite:
The deep bite occurs in the initial stages of
development and is accentuated by the more
upright deciduous incisors compared to their
successors.
This deep bite is reduced later due to:
(a) Eruption of deciduous molars
(b) Attrition of incisors
(c) Forward movement of the mandible due
to growth
The mixed dentition period:
This period ranges from 6 to 12 years of age.
This period can be divided into three phases:
(a) First transitional period
Cb) Intertransitional period
Cc) Second transitional period
(A) First transitional period:
It is characterized by the following:
(i) Emergence of first permanent molars
(ii) Exchange of deciduous incisors with
permanent incisors.
(i) Emergence of first permanent molars:
• Mandibular first molar is the first
permanent tooth to erupt at
around 6 years of age.
• The distal surface of the second
deciduous molar, i.e. (E) guides the
first permanent molars into the
dental arch.
• The location and the relationship of
first permanent molars depend
much on the distal surface
relationship between upper and
lower second deciduous molars
E
E
(SN Q.6 and SE Q.8)
• {(The distal surface relationship between the
upper and lower second deciduous molars can
be of three types:
a. Flush terminal plane (76°/o)
b. Mesial step terminal plane (14°/o)
c. Distal step terminal plane (10°/o))}
a. Flush terminal plane:
FIG. 4.2 Flush terminal plane.
(SN Q.7 and SE Q.8)

• {(The distal surface of upper and lower second
deciduous molars is in one vertical plane. This
type of relationship is called flush or vertical
terminal plane relationship, which is a normal
feature of deciduous dentition.
• The erupting first permanent molars may also be
in a flush or end on relationship which shifts to
class relation by
a. Early shift
b. Late shift)}
• Early shift:
Occurs during early mixed dentition period,
where eruptive force of the first permanent
molar is sufficient to push the deciduous first
and second molars forward to close primate
spaces and establish class I molar relationship.
• Late shift:

Occurs in the late mixed dentition period. In
children lacking primate spaces, the erupting
permanent first molars drift mesially, utilizing
the Leeway space, when deciduous second
molars exfoliate.
b. Mesial step terminal plane:
I
I
I
6 E
FIG. 4.3 Mesial step terminal plane.
In this type of relationship:

• Distal surface of mandibular second
deciduous molar is more

(~)
mesial than that of maxillary second
deciduous molar
(~)
• The permanent molars erupt directly into
the Angle's class I occlusion.
If forward growth of mandible
Leads to Establishes
Angle's class Ill molar Angle's class I molar

relationship relationship
{SN Q.6}
c. Distal step terminal plane:
I
r---- ...... I
I
6 E
6 I E D
I
I
I
FIG. 4.4 Distal step terminal plane.
In this type of relationship, the distal surface of

E E E E
is more distal to that of
Erupting permanent molars assume Angle's class

II occlusion here.}
(ii) The exchange of incisors:
The deciduous incisors are replaced by
permanent incisors during first transition
period.
The mesiodistal width of permanent incisors
is larger than deciduous teeth that they
replace.
Incisal liability is the difference between the
amount of space needed for
accommodation of the incisors and the
amount of space available for them to
occupy. It was described by Warren Mayne
in 1969.
lncisal liability
I
7 mm in maxillary arch 5 mm in mandibular arch
Utilization of inter-dental spaces seen

in primary dentition
lncisal liability can --- Increase in inter-canine width

be overcome by
Change in incisor inclination
(B) Intertransitional period:

• It is relatively stable and no changes occur
during this phase to mixed dentition.
• The maxillary and mandibular arches consist
of sets of deciduous and permanent teeth
during this period.
(C) Second transitional period:
i. Replacement of deciduous molars and
canines by premolars and permanent
cuspids, respectively, is a characteristic of
this phase.
ii. The Leeway space of Nance is the excess
space available after the exchange of
deciduous molars and canines with
permanent teeth. It is utilized for mesial
drift of mandibular molars to establish class
I molar relation.
iii. Ugly duckling stage (7-11 years of age): Also
known as Broadbent's Phenomena, it is a
transient or self-correcting malocclusion
seen in maxillary incisor region, particularly
during eruption of permanent canines.
During eruption of permanent canines, they
impinge on roots of lateral incisors
displacing them mesially, which in turn
results in transmission of force onto the
roots of central incisors, which also get
displaced mesially.
A resultant distal divergence of crowns of
two central incisors causes a midline
diastema.
This situation has been described by
Broadbent as Ugly Duckling stage as
children tend to look ugly during this
phase.
Gingival groove
FIG. 4.5 Maxillary gum pad.
{SN Q.9}
The Permanent Dentition Period:
This period extends from shedding of last primary
tooth and eruption of all permanent teeth.
The frequently seen eruption sequence of the
permanent dentition is as follows:
• Maxillary arch 6-1-2-4-3-5- 7
or
6-1-2-3-4-5-7
• Mandibular arch 6-1-2-3-4-5- 7
or
6-1-2-4-3-5-7)
Q.2. Describe the development of dentition and intra-

arch tooth relationships from 6th year to 12th year
of a child's life.
Ans.
[Same as LE Q.1]
Q.3. Define normal occlusion. Describe normal

occlusion in deciduous dentition and its further
development till the age of 12 years.
Ans.
[Sarne as LE Q.1]
Short essays:
Q.1. Space of Nance.

Ans.
{SNQ.5}
i. The combined mesiodistal width of permanent
canines and premolars is usually less than deciduous
canines and molars which they replace. This surplus
space is called the Leeway space of Nance.
ii. The Leeway space is greater in mandibular arch
compared to maxillary arch.
In maxillary arch ..... 1.8 mm (0.9 mm per side of the
arch)
In mandibular arch _. 3.4 mm (1.7 mm on each size
of arch)
iii. This space is utilized for the establishment of class I
molar relation by facilitating mesial drift of
mandibular molars.
Q.2. Describe briefly the development of dentition

and occlusion.
Ans.
Development of dentition and occlusion is as follows:
DEVELOPMENT OF DENTI110H AIC) OCCWS10H
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Q.3. Incisal liability.
Ans.
{SN Q.3}
• Incisal liability was described by Warren Mayne in
1969.
• The mesiodistal width of permanent incisors is larger
compared to primary incisors.
• For proper alignment of anterior teeth, the erupting
permanent incisors require more space.
• This difference between the amount of space needed
for the incisors and the amount available for them is
called the 'incisal liability'.

• A favourable incisal liability exists when the primary
dentition is an open dentition, whereas an
unfavourable situation exists in closed dentition.
• The incisal liability is about 7.6 mm in maxillary arch
and 6 mm in mandibular arch.
This space discrepancy is compensated by the following
three mechanisms:
i. Increased intercanine width:
During the period of permanent incisor
eruption, significant amount of increase in
intercanine arch width occurs. It is about 3 to
4mm.
ii. Interdental spacing:
Spacing present in primary dentition helps in
alignment of incisors. The primate space
present in the upper arch mesial to primary
canine is also used.
iii. Labial eruption of incisor:
Deciduous incisors stand upright. The
permanent incisors, which replace them, are
proclined labially, placing them in a wider
arch.
Q.4. Anthropoid spaces.

Ans.
• Generalized spaces present in the deciduous dentition
which plays important role in the normal
development of permanent dentition are called
physiological spaces or developmental spaces
• The anteroposterior growth of jaws is the reason for
physiological spaces. Absence of spaces indicates
development of crowding in permanent dentition.
• Primary dentition in which interdental spaces are
present is called open dentition or spaced dentition.
• For the normal development of permanent dentition,
presence of spaces in primary dentition is important.
• Invariable spacing exists mesial to maxillary canines
and distal to mandibular canines. These
physiological spaces are called primate spaces or
simian spaces or anthropoid spaces as they are seen
commonly in primates. These spaces help in the
placement of canine cusps of opposing arch.
• Absence of spaces in primary dentition is an
indication that crowding of teeth may occur when
larger permanent teeth erupt.
• Primate spaces are used in early mesial shift.
Q.5. Transient malocclusions.

Ans.
{SN Q.10}
• Transient malocclusions are also known as self-
correcting malocclusions or transitional
malocclusions.
• Transient malocclusions are those conditions which
will look like malocclusion at some particular time.
But with normal growth, the condition gets corrected
on its own without any treatment.
Transient malocclusions are observed in various
stages of occlusal development as follows:
A. Stage of predental jaw relation
Existing transient
Correction mechanism
malocclusions
i. Retrognathic Gets corrected with cephalocaudal
mandible growth and differential growth of
mandible
ii. Complete Transverse and sagittal growth of
overlap of mandibular gum pad
maxillary gum
pad
iii. Anterior open Eruption of primary incisors
bite
iv. Infantile With initiation of function at about 18
swallow months of age
B. Stage of primary dentition
Type of
transient
Correction mechanism
malocclusion
present
i. Deep bite Eruption of primary molars
ii. Increased Attrition of incisal edges
overjet
iii. Flush More forward growth of mandible
terminal
plane
iv. Spacing Early mesial shift
v. Edge to Closes with eruption of permanent
edge at successors shedding of primary incisors
about 6 and eruption of permanent incisors
years of
age
C. Mixed dentition
Transient
Reason for correction
malocclusion
i. Deep bite Physiological bite raisers at 6 and 12 years
with the eruption of first and second
permanent molars. The overlying
gingival
. pad of tissue will act as bite
raiser
ii. Ugly Eruption of maxillary canine
duckling
stage
iii. Lower Increase in intercanine width
anterior
crowding
iv. End on Late mesial shift
molar
relationship
v. Flush Both late mesial shift and differential jaw
terminal growth
plane
Q.6. Andrew's keys to normal occlusion.

Ans.
{SN Q.11}
There are two keys of occlusion:
i. Andrew's keys of static occlusion
ii. Roth's keys of functional occlusion
i. Andrew's keys of static occlusion
Key 1: Molar relation:
• Mesiobuccal cusp of maxillary first molar rests
in the mesiobuccal groove of mandibular first
molar.
• Distal surface of the distobuccal cusp of
maxillary first molar should occlude with
mesial surface of the mesiobuccal cusp of
mandibular second molar.
• Mesiolingual cusp of the maxillary first molar
should occlude in the central fossa of
mandibular first molar.
Key 2: Crown angulations (tip):
• The gingival portion of the long axis of each
crown should be distal to the incisal portion;
this is known as crown angulation.
• Measured by the inclination of long axis of the
crown to a line perpendicular to the occlusal
plane.
Key 3: Crown inclination (torque):
• The buccolingual inclination of the long axis of
the crown, not the long axis of the entire tooth
is known as crown inclination.
• Negative crown inclination or lingual crown
inclination occurs in maxillary and
mandibular posteriors whereas positive or
labial inclination is seen in maxillary incisors.
Key 4: Rotation:
• The resulting angle between the line
perpendicular to the occlusal plane and one
tangent to the middle of the labial or buccal
clinical crown is known as rotation.
• Absence of rotation.
• Arch should be devoid of any rotated tooth.
• A rotated molar occupies more mesiodistal
space, creating a situation unreceptive to
normal occlusion, while a rotated incisor
occupies less space.
Key 5: Interproximal contact:
• Proximal contacts should be tight and no
spacing should be present.
Key 6: Curve of Spee:
• Deep curve of Spee results in crowding.
• Flat curve of Spee is most receptive for normal
occlusion.
• Reverse curve of Spee results in spacing.
{SN Q.14}
ii. Roth's keys of functional occlusion
Key 1: Coincidence of intercuspal position (ICP) and
retruded contact position (RCP).
Key 2: Maximum and stable cusp to fossa contacts
throughout the buccal segments.
Key 3: Disclusion of posterior teeth in mandibular
protrusion by even contacts on incisors.
Key 4: Lateral movements of the mandible are
guided by the working side canines, with
disclusion of all other teeth on both working and
non-working sides.
Q.7. Ugly duckling stage.

Ans.
{SN Q.4}
• Ugly duckling stage is also known as Broadbent's
phenomena or physiological median diastema.
• Ugly duckling stage is a transient form of
malocclusion, wherein midline diastema is present
between maxillary central incisors. It is commonly
seen between 7 and 11 years of age.
• During the eruption stages of canine, it will be
impinging on the roots of lateral incisors, and the
resulting pressure causes the lateral incisor to erupt
into oral cavity with divergence of crown distally.
• Even after the lateral incisor erupts fully, this
pressure effect from the erupting canine persists and
is also transmitted to the central incisors, which
results in the divergence of crowns and convergence
of roots towards midline. This bilateral effect causes
a temporary midline diastema.
• This temporary spacing that occurs between central
incisors and sometimes between central and lateral
incisors gets closed automatically as the canine
comes into occlusion.
rr,1_:. - -.L.- - - :. - - _ ,, - _, -- __ , , ,_,:. __ -· -L.- -· - ,_ - - - -- - - !.L.
• This stage is called ugly duckling stage because it
represents a metamorphosis from an unaesthetic
phase to an aesthetic phase.
Clinical significance:
• As a guideline, spontaneous closure of maxillary
midline diastema up to 2 mm is more likely, while
total closure of a median diastema greater than 2
mm is unlikely.
• During the ugly duckling stage, any attempt to close
the median diastema will be hazardous. Apex of
lateral incisors will be damaged and canine may be
deflected from its normal path of eruption.

Q.8. Terminal planes.
Ans.
[Ref LE Q.1]
Q.9. Curve of Spee.

Ans.
• Curve of Spee refers to the anteroposterior curvature
of occlusal surfaces beginning at the tip of lower
cuspid, and following the cusp tips of bicuspids and
molars continuing as an arc through the condyle. If
the curve is extended, it would farm a circle of about
4-inch diameter.
• The curve results from variations in axial alignment
of lower teeth. The long axis of each lower tooth is
aligned nearly parallel to its individual arc of closure
around the condylar axis. This requires a gradual
progressive increased mesial tilting of teeth towards
molars which creates the curve of Spee.
• Deep curve of Spee results in crowding.
• Flat curve of Spee is most receptive for normal
occlusion.
• Reverse curve of Spee results in spacing.
Q.10. Gum pads.

Ans.
• Neonates are without teeth for about 6 months of life.
The alveolar arches in infants during this period are
known as gum pads.
The features of gum pads are as follows:
i. They are pink in colour and firm in consistency
covered by dense layer of fibrous periosteum.
ii. They are horseshoe shaped and develop in two
parts:
(a) Labiobuccal portion
(b) Lingual portion
Dental groove
These two portions are separated by a groove
called the dental groove.
Transverse grooves
iii. The gum pads are divided into 10 segments by
transverse grooves. Each segment consists of
one developing deciduous tooth sac.
Lateral sulcus
iv. Transverse groove between the canine and the
first deciduous molar segment is called the
lateral sulcus.
The lateral sulcus of mandibular arch is
normally more distal than that of maxillary
arch.
The lateral sulci are useful in judging the
interarch relationship of maxilla and
mandible at every early stage.
v. Upper and lower gum pads are almost similar
to each other.
Relationship of gum pads
• When upper and lower gum pads are
approximated, there is a complete overjet all
around, as the upper gum pad is wider as well
as longer than the lower gum pad.
• Mandibular lateral sulci are posterior to
maxillary ones.
• Class II pattern is exhibited as maxillary gum
pad being more prominent.
• Anterior open bite: This infantile open bite is
considered normal. Contact occurs between
upper and lower gum pads in the first molar
region and a space exists between them
anteriorly, known as infantile open bite, which
helps in sucking.
Q.11. Leeway space of Nance.

Ans.
[Same as SE Q.1]
Q.12. Physiological spaces.

Ans.
[Same as SE Q.4]
Q.13. Write briefly about Roth's keys of occlusion.

Ans.
[Same as SE Q.6]
Q.14. Flush terminal plane.

Ans.
[Same as SE Q.8]
Short notes:
Q.1. Gum pads.

Ans.
i. The alveolar arches at the time of birth are called gum
pads and are firm and pink.
ii. Maxillary gum pads develop in two parts, namely
labiobuccal and lingual; these are demarcated by
dental groove. Labiobuccal part grows fast and is
divided into 10 segments by transverse grooves,
which correspond to the deciduous tooth sac.
iii. The groove between canine and deciduous first
molar is called lateral sulcus.
iv. Gingival groove demarcates palate from gum pads.
v. Lower gum pads are V-shaped, and are similar to
maxillary gum pads, but the segments are less
defined when compared with maxillary gum pad.
vi. Gum pads relationship is arbitrary, as they do not
have definite relationship. When upper and lower
gum pads are approximated, there is a complete
overjet all around. Class II pattern is exhibited and
anterior open bite, this infantile open bite is
considered normal.
Q.2. Primate spaces.

Ans.
• Generalized spaces present in the deciduous dentition
which plays an important role in the normal
development of permanent dentition are called
primate spaces, physiological spaces or
developmental spaces.
• The anteroposterior growth of jaws is the reason for
physiological spaces. Absence of spaces indicates
development of crowding in permanent dentition.
• Invariably, spacing exists mesial to the maxillary
canines and distal to the mandibular canines. These
physiological spaces are called primate spaces or
simian spaces or anthropoid spaces as they are seen
commonly in primates. These spaces help in the
placement of canine cusps of opposing arch.
• Primate spaces are used in early mesial shift.
Q.3. Incisor liability.

Ans.
[Ref SE Q.3]
Q.4. Ugly duckling stage.

Ans.
[Ref SE Q.7]
Q.5. Leeway space.

Ans.
[Ref SE Q.1]
Q.6. Distal flush terminal plane.

Ans.
[Ref LE Q.1]
Q.7. Flush terminal plane.

Ans.
[Ref LE Q.1]
Q.8. Theories of eruption.

Ans.
• The exact mechanism by which the tooth erupts is
still unclear. Cross-linking of maturational fibres of
periodontal ligament provides force for eruption.
This seems to be a contemporary view.
Various theories of eruption are as follows:
• Pulp theory
• Vascular theory
• Root elongation theory
• Alveolar bone growth theory
• Genetic theory
• Follicular theory
• Hammock ligament theory
Q.9. Sequence of eruption of permanent teeth.

Ans.
[Ref LE Q.1]
Q.10. Transient malocclusion.

Ans.
[Ref SE Q.5]
Q.11. Andrew's keys to normal occlusion.

Ans.
[Ref SE Q.6]
Q.12. Enumerate the stages of eruption of normal

occlusal development.
Ans.
Occlusal development can be divided into the following
periods or stages:
i. Pedental period: birth - 6 months
ii. Deciduous dentition period: 6-21/2 to 31/2 years
iii. Mix dentition period: 6-12 years
iv. Permanent dentition period: starts after
shedding of last primary tooth
Q.13. Centric relation.

Ans.
• Centric relation is the relation of mandible to maxilla
when the mandibular condyles are in the most
superior and retruded position in glenoid fossa with
the articular disc properly interposed.
• Centric relation is also called ligamentous position or
terminal hinge position.
• At centric relation position, both condyles are
simultaneously seated most superiorly and far back
in unstrained position in respective glenoid fossa.
Q.14. Roth's keys of functional occlusion.

Ans.
[Ref SE Q.6]
Q.15. Premature loss of deciduous teeth.

Ans.
Premature or early loss of deciduous teeth causes:
i. Migration of adjacent teeth into the space that
prevents eruption of successors.
ii. Premature loss of deciduous teeth leads
development of malocclusion.
iii. Loss of deciduous second molar can cause
marked forward shift of permanent first molar,
thereby blocking eruption of second premolar,
which gets impacted or deflected to abnormal
position.
Q.16. Enumerate the stages of tooth development.

Ans.
Development of tooth was divided into 10 stages by
Nolla as follows:
i. Stage 1 - presence of crypt
ii. Stage 2 - initial calcification
iii. Stage 3 - one-third of crown completed
iv. Stage 4 - two-thirds of crown completed
v. Stage 5 - crown almost completed
vi. Stage 6 - crown completed
vii. Stage 7 - one-third of root completed
viii. Stage 8 - two-thirds of crown completed
ix. Stage 9 - root almost completed with open apex
x. Stage 10 - apical end of the root completed
Q.17. Leeway space of Nance.

Ans.
[Same as SN Q.5]
Q.18. Transitional period.

Ans.
[Same as SN Q.10]
Q.19. Enumerate few self-correcting malocclusions.

Ans.
[Same as SN Q.10]
Q.20. Enumerate Andrew's six keys to normal

occlusion.
Ans.
[Same as SN Q.11]
Topic 5 Functional development
Long essays:
1. Discuss in detail various functions of
stomatognathic system.

Short essays:
1. Trajectories of force.
2. Deglutition. [Ref LE Q.1]
3. Buccinator mechanism.
Short notes:
1. Trajectories of force in mandible. [Ref SE Q.1]
2. Wolff's law of transformation of bone.
3. Infantile swallow. [Ref LE Q.1]
4. Buccinator mechanism.
5. Trajectories of facial skeleton.
6. Pterygoid response.
7. Discuss about Wolff's law of transformations of
bone. [Same as SN Q.2]
Solved answers
Long essays:
Q.1. Discuss in detail various functions of

stomatognathic system.
Ans.
• Salzmann defined stomatognathics as an approach to
the practice of orthodontics which takes into
consideration the interdependence of form and
function of teeth, jaw relationship,
temporomandibular articulation, craniofacial
conformation and dental occlusion.
• The various functions of stomatognathic system are
as follows:
A. Mastication
B. Deglutition
C. Respiration
D. Speech
A. Mastication
• Mastication can be grouped as follows:
a. Infant feeding (before teeth eruption)
b. Mature or adult mastication (after teeth
eruption)
a. Inf ant feeding:
{SN Q.3}
• Infants consume food by suckling, an automatic
reflex.
• In infants, suckling and swallowing proceed
together as suckle-swallow, which is
characterized by caving in of cheeks, bobbing
of the hyoid bone, extended head with
anterior mandibular thrust and elongated
tongue, with lips pursed around the nipple.
Moyers lists the features of infantile swallow as
follows:
• Infantile swallow is guided by the lips and
tongue.
• Jaws are apart with the tongue placed
between the gum pads.
• Mandible is positioned by muscles of facial
expression.
The various types of infant feeding are as
follows:
i. Breast/ eeding
Milk is directed to the pharynx by the
peristaltic movement of the tongue.
ii. Bottle feeding
Milk is expelled into the mouth.
iii. Spoon feeding
Here lips are sealed around the edge of a
spoon to draw food into the mouth.
Tongue passes the bolus of food to
swallowing between gum pads and
erupting teeth.
Mature swallowing patterns are observed
usually by 18 months of age.
b. Adult mastication:
Mastication is defined as the reduction of food
in size, changing its consistency, mixing it
with saliva and forming into a bolus suitable
for swallowing.
The features of adult swallowing are follows:
• Teeth are together.
• Mandible is stabilized by the muscles of
mastication.
The six stages of mastication as outlined by
Murphy are as follows:
i. Preparatory phase:
• The ingested food is positioned by
the tongue.
• Mandible moves towards the
chewing side.
ii. Food contact phase:
• After food is ingested, there is a
momentary pause in chewing as
the sensory receptors study the
consistency of food.
iii. Crushing phase:
• Crushing of ingested food starts with
high velocity, and later slows
down.
iv. Tooth contact phase:
• After 4-5 strokes of crushing phase,
tooth contact happens
accompanied by change in
direction of chewing.
v. Grinding phase:
• During this phase, unilateral
chewing of food particles takes
place.
• During grinding, vigorous contact of
maxillary and mandibular molars
occurs.
vi. Centric occlusion:
• Movement of teeth comes to a halt.
• After this stage, preparatory stage of
the next stroke of mastication
begins.
[SE Q.2]
{B. Deglutition
Stages of deglutition:
Fletcher had divided the deglutition pattern into
four stages:
i. Preparatory phase:
• This phase starts as soon as food is ingested.
• The liquid or crushed food is placed in swallow
preparatory position and mouth is sealed by
lips or tongue.
ii. Oral phase
• Soft palate moves upward and tongue drops
downward and backward.
• Larynx and hyoid move upward.
• Muscles of mastication play an active role in
stabilization.
• A smooth path is created for the bolus, and
solid food is pushed by the tongue and liquid
food just flows down.
iii. Pharyngeal phase
• Begins as the bolus of food passes through the
fauces.
• Nasopharynx is closed and the tongue and
hyoid bone move forward.
iv. Oesophageal phase
• Food passes through the cricopharyngeal
sphincter through oesophagus to the stomach.}
C. Speech and malocclusion
• Speech is a learned behaviour.
• Lips, tongue and velopharyngeal structures
modify the outgoing breath stream to produce
different variations in speech.
• Bilabial sounds are the first sound to be
developed.
Examples of various sounds:
Bilabial (lips) -+ p.b
Labiodental -+ f,v
Linguodental -+ th
Linguoalveolar -+ t,d,5
Linguopalatal -+ 'ch' 'sh'
Short essays:
Q.1. Trajectories of force.

Ans.
• The trajectorial theory states that the lines of
orientation of the bony trabeculae follow the
pathways of maximal pressure and tension.
• Benninghoff did extensive study on dried craniofacial
bones and said that stress trajectories or lines of
orientation of the bony trabeculae involved not only
the cancellous bone but also the compact bone.
• These trajectories or functional lines are otherwise
called Benninghoff lines.
• The stress trajectories respond to the demands of
functional forces collectively as a unit and not as a
single bone.
Accordingly, the head is made up of only two
functional units:
Ci) Craniofacial unit
(ii) Mandible
i. Craniof acial unit
• The trajectories extend in a fan-like fashion
from the mid-palatal suture across the alveolar
bone through the maxilla and end at the base
of the skull.
• The bones of the face are united with the
cranial bones by these fan-like trajectories,
which continue across the facial bones and do
not stop at the suture.
I. Maxillary trajectories:
Maxilla provides maximum strength with minimum
material because of the following trajectories. They
are as follows:
Maxilla
trajectories
Horizon1aJ reinforcing members:

.____... • Trajectories from hard palate,
orbital walls, zygomatic arches, palatal
bones and lesser wing of sphenoid
..... .. .. ... . .
a. Vertical pillars:
i. Frontonasal vertical pillar/buttress
• This pillar or buttress runs vertically along
piriform aperture and crest of the nasal bones
and ends in the frontal bone, transmitting
pressures from the incisors, canines and first
premolar.
ii. Malar zygomatic vertical pillar/buttress:
• In the zygomatic area, it splits into three parts:
one passes through the zygomatic arch and
other along the lateral border of orbit and the
last along the lower border of orbit; finally all

three parts ends in base of the skull.
• It transmits stress from the posterior teeth and
also receives force of the mass et er muscles.
iii. Pterygoid vertical pillar/buttress:
• Runs vertically from the chonchae of nasal
cavity and posterior teeth ending in the middle
portion of the base of the skull
b. Horizontal reinforcing members:
• Supra orbital rim acts as a receptor of forces from
canine and zygomatic pillar.
• Other reinforcing members are infraorbital,
zygomatic buttress, hard palate, walls of orbit
and lesser wings of sphenoid.
II. Trajectories of mandible
{SN Q.1}
Mandible is made of major and minor trajectories
i. Major trajectories:
• Trabecular columns originate beneath the teeth
in the alveolar process and join together into a
common stress pillar or trajectory system.
• Mandibular canal and nerve are protected by
this concentration of trabeculae.
• High resistance to bending forces is provided
by the thick cortical layer of trabeculae
present along the lower border of the
mandible.
ii. Minor trajectories:
• These minor accessory stress trajectories are
due to the effect of muscle attachments.
Example: Trajectories seen at the symphysis, gonial
angle and one trabecular pattern are seen running
downwards from the coronoid process into the ramus
and body of the mandible.
Q.2. Deglutition.
Ans.
[Ref LE Q.1]
Q.3. Buccinator mechanism.

Ans.
• Teeth and supporting structures of the jaw are under
the control of adjacent muscles.
• The balance between the muscles is responsible for
the integrity of dental arches and the relation of
teeth to the arches.
• Buccinator mechanism is a phenomenon where a
continuous band of muscles encircle the
dentoalveolar region from the buccal aspect and is
firmly anchored at the pharyngeal tubercle of
occipital bone.
• It starts with the decussating fibres of orbicularis oris
joining the right and left fibres of the lip which
constitute the anterior component of buccinator
mechanism.
• It then runs laterally and posteriorly around the
corner of the mouth, joining other fibres of the
buccinator muscle, which gets inserted into the
pterygomandibular raphe.
• Here it mingles with the fibres of superior constrictor
muscle and runs posteriorly and medially to get
fixed to the pharyngeal tubercle.
• All these 13 muscles with elasticity and contractility
act like a rubber band tightly encircling the bone
system, i.e. mandible.
• Tongue acts opposing the buccinator mechanism
from within exerting an outward force.
• The dentition is in a constant state of dynamic
equilibrium.
• There is a balance of forces between muscles that are
believed to influence the position and stability of the
dentoalveolar complex.
• Malocclusion is caused due to any imbalance in
buccinator mechanism.
• Due to certain deleterious oral habits like thumb
sucking, tongue thrusting, etc. the equilibrium
between buccinator mechanism and tongue is lost,
causing constricted maxillary arch, increased
proclination and open bite etc.
Short notes:
Q.1. Trajectories of force in mandible.

Ans.
[Same as SE Q.1]
Q.2. Wolff's law of transformation of bone.

Ans.
Wolff's law of transformation of bone:
• In the year 1870, Julius Wolff attributed the
arrangement of trabecular pattern of bone to
functional forces.
• A change in the direction and magnitude of force
could produce a marked change in the internal
architecture and external form of the bone. This is
called 'Wolff's law of transformation of bone'.
• Increase in function leads to increase in density of
bone, while lack of function leads to decrease in
trabecular pattern.
• Simply stated, stresses of tension or pressure on
bones stimulate changes within the bone.
Q.3. Infantile swallow.

Ans.
[Ref LE Q.1]
Q.4. Buccinator mechanism.

Ans.
• Buccinator mechanism is a phenomenon where a
continuous band of muscles encircle the
dentoalveolar region from the buccal aspect and is
firmly anchored at the pharyngeal tubercle of
occipital bone.
• It starts with the decussating fibres of orbicularis oris
joining the right and left fibres of lip which
constitute the anterior component of buccinator
mechanism.
• It then runs laterally and posteriorly around the
corner of the mouth, joining other fibres of the
buccinator muscle, which gets inserted into the
pterygomandibular raphe.
• Here it mingles with the fibres of superior constrictor
muscle and runs posteriorly and medially to get
fixed to the pharyngeal tubercle.
• All these 13 muscles with elasticity and contractility
act like a rubber band tightly encircling the bone
system, i.e. mandible.
• Tongue acts opposing the buccinator mechanism
from within exerting an outward force.
Q.5. Trajectories of facial skeleton.

Ans.
• Benninghoff stated that stress trajectories or lines of
orientation of the bony trabeculae involve not only
the cancellous bone but also the compact bone.
• Maxilla provides maximum strength because of the
following trajectories:
Frontonasavcanine pillar
Vertical pillars ----1--+ Malar zygomatic pillar
Maxilla Pterygoid pillar

trajectories
Horizontal reinforcing members

• Trajectories from hard palate, orbital walls,
zygomatic arches, palatal bones and lesser
wing of sphenoid
Major trajectories
Mandibular
trajectories
Minor trajectories
• Major trabecular columns originate beneath the teeth

in the alveolar process and join together into a
common stress pillar or trajectory system.
• The minor accessory stress trajectories are due to the
effect of muscle attachments, e.g. trajectories seen at
the symphysis, gonial angle etc.
Q.6. Pterygoid response.

Ans.
• Pterygoid vertical pillar/buttress runs vertically from
the chonchae of nasal cavity and posterior teeth
ending in the middle portion of the base of the skull.
• It is one of the vertical pillars of maxillary
trajectories.
• The trajectorial theory states that the lines of
orientation of the bony trabeculae follow the
pathways of maximal pressure and tension.
• The stress trajectories respond to the demands of
functional forces collectively as a unit and not as a
single bone.
Q. 7. Discuss about Wolff's law of transformations of

bone.
Ans.
[Same as SN Q.2]
Topic 6 Occlusion - basic concepts
Long essays:
1. What are six keys of normal occlusion? State how
Ackerman profit system is an improvement over
Angle's classification.

Short essays:
1. What are the forces of occlusion?
2. Describe six keys to normal occlusion. [Ref LE Q.1]
3. Roth's keys of functional occlusion.
4. Occlusal plane.
Short notes:
1. Curve of Spee.
2. Overjet and overbite.
3. Normal occlusion concept. [Ref LE Q.1]
4. Centric relation and centric occlusion.
5. Enlist Andrew's six keys to normal occlusion. [Ref
LE Q.1]
6. Overjet. [Same as SN Q.2]
7. Features of normal occlusion. [Same as SN Q.3]
8. Describe six keys to normal occlusion. [Same as SN
Q.S]
Solved answers
Long essays:
Q.1. What are six keys of normal occlusion? State

how Ackerman profit system is an improvement over
Ans.
(SN Q.S and SE Q.2)
{(Andrew in 1970 put forward the keys to normal
occlusion.
The Andrew's six keys to normal occlusion are as
follows:
i. Molar interarch relationship
ii. Mesiodistal crown angulation
iii. Labiolingual crown inclination
iv. Absence of rotation
v. Tight contacts
vi. Curve of Spee)
i. Molar interarch relationship
I
u
I
I
I
I
I
I
616
• Mesiobuccal cusp of should occlude in T
the groove between mesial and mesiobuccal cusp
of ~
• Mesiolingual cusp of ~ should occlude in
central fossa of ~
616
• Crown of T must be angulated so that
distal marginal ridge occludes with mesial
marginal ridge of
ii. Mesiodistal crown angulaton
?tr
\
\ I
\ I
I
'
\ I
\ I
\ I
\ I
I I
\ I
\ I
\ I
\ I
\ I
\ I G
\
\ D
\
\
I
M'\ I
\ I
•
For occlusion to be considered normal, the gingival

part of the long axis of crown must be distal to the
occlusal part of the line. Different teeth exhibit
different crown angulation.
iii. Labiolingual crown inclination
• The crown inclination is determined from a mesial
or distal view.
• If gingival area of the crown is more lingually
placed than the occlusal area, it is called +ve crown
inclination.
• If gingival area of the crown is more labially or
buccally placed than the occlusal area, it is called -
ve crown inclination.
iv. Absence of rotation
• Normal occlusion is characterized by the absence of
any rotation.
• Rotated posterior teeth occupy more space in arch.
• Rotated anterior incisors occupy less space in arch.
v. Tight contacts
To consider an occlusion as normal, there should be
tight contact between adjacent teeth.
vi. Curve of Spee
A normal occlusion plane according to Andrew
should be flat, with the curve of Spee not
exceeding 1.5 mm.}
{SN Q.3}
Normal occlusion:
• Angle's concept of normal occlusion is based on key
and line of occlusion.
Key of occlusion:
• Angle considered maxillary first molar as the key of
occlusion, as it is most constant at its position, and he
related it to key ridge position.
• According to Angle, the mesiobuccal cusp of upper
first molar rests in the mesiobuccal groove of
mandibular first molar in normal occlusion, i.e. class
I molar relation.
Line of occlusion:
• There are two lines of occlusion, namely maxillary
and mandibular.
• The maxillary line of occlusion is a smooth curve that
passes through central fossa of upper molars and
along the cingulum of upper canines and incisors.
• Mandibular line of occlusion runs along the buccal
cusps of posteriors and incisal edges of anteriors.
According to Angle, in normal occlusion, there
should be full complement of teeth present.
Lines of occlusion are intact in both maxillary and
mandibular arches and molars in class I relation.
Short essays:
Q.1. What are the forces of occlusion?

Ans.
The forces of occlusion are of three types:
a. Forward or anterior force
i. Forward force is also called anterior component
force. It comes into effect after the eruption of first
permanent molar into occlusion.
ii. This force is produced due to relationship of long
axis of teeth to the occlusal surfaces and action of
muscles like buccinator and masseter on the teeth.
b. Distal and lingual force
i. Distal and lingual forces are produced by
circumoral muscles and buccinators.
1LLU.::>L1C.::> .1.1.l\.C JJULL11lUlU1 UllU 1ua.::,.::,clCl Ull lllC lCClll.
b. Distal and lingual force

i. Distal and lingual forces are produced by
circumoral muscles and buccinators.
ii. These forces act on incisors and help to keep
canines in place.
c. Anterior resultant force
i. This force is the anterior resultant of the two forces
which act in the opposite direction.
ii. In spite of these forces, teeth have inherent
disposition to drift mesially.
Q.2. Describe six keys to normal occlusion.

Ans.
[Ref LE Q.1]
Q.3. Roth's keys of functional occlusion.

Ans.
Roth's keys of functional occlusion are as follows:
Keyl.
Coincidence of intercuspal position (ICP) and
retruded contact position (RCP).
Key 2.
Maximum and stable cusp to fossa contacts
throughout the buccal segments.
Key 3.
Disclusion of the posterior teeth in mandibular
protrusion by even contacts of incisors.
Key 4.
Lateral movements of mandible are guided by the
working side canines, with disocclusion of all other
teeth on both working and non-working sides.
Q.4. Occlusal plane.

Ans.
Imaginary occlusal planes and curves
Curve of Spee:
• A-P curvature of occlusal surfaces beginning at the tip

of lower cuspid and following the cusp tips of
tricuspids, and molars continuing as an arch through
the condyle.
• If the curve is extended, it would follow a circle of
about 4 inch diameter.
Curve of Wilson:
• This is a curve that contacts the buccal and lingual
cusp tips of the mandibular buccal teeth. The curve
of Wilson is mediolateral on each side of the arch.
• It results from inward inclination of the lower
posterior teeth.
• It helps in two ways:
Teeth are aligned parallel to direction of medial
pterygoid for opposing resistance to mastication and
elevated buccal cusps prevent the food from going
palatally.
Short notes:
Q.1. Curve of Spee.

Ans.
• Curve of Spee refers to anteroposterior curvature of
the occlusal surfaces beginning at the tip of the lower
cuspid and following the cusp tips of the bicuspids
and molars continuing as an arc through the
condyle.
• If the curve is extended, it would form a circle of
about 4 inch diameter.
• The curvature results from variations in axial
alignment of lower teeth.
• The long axis of each lower tooth is aligned nearly
parallel to its individual arc of closure around the
condylar axis.
• This requires a gradual progressive increased mesial
tilting of teeth towards molars, which creates the
curve of Spee.
Q.2. Overjet and overbite?

Ans.
i. Overjet:
• Overj et is seen more initially in primary dentition.
The average overjet in primary dentition is 1-2
mm.
• With the movement of whole dental arch
anteriorly, overjet decreases.
ii. Overbite:
• In normal overbite, the upper incisors slightly
overlap the lower incisors. It is usually expressed
in millimetres.
• Normal value of overbite: 1-3 mm.
• The overbite is described as the percentage of
mandibular incisor crown length overlapped by
maxillary central incisors.
• 5°/o-20°/o of overlap of mandibular incisors is
considered normal.
Q.3. Normal occlusion concept.

Ans.
[Ref LE Q.1]
Q.4. Centric relation and centric occlusion.

Ans.
Centric relation
• Centric relation is also called 'ligamentous position or
terminal hinge position'.
• Centric relation is the relation of mandible to maxilla
when the mandibular condyles are in the most
superior and retruded position in their glenoid fossa
with the articular disc properly interposed.
Centric occlusion
• Centric occlusion is also called 'inter-cuspal position
or convenience occlusion'.
• Centric occlusion is that position of the mandibular
condyle where the teeth are in maximum
intercuspation.
Q.5. Enlist Andrew's six keys to normal occlusion.

Ans.
[Ref LE Q.1]
Q.6. Overjet.
Ans.
[Same as SN Q.2]
Q.7. Features of normal occlusion.

Ans.
[Same as SN Q.3]
Q.8. Describe six keys to normal occlusion.

Ans.
[Same as SN Q.5]
Topic 7 Classification of
malocclusion
Long essays:
1. Classify malocclusion and list its advantages?
Discuss different methods of classifications on

malocclusion.
2. Define classification of malocclusion and explain
in detail Angle's classification and validity of
3. State how Ackerman-Proffit system is an
improvement over Angle's classification. Discuss
in brief the modifications to Angle's classification
of malocclusion.
4. Describe Angle's class II division 1 malocclusion.
Discuss how it differs from Angle's class II division
2.
5. Enumerate differences between true class III and
pseudo-class III.
6. Name different methods of classification of
malocclusion. Describe Simon's classification of
malocclusion. [Same as LE Q.1]
7. Describe various classifications of malocclusion.
Enumerate merits and demerits of Angle's
classification. [Same as LE Q.2]
8. Describe Angle's classification of malocclusion and
mention the limitations of this classification.
[Same as LE Q.2]
9. Discuss in brief Angle's classification of
malocclusion along with its merits, demerits and
modifications. [Same as LE Q.2]
10. Describe Deway-Anderson's modification of
Angle's classification in detail. [Same as LE Q.4]
11. Describe the characteristics of class II division 1
and class II division 2 malocclusion. [Same as LE
Q.5]
Short essays:
1. Ackerman-Proffit classification of malocclusion.
[Ref LE Q.3]
2. Angle's class II division 1 malocclusion - Clinical
features.
3. Drawbacks of Angle's classification.
4. Angle's classification of malocclusion. [Ref LE Q.4]
5. Characteristics of Angle's class II division 2
malocclusion. [Ref LE Q.2]
6. Simon's classification of malocclusion. [Ref LE Q.1]
7. Dewey's classification of malocclusion. [Ref LE Q.4]
8. Pseudo-class III malocclusion.
9. Limitations of Angle's classification. [Same as SE
Q.3]
10. Clinical features of class II division 2
malocclusion. [Same as SE Q.5]
Short notes:
1. Bennett's classification.
2. Simon's classification of malocclusion. [Ref LE Q.1]
3. Validity of Angle's classification. [Ref LE Q.2]
4. FH plane.
5. Pseudo-class III malocclusion.
6. Clinical features of class III malocclusion.
7. Clinical features of class II division 2.
8. Define malocclusion. Name few classifications of
malocclusion.
9. Ackerman-Proffit classification.
10. Features of class II division 1 malocclusion.
11. Distocclusion.
12. Lischer's modifications of Angle's classification.
[Ref LE Q.4]
13. Skeletal classification of malocclusions.
14. Mention three planes used in Simon's
classification.
15. Dewey's modification of Angle's classification of
malocclusion.
16. Key ridge.
17. Drawbacks of Angle's classification. [Same as SN
Q.3]
18. Mention two merits and demerits of Angle's
classification. [Same as SN Q.3]
19. True class III. [Same as SN Q.6]
20. Name different classifications of malocclusion.
[Same as SN Q.8]
21. Enlist various systems of classification of
malocclusion. [Same as SN Q.8]
Solved answers
Long essays:
Q.1. Classify malocclusion and list its advantages?

Discuss different methods of classifications on
malocclusion.
Ans.
Grouping of various malocclusions into a simpler or
smaller divisions or groups is known as classification.
Strang (1938) defined classification as 'A process of
analysing cases of malocclusion for the purpose of
segregating them into a smaller number of groups,
which are characterized by certain specific and
fundamental variations from normal occlusion of the
teeth; which variations become influential and deciding
factors in providing the fundamental data for the
preparation of a systematic and correlated plan of
treatment'.
Advantages of classifying malocclusion:
It helps in:
i. Diagnosis and treatment planning.
ii. Visualizing and understanding the problem
associated with malocclusion.
iii. Ease of communication among professionals.
iv. Comparison of various malocclusions.
Intra-arch malocclusion (variations in

individual tooth position and malocclusion
affecting a group of teeth within an arch)
Types of _____. lnterarch malocclusion (malrelation of

malocclusion -- dental arches to one another upon normal
skeletal bases)
Skeletal malocclusion (malocclusion

involving underlying bony bases)
Intra-arch malocclusion:
Commonly seen individual teeth malpositions are as
follows:
i. Buccal inclination or tipping - proclination (when the
tooth is outside the line of occlusion)
ii. Lingual inclination or tipping - retroclination (when
the tooth is inside the line of occlusion)
iii. Mesial inclination or tipping- crown tilted mesially
or farther forward than normal
iv. Distal inclination or tipping - crown tilted distally or
backwards than normal
v. Buccal displacement - tooth that is bodily moved in
Iahial/buccal direction
vi. Lingual displacement - tooth that is bodily moved in
lingual direction
vii. Mesial displacement - tooth that is bodily moved in
mesial direction
viii. Distal displacement - tooth that is bodily moved in
distal direction
ix. Infraversion or infra-occlusion - this is a tooth which
has not erupted enough as compared to other teeth in
the arch
x. Supraversion or supraocclusion - tooth which has
over erupted as compared to other teeth in the arch
xi. Rotations - tooth movements around its long axis
xii. Distolingual or mesiobuccal rotation - tooth which
has moved around its long axis so that distal aspect is
more lingually placed
xiii. Mesiolingual or distobuccal rotation - tooth which
has mesial aspect is more lingually placed
xiv. Transposition - where the teeth have
exchanged/interchanged their positions
Interarch malocclusion: occurs in three planes.
Occurs in three planes
+
Sagittal
+
Vertical
i
Transverse
-<.
Pre-normal Post-normal
+
Includes deep bite
+
Example: various
occlusion occlusion and open bite types of
Lower arch Lower arch (where abnormal crossbites
is more is more vertical relation (the term
forwardly distally exists between crossbite
placed when placed when teeth of U/L arch)
patient bites
in centric
occlusion.
patient bites
in centric
occlusion.
refers to
abnormal
transverse
relationship
I
between U/L
Deep bite Open bite arches)
(overbite (no vertical
there is overlap
excessive between U/L
overlap teeth either
between U/L in anterior/
anteriors) posterior
region)
Skeletal malocclusion: due to abnormalities in the

maxilla/mandible; defects can be in size, position or
relationship between the jaws. Occurs in one or both the
jaws and in various combinations.
Occurs in three planes
+
Sagittal
+
Vertical
+
Transverse
»<.
Forward More backward
+
Abnormalities
+
Result of
placement placement in vertical narrowing or
of jaw- ofjaw- measurements widening of
prognathism. retrognathism. can affect lower jaws, usually
facial height. referred to as
cross bites.
(SN Q.2 and SE Q.6)

{(In Simon's classification of malocclusion, the dental
arches are related to three planes:
i. Anteroposterior plane
ii. Transverse plane
iii. Vertical plane
In Simon's sy tcm,clcntal archc arc related

to three anthropometric planes:
i. Frankfort horizontal plane
ii. Orbital plane
iii. Mid agirtal plane
In Simon's system, dental arches arc related
to three anthropometric plane :
i. Frankfort horizontal plane
ii. Orbital plane
iii. Mid agiual plane
ATTRACTION
Dental arch or part of it is
FH plane clo er than normal 10 Fl-I plane.
AB. TRACTlON
Dental arch or part of it is
farther away from the Fii plane.

ORBITAL PLANE PROTRACT!()
(: imon' law of Dental arch or part of it i farther
canines) Sagiual away from orbital plane.
or AP direction
RETRACTlON
Dental arch or part of it i clo er
or more posterior plane in
relation to orbital plane.
MIDSAGITTAL DISTRACTION
Dental arch or part of it is away
PLAN!-:
from mid agiual plane.
(transver e
direction) CONTRACTION
Dental arch or part of it i
closer lo rnidsagiual plane.
Q.2. Define classification of malocclusion and

explain in detail Angle's classification and validity of
Ans.
• Grouping of various malocclusions into a simpler or
smaller divisions or groups is known as
classification.
• Angle's system of classification has taken into
consideration the anteroposterior relationship of
teeth with each other.
• Angle introduced this classification with the concept
of key and line of occlusion.
• Maxillary first permanent molar is considered to be
the key of occlusion, and he stated that the position
of the maxillary first permanent molar is relatively
constant.
Angle's classification:
Angle's three classes of malocclusion:
+
Class I
+
Class II
+
Class 111
• •+
Division 1
and
Division 2
+
True
class Ill
Pseudo
class Ill
•
Skeletal
class Ill
Angle's classification of malocclusion.
The three classes of Angle's malocclusion are based on

the permanent first molar relationship.
Angle's class I malocclusion (neutrocclusion)
Molar relation in Angle's class I:
The mesiobuccal cusp of the upper first molar
occludes with the mesiobuccal groove of the
lower first molar.
Canine relation:
The mesial incline of the upper canine occludes
with the distal incline of the lower canine,
whereas the distal incline of the upper canine
occludes with mesial incline of lower first
premolar.
Line of occlusion:
Line of occlusion will be altered in maxillary and
mandibular arches:
Individual tooth irregularities like crowding,
spacing, rotations and absence of tooth will be
seen.
Interarch problems like deep bite, open bite,
proclination or increased overjet and crossbite
will be present.
Class I. Bimaxillary protrusion
Class I bimaxillary malocclusion is a condition
where both key of occlusion and line of
occlusion are not altered but the upper and
lower anteriors are proclined and exist usually
in an edge-edge relationship.
Angle's class II malocclusion (.distocclusion)
Class II malocclusion has got two divisions, namely
division 1 and division 2.
Angle's class II division 1 malocclusion
Molar relation:
Lower dental arch is distally positioned in
relation to upper arch. The distobuccal cusp of
the upper first
permanent molar occludes with the mesiobuccal
groove of the lower first permanent molar.
Class II canine relation:
The distal incline of upper canine occludes with
the mesial incline of lower canine.
Other features are as follows:
• V-shaped or narrow constricted maxilla
• Proclined maxillary incisors
<Lip trap
• Deep bite and exaggerated curve of Spee
Class II division 1 subdivision
Condition where class II molar relationship is
unilateral, i.e. present only on one side with
normal class I molar occlusion on the other side.
[SE Q.5]
{Angle's class II division 2 malocclusion:
Class II division 2 malocclusion is characterized by
class II molar relationship with retroclined
upper
. . centrals that are overlapped by the lateral
incisors.
Includes variations like retroclined centrals+
lateral incisors and very rarely includes
retroclined canines as well.
Class II molar relation:
Lower dental arch is distally positioned in relation
to upper arch. The distobuccal cusp of the upper
first molar occludes with the mesiobuccal groove
of the lower first molar.
Class II canine relation:
The distal incline of the upper canine occludes
with the mesial incline of the lower canine.
Line of occlusion: Altered.
Other clinical features:
i. Molars in distocclusion
ii. Retroclined central incisors and rarely
other anteriors as well
iii. Deep bite
iv. Broad square face with pleasing straight
profile
v. Square-shaped arch and exaggerated
curve of Spee
vi. Backward path of closure
vii. Deep mentolabial sulcus
viii. Absence of abnormal muscle activity
They have perfectly acceptable function
as well as facial appearance. In severe
cases, the bite is often very deep and
poses the risk of periodontal trauma in
maxillary palatal and mandibular labial
aspects.}
Class II division 2 subdivision:
Condition when the class II molar relation exists
on only one side with normal molar relation on
the other side is known as class II division 2
subdivision.
Angle's class Ill malocclusion (mesio-occlusion)
Class III malocclusion is a condition in which the
lower molar is positioned mesial to the upper
molar.
Class III subdivision: Condition in which class III
molar relation is present only on one side with
normal molar relation on the other side is known as
class III subdivision.
True class III:
• This is a skeletal malocclusion; it could be due to
retrognathic maxilla, prognathic mandible or
combination of both.
• In this, class III molar relation exists in both
centric occlusion and rest position.
Pseudo-class III/habitual class III:
• This is not a true class III malocclusion.
• When the mandible moves from rest position to
occlusion due to occlusal prematurities, it slides
forward into a pseudo-class III position.
• These patients show normal molar relationship
in the rest position, while class III relation in
centric occlusion.
Clinical features of class III malocclusion are as
follows:
• Molar relation:
Mesiobuccal cusp of the upper first permanent
molar occludes with the interdental space
between the lower first and second permanent
molars.
• Canine relation:
Upper canine occludes with the interdental
space between lower first and second
premolars.
• Line of occlusion: may or may not be altered.
• Reverse overjet or anterior crossbite.
• Posterior crossbite.
True class III and pseudo-class III malocclusions can
be differentiated by taking a cephalogram in both rest
position and occlusion.
{SN Q.3}
Merits and demerits of Angle's
classification/advantages and disadvantages of
Angle's classification/validity of Angle's
classification
Merits:
i. It is the most popular system of classification of
malocclusion.
ii. It is the most traditional and oldest system of
classification still in use.
iii. Easy to communicate.
iv. Most practical and easy to comprehend.
v. Widely used for academic purposes.
Demerits:
i. Angle considered only anteroposterior plane in his
system of classification. He did not consider
transverse and vertical planes.
ii. The position of the maxillary first permanent
molar is not stable as considered by Angle.
iii. Classification is not applicable when first
permanent molars are missing.
iv. Not applicable in deciduous dentition.
v. Consideration is not given to skeletal problems.
vi. Angle's classification considers only static
occlusion.
vii. Aetiology of malocclusion is not highlighted.
viii. This classification does not differentiate between
dentoalveolar and skeletal malocclusions.
ix. Angle did not consider individual tooth
malpositions.
ix. Angle did not consider individual tooth
malpositions.
There are two modifications to Angle's classification:
i. Lischer's modification
ii. Dewey's modification
Q.3. State how Ackerman-Proffit system is an

improvement over Angle's classification.
Ans.
[SE Q.1]

• {Ackerman and Proffit introduced a new method of
classification to overcome the defects of Angle's
classification.
• This system included Angle's classification and five
major characteristics of malocclusion within a Venn
symbolic diagram (Fig. 7.1).
• This is an all-inclusive method of categorizing
malocclusion. In this classification, each
malocclusion can be described by five major
characteristics.
Procedure
Group 1 (Intra-arch alignment and symmetry):
• Involves assessment of alignment and symmetry of
dental arches. Individual tooth irregularities are
described.
• As the degree of alignment and symmetry is common
to all dentition, it is represented as Group 1.
• It is classified in this step as ideal, crowded or spaced.
• Crowding, rotations, spacing, and mutilated
conditions are possible malocclusions in this step. If
no abnormality is present, it is called ideal.
Group 2 (Profile):
• Proceeding inside the Venn diagram, it involves
consideration of the profile of the patient.
• The profile is described as straight, convex and
concave.
• The facial divergence is considered as anterior or
posterior divergence.
Group 3 (Type):
The term type is used to describe the kinds of
crossbites. Lateral or transverse arch
characteristics are evaluated.
Crossbites are classified as:
i. Buccal and palatal
ii. Unilateral and bilateral
iii. Skeletal and dental
Group 4 (Class):
i. It involves assessment of sagittal relationship.
ii. It is classified as Angle's class I/class II/class III
malocclusion.
iii. Differentiation is made between skeletal and
dental malocclusions.
Group 5 (Bite depth):
• Malocclusion in vertical plane is considered.
• Patient's skeletal and dental relationships are
analysed for problems in the vertical plane.
• Vertical deviations:
i. Open bite - Anterior open bite, posterior open
bite, skeletal open bite and dental open bite.
ii. Deep bite - Dental or skeletal and posterior
collapsed bite.
The overlapping groups are seen in the centre
of the Venn diagram.
Group 9 will have the most severe form of
malocclusion comprising problems in all the three
dimensions.}
GroupJ
'll'lnlwlM
Domllon
(lllerll)
Group I
- -
Ve'1ICO ~o~7
11ens*H Sagnc u:llr'I.CIII
M9"1rnenl 11,,,.11:
Type 8"" - C..
,._ Group s.---~ ...
!!..!!El..--
v..11a1 -
Open Ole AnllriOf pcm:1u
Oeept>i. ""'"""'
CollpYG -
Orwp 1
Alog,"•• 8""
Oofllll - ....
depd,
p,_
lnr-e-lf'Ch
,.,......,)
afigrwnent-.S)i ,. 1 IC ti 1
(
Ackerman-Proffit
FIG. 7 .1 system -
Venn symbolic diagram.
Advantages and disadvantages of Ackerman and

Proffit method of classification are as follows:
Advantages:
i. The complexities of malocclusion are explained.
ii. In addition to anteroposterior malrelations,
transverse as well as vertical discrepancies are
taken into consideration, i.e. all three planes
are considered.
iii. Profile of the patient is given due
consideration.
iv. Differentiation between skeletal and dental
problems is made.
v. This classification helps in complete diagnosis
and differential treatment planning.
vi. Readily adaptable to computer processing.
Disadvantages:
i. Classification did not consider the aetiological
aspects.
ii. It is based only on static occlusion, whereas
functional occlusion is not considered.
Q.4. Discuss in brief the modifications to Angle's

classification of malocclusion.
Ans.
There are two modifications to Angle's classification of
malocclusion:
i. Lischer's modification
ii. Dewey's modification
Lischer's modification
{SN Q.12}
i. The following names are given by Lischer to Angle's
classification:
• Neutrocclusion - class I
• Distocclusion - class II
• Mesia-occlusion - class III
ii. To describe malpositions of individual teeth, the
following nomenclature was given by Lischer which
indicates the direction of deviation from normal
position.
• Mesioversion - mesial to the normal position
• Distoversion - distal to the normal position
• Linguoversion - lingual to the normal position
• Labioversion/buccoversion - towards the lip or
cheek
• Infraversion - away from the line of occlusion
• Supraversion - crossing the line of occlusion
• Axiversion - wrong axial inclination
• Torsiversion - rotated on its long axis
• Transiversion - transposition, wrong position in the
arch
Dewey's modification
[SE Q.7]
{Martin Dewey has further divided Angle's class I and
III into various types:
• Class I is divided into five types
• Class III is divided into three types
• Class II has no types
Class I
Type 1: Crowded maxillary anterior teeth.
Canines may be abnormally positioned. Other
individual teeth irregularities present.
Type 2: Proclined or labioversion of maxillary
central and lateral incisors.
Type 3: Class I with anterior crossbite present.
Type 4: Class I with posterior crossbite present.
Molars and premolars are in buccoversion.
Type 5: Mesioversion of molars.
Class III
Typel: Well-aligned teeth and dental arches.
Edge-edge relationship exists.
Type 2: Crowded mandibular incisors. Normally
placed
. .
lower incisors behind the upper
incisors.
Type3: Crowded maxillary incisors.
Underdeveloped maxilla anterior crossbite
present.}
Q.5. Describe Angle's class II division 1 malocclusion.

Discuss how it differs from Angle's class II division 2.
Ans.
Differences between class II division 1 and class II
division 2 malocclusion are as follows:
Feature Class II division 1 Class II division 2

i. Profile Convex Straight to mild
convexity
ii. Lips Incompetent short Competent normal
upper lip and upper and lower
everted lower lips
lip
111. Deep Normal, or may be
Mentolabial deep sometimes
sulcus
iv. Mentalis Hyperactive Normal
muscle
v. Molar Not prominent Prominent
process
vi. Lower Normal or may be Decreased
facial increased or
height decreased
vii. Arch form 'V'-shaped 'U'-shaped or square
shape
viii. Palate Deep Normal
ix. Incisors Proclined Central incisors are
(maxillary) retroclined, lateral
incisors are
proclined
x. Overjet Increased Decreased
xi. Overbite Deep overbite Closed bite
xii. Crown Normal Axis of crown and root
root is bent and referred
angulation to as collum angle
xiii. Path of Normal Backward path of
closure closure
Q.6. Enumerate differences between true class III

and pseudo-class III.
Ans.
Differences between true class III and pseudo-class III
are as follows:
True class
Feature Pseudo-class III
III
i. Profile Concave Straight or concave
ii. Aetiology Heredity Habitual or developmental
111. Absent Present
Premature
contacts
iv. Path of Forward Deviated
closure
v. Gonial r or! Normal
angle
vi. Retrusion Not possible Possible
of
mandible
Vil. Orthopaedic Elimination of prematurities
Treatment or and replacement of last
surgical posterior teeth by
correction functional space
No further maintainers.
changes If left untreated, it becomes
occur if established into true class
left III malocclusion.
untreated.
Surgical procedures that can be carried out for

skeletal class III malocclusion are as follows:
i. Le Fort I osteotomy- for maxillary deficiency
ii. Osteotomy of the mandible
iii. Sliding ostecotomy in ram us or body of the
mandible
iv. Sagittal split osteotomy - to correct mandibular
prognathism
v. Genioplasty - to correct chin prominence
These skeletal procedures have to be modified
according to the vertical malrelation, i.e. associated
open bite or deep bite.
Q.7. Name different methods of classification of

malocclusion.
An,;:
Q.7. Name different methods of classification of
malocclusion.
Ans.
[Same as LE Q.l]
Q.8. Describe various classifications of malocclusion.

Enumerate merits and demerits of Angle's
classification.
Ans.
[Same as LE Q.2]

Q.9. Describe Angle's classification of malocclusion
and mention the limitations of this classification.
Ans.
[Same as LE Q.2]
Q.10. Discuss in brief Angle's classification of

malocclusion along with its merits, demerits and
modifications.
Ans.
[Same as LE Q.2]
Q.11. Describe Deway-Anderson's modification of

Angle's classification in detail.
Ans.
[Same as LE Q.4]
Q.12. Describe the characteristics of class II division

1 and class II division 2 malocclusion.
Ans.
[Same as LE Q.5]
Short essays:
Q.t. Ackerman-Proffit classification of malocclusion.

Ans.
[Ref LE Q.3]
Q.2. Angle's class II division 1 malocclusion - clinical

features.
Ans.
Angle's class II malocclusion has got two divisions,
namely division 1 and division 2.
Angle's class II division 1 malocclusion:
class II molar relation with proclined maxillary
anterior teeth.
Clinical features:
i. Class II molar relation: Lower dental arch is
distally positioned in relation to upper arch.
The distobuccal cusp of the upper first
permanent molar occludes with the
mesiobuccal groove of the lower first
permanent molar.
ii. Class II canine relation: The distal incline of
upper canine occludes with mesial incline of
lower canine.
iii. Proclined maxillary anteriors with V-shaped or
narrow constricted maxilla.
iv. Convex profile.
v. Increased overjet, deep bite and exaggerated
curve of Spee.
vi. Short hypotonic upper lip, lip trap and lack of
anterior lip seal.
vi. Patient exhibits abnormal muscle activity.
vii. Proclined lower anteriors, a natural
compensation to decrease overjet.
Class II division 1 subdivision:
Condition where the class II molar relationship is
unilateral, i.e. present only on one side with
normal class I molar occlusion on the other side.
Q.3. Drawbacks of Angle's classification.

Ans.
Limitations or demerits or drawbacks of Angle's
classification:
i. Angle considered only anteroposterior plane in his
system of classification. He did not consider
transverse and vertical planes.
ii. The position of the maxillary first permanent molar
is not stable as considered by Angle.
iii. Classification is not applicable when first
permanent molars are missing.
iv. Not applicable in deciduous dentition.
v. Consideration is not given to skeletal problems.
vi. Angle's classification considers only static occlusion.
vii. Aetiology of malocclusion is not highlighted.
ix. Angle has not considered individual tooth
malpositions.
Q.4. Angle's classification of malocclusion.

Ans.
[Ref LE Q.4]
Q.5. Characteristics of Angle's class II division 2

malocclusion.
Ans.
[Ref LE Q.2]
Q.6. Simon's classification of malocclusion.

Ans.
[Ref LE Q.1]
Q.7. Dewey's classification of malocclusion.

Ans.
[Ref LE Q.4]
Q.8. Pseudo-class III malocclusion.

Ans.
Class III malocclusion is a condition in which the lower
molar is positioned mesial to the upper molar.
• Pseudo-class III/habitual class III is not a true class III
malocclusion.
• These patients show normal molar relationship in
rest position, while class III relation in centric
occlusion.
Aetiology:
Habitual or developmental.
The clinical features of pseudo-class III malocclusion are
as follows:
i. Profile is either straight or concave.
ii. Premature contacts and deviated path of
closure are present.
iii. Gonial angle is normal.
iv. Retrusion of mandible is possible.
Treatment of pseudo-class III consists of the following:
Elimination of prematurities and replacement of last
posterior teeth by functional space maintainers. If
left untreated, it becomes established into true
class III malocclusion.
Q9. Limitations of Angle's classification.

Ans.
[Same as SE Q.3]
Q10. Clinical features of class II division 2

malocclusion.
Ans.
[Same as SE Q.5]
Short notes:
Q.1. Bennett's classification.

Ans.
Norman Bennet classified malocclusion based on its
aetiology
Class I - Malocclusion or abnormal position of one or
more teeth due to local causes
Class II - Malocclusion due to developmental defects of
bone in either arches
Class III - Malocclusion due to abnormal relationship
between upper and lower arches and between either
arch or facial contour, and correlated abnormal
formation of either arch
Q.2. Simon's classification of malocclusion.

Ans.
[Ref LE Q.1]
Q.3. Validity of Angle's classification.

Ans.
[Ref LE Q.2]
Q.4. FH plane.
Ans.
i. Frankfort horizontal plane or eye-ear-plane (E-E-P) is
obtained by drawing a line through the margin of
inferior orbit below the eyeball and upper margin of
auditory meatus.
ii. This plane helps to detect deviations in the vertical
plane.
iii. Height
. of the dental arches and teeth is related to the
cranium.
iv. Dental arch closer to this plane is called attraction,
and farther away from this plane is called
abstraction.
Q.5. Pseudo-class III malocclusion.

Ans.
• Pseudo-class III/habitual class III is not a true class III
malocclusion.
rest position, while class III relation in centric
occlusion.
• It is habitual or developmental in origin.
• Profile is either straight or concave with premature
contacts and deviated path of closure.
• Retrusion of mandible is possible.
• Treatment of pseudo-class III consists of elimination
of prematurities and replacement of last posterior
teeth by functional space maintainers.
Q.6. Clinical features of class III malocclusion.

Ans.
• Angle's class III malocclusion (mesio-occlusion) is a
condition in which the lower molar is positioned
mesial to the upper molar.
• True class III is a skeletal malocclusion, it could be
due to retrognathic maxilla, prognathic mandible or
combination of both. Here class III molar relation
exists in both centric occlusion and rest position.
Clinicalfeatures of class III malocclusion are as follows:
• Molar relation: Mesiobuccal cusp of the upper first
permanent molar occludes with the interdental
space between the lower first and second permanent
molars.
• Canine relation: Upper canine occludes with the
interdental space between lower first and second
premolars.
• Line of occlusion: may or may not be altered.
• Reverse overjet or anterior crossbite and posterior
crossbite.
• Concave profile.
Q.7. Clinical features of class II division 2.

Ans.
• Angle's class II division 2 malocclusion is
characterized by class II molar relationship with
retroclined upper centrals that are overlapped by the
lateral incisors.
Clinicalfeatures:
ii. Retroclined central incisors 1
iii. Deep bite
iv. Broad square face with pleasing straight profile
v. Backward path of closure
vi. Deep mentolabial sulcus
vii. Absence of abnormal muscle activity
These have perfectly acceptable function as well as
facial appearance.
Q.8. Define malocclusion. Name few classifications of

malocclusion.
Ans.
Malocclusion is defined as a condition where there is
departure from normal relation of teeth in the same
arch and to teeth in the opposing arch.
Quantitative and qualitative methods of classification
are as follows:
Qualitative methods of classification:
i A ncrl,:,'c;: rl::ic::c::inr::itinn
Q.8. Define malocclusion. Name few classifications of
malocclusion.
Ans.
Malocclusion is defined as a condition where there is
departure from normal relation of teeth in the same
arch and to teeth in the opposing arch.
Quantitative and qualitative methods of classification
are as follows:
Qualitative methods of classification:
i. Angle's classification
ii. Simon's classification

iii. Bjork's classification
iv. Ackerman-Proffit classification
v. Bennett's classification, etc.
Quantitative methods of classification:
i. Massler and Frankel
ii. Summer's occlusal index
iii. Occlusal feature index by Poulton
iv. Index for orthodontic treatment need by Shaw,
etc.
Q.9. Ackerman-Proffit classification.

Ans.
• Ackerman and Proffit introduced a new method of
classification system, which included Angle's
classification and five major characteristics of
malocclusion within a Venn symbolic diagram.
• The Venn diagram is analysed in the following steps:
Step 1 (Assessment of intra-arch alignment and
symmetry):
• It is classified as ideal, crowded or spaced.
Step 2 (Profile):
• The profile is described as straight, convex and
concave.
Step 3 (Type):
The term type is used to describe the various kinds
of crossbites like buccal and palatal, unilateral
and bilateral or skeletal and dental.
Step 4 (Class; assessment of sagittal relationship)
It is classified as Angle's class I/class II/class III
malocclusion.
Step 5 (Bite depth; vertical plane is considered)
• Open bite __. anterior, posterior, skeletal or dental
• Deep bite __. dental or skeletal and posterior collapsed
bite
The overlapping groups are seen in the centre of a
Venn diagram. It has the most severe form of
malocclusion comprising problems in all the three
dimensions.
Q.10. Features of class II division 1 malocclusion.

Ans.
class II molar relation, i.e. the distobuccal cusp of
the upper first permanent molar occludes with the
mesiobuccal groove of the lower first permanent
molar with proclined maxillary anterior teeth.
Clinical features:
i. Convex profile
ii. Increased overjet, deep bite and exaggerated
curve of Spee
iii. Short hypotonic upper lip, lip trap and lack of
anterior lip seal
iv. Patient exhibits abnormal muscle activity
v. Proclined lower anteriors, a natural
compensation to decrease overjet.
Q.11. Distocclusion.
Ans.
• Angle's class II malocclusion is known as
distocclusion.
• In class II molar relation, the distobuccal cusp of the
upper first molar occludes with the mesiobuccal
groove of the lower first molar.
• Class II malocclusion has got two divisions, namely
division 1 and division 2.
class II molar relation with proclined maxillary
anterior teeth.
class II molar relationship with retroclined upper
centrals that are overlapped by the lateral incisors.
Class II division 1 or 2 subdivision:
Condition when class II molar relation exists on only
one side with normal molar relation on the other
side is known as class II division 1 or 2 subdivision.
Q.12. Lischer's modifications of Angle's classification.

Ans.
[Ref LE Q.4]
Q.13. Skeletal classification of malocclusions.

Ans.
Skeletal classification is based on the facial skeletal
pattern and also relationship of teeth.
Skeletal class I:
The bones of the face, maxilla and mandible are in
normal relation to each other.
Skeletal class II:
• Mandibular development is retarded when
compared with maxilla.
• Distal relationship of mandible to maxilla.
Skeletal class III:
Increased growth of mandible with prognathic
profile.
Q.14. Mention two differences between true and

pseudo-class III.
Ans.
Differences between true and pseudo-class III are as
follows:
Feature True class Pseudo-class III

III
i. Profile Concave Straight or
concave
ii. Premature contacts Absent Present
iii. Path of closure Forward Deviated
iv. Gonial angle r or ! Normal
v. Retrusion of Not possible Possible
mandible
Q.15. Mention three planes used in Simon's

classification.
Ans.
• In Simon's system, dental arches are related to three
anthropometric planes.
• Simon had put forward a craniometric classification
of malocclusion using three anthropometric planes,
.
i.e.
i. The Frankfort horizontal plane
ii. The orbital plane
iii. The midsagittal plane
Q.16. Dewey's modification of Angle's classification

of malocclusion.
Ans.
Dewey's modification of Angle's classification:
Martin Dewey has further divided Angle's class I and
III into various types:
• Class I: Divided into five types.
Type 1: Crowded maxillary anterior teeth.
Type 2: Proclined or labioversion of maxillary
central and lateral incisors.
Type 3: Class I with anterior crossbite present.
Type 4: Class I with posterior crossbite present.
Type 5: Mesioversion of molars.
• Class II: No types.
• Class III: Divided into three types.
Type 1: Well-aligned teeth and dental arches. Edge-
edge relationship exists.
Type 2: Crowded mandibular incisors.
Type3: Crowded maxillary incisors.
Q.17. Key ridge.

Ans.
i. Key ridge is the inferior point of anterior border of
bony buttress of zygoma.
ii. Angle said maxillary first molar is the most constant
in position, and related it to key ridge position.
iii. Angles conviction was supported by Atkinson, who
suggested a relative constancy of maxillary first
molar and the bony buttress of the zygoma, which he
called the key ridge.
Q.18. Drawbacks of Angle's classification.

Ans.
[Same as SN Q.3]
Q.19. Mention two merits and demerits of Angle's

classification.
Ans.
[Same as SN Q.3]
Q.20. True class III.

Ans.
[Same as SN Q.6]
Q.21. Name different classifications of malocclusion.

Ans.
[Same as SN Q.8]
Q.22. Enlist various systems of classification of

malocclusion.
Ans.
[Same as SN Q.8]
Topic 8 Aetiology of malocclusion
Long essays:
1. Define malocclusions. Discuss aetiology of
malocclusion.
2. Discuss the environmental or local causes of

malocclusion.
3. Enumerate various postnatal causes of
malocclusion. Elaborate endocrinal factors.
4. Discuss the genetic and hereditary factors
contributing towards the formation of
malocclusion.
5. Explain in detail aetiology of malocclusion. [Same
as LE Q.1]
6. Classify the aetiology of malocclusion. Discuss
general factors in detail. [Same as LE Q.1]
7. Role of genetics in malocclusion. [Same as LE Q.4]
Short essays:
1. Supernumerary tooth. [Ref LE Q.2]
2. Importance of genetics in malocclusion.
3. Mention local factors in the aetiology of
malocclusion.
4. Graber's classification of aetiological factors in
malocclusion. [Ref LE Q.2]
5. Enumerate the prenatal causes of malocclusion.
6. Butler's field theory.
7. Tera to gens.
8. Genetic malocclusions. [Same as SE Q.2]
Short notes:
1. Ankylosis.
2. General factors causing malocclusion.
3. Prenatal causes for malocclusion.
4. Local factors causing malocclusion. [Ref LE Q.2]
5. Teratogens.
6. Supernumerary tooth. [Ref LE Q.2]
7. Dilacerated tooth.
8. Submerged tooth.
9. Supplemental teeth. [Ref LE Q.2]
10. Genetic malocclusions.
11. Enlist causes of midline diastema.
12. Acromegaly.
13. How dental caries cause malocclusion. [Ref LE
Q.2]
14. Aetiology of crowding.
15. Prolonged retention of deciduous teeth. [Ref LE
Q.2]
16. Blanch test.
17. Mention local factors in aetiology of
Solved answers
Long essays:
Q.1. Define malocclusions. Discuss aetiology of

malocclusion.
Ans.
According to Gardiner, White and Leighton,
malocclusion is defined as a condition in which there is
a departure from the normal occlusion of the teeth to
other teeth within the same arch and to the teeth in the
opposing arch.
Aetiology of malocclusion:
Broad aetiological
factors --
Graber has classified

aetiological factors as --
Classification of aetiology of malocclusion
Mo)er'& cbs.sifiatm-
i Heredity: a. Neuro1TU5Cular sysllem

b. Bone
c. Teeiti
dSoftput.
ii. Oeveloi:xnerial defects ofmknownotigin
iii. Trcure: a. Preretal tra.Jrre and birlh tr;uries
b. Pos1nalal tJaDra
iv. Physical agents: a. PrP:rmbire emaction of pinesy teeth
b. Nobe oHood
v. Ilabus: a. 1lurb sudcing ard qer su:lcing
b. To1l;'E thru.ting
c. Up sucking .nl lip bitirg
dPosture
e. Nail bitirg
£. Other habits
vi. Diseases: a. Sy:.ierric asea;es
b. Erdocrine c&sordeis
c. Local diseases
(i) Nac;o~eal diseases anddstuibed respiaoty function
(ii) Gingival and periodontal dise~
(ili)Tumm;
(iv) Caries
White and Gardiner's classification:
i t t
Dental base Pre-eruption Posteruption
abnormalities abnormalities Abnormalities
•
i. Anteroposterior i. Abnormalities in
malrelationship position of
i. Muscular •
a. Active muscle
•
ii. Vertical developing tooth force
malrelationship germ b. Rest position of
iii. Lateral ii. Missing teeth musculature
malrelationship iii. Supernumerary c. Sucking habits
iv. Disproportion teeth and teeth d. Abnormalities in
of size between abnormal in form path of closure
teeth and basal iv. Prolonged ii. Premature loss of
bone retention of deciduous teeth
v. Congenital deciduous teeth iii. Extraction of
anomalies v. Large labial permanent teeth
frenum
vi. Traumatic injury
[SE Q.4]
{Graber's classification of malocclusion:
General F.lc10<s Local Fac1ors

I Herld~y Supomumenry IM1h
1.Anom•fie,
ol no -[ M~slng , ... h
(congenilal absttlce of loss
2. Congenilol Ptffl>lal d'"' 10 accidenls. canes ecc.)
(traum.1, ma11emal diet German 1noa.sles) 2 Anom.ilitS ol 100111 silt
3. Anomohes ol 1001h ,i..i,,
3. &M,onmentll • Abnormal labial frenurn mucosal barnen
-{ 5. Prematuta loss m deciduous letth
Pos1natnl 6 Prolonged re11111,on ol ll'lth
(blr1h Injury, ••ebral·pal,y. TMJ 11ju,y) 7 o....
,.d eru~n path
4 Predisposing metabolic and cilllllllC d,,.... 8. Abnorn,al 1rup1ive palh
•· Endocrine Imbalance
b. Metabolic disturbanceis
c. lnlec1rous disoam
5. 01,wy p,oblems (nulrll,onal deOClen<Y) 9 AnkyloSII
6 Abnormal pressure habllS Md tuncllonal abon•lons IO 0-1 catle$
1. Abnonn>I sudlino 11 lmpropor denlal restorallOn
b. Thumb/1ing11 &ud<lng
c, Tonp 1hrustllongue suck1119
d. Lit> Mid nail bd1ng
e. Abna<mal swallOWlnO habit• (Improper deglut<IOO)
I. Speech detects
g. RespnlOfY 1bnorma1,,.. (moulh brulh11g)
h. Ton..is and adenOlds
I. Psycriooenic hes and bnDd"'1
7. Posture
8. Traumaandacctdems
Q.2. Discuss the environmental or local causes of

malocclusion.
Ans.
{SN Q.4}
Various environmental or local factors that cause
malocclusion are as follows:
A. Disturbances of dental development
i. Anomalies of number
• Supernumerary teeth
• Missing teeth
ii. Anomalies of tooth size
iii. Anomalies of tooth shape
iv. Premature loss of deciduous teeth
v. Prolonged retention of deciduous teeth
vi. Delayed eruption of permanent teeth
vii. Abnormal eruptive path
B. Trauma to the teeth
C. Mucosal barriers
i. Abnormal labial frenal attachment
ii. Soft tissue impaction
I
D. Dental caries
E. Improper dental restoration
i. Anomalies of number of teeth
• Supernumerary teeth
• Supplemental teeth
• Missing teeth
(SN Q.6 and SE Q.1)
{(Supernumerary teeth
• Teeth that are extra to the normal complement
are known as supernumerary teeth. They do
not resemble normal teeth and are usually
conical in shape.
• They can occur singly or in pair.
Example: Mesiodense and paramolars
Mesiodense is most frequently seen
supernumerary tooth.)}
{SN Q.9}
Supplemental teeth:
• Extra teeth that resemble normal teeth are
called supplemental teeth.
Example: most often seen in

region
• {Effects of supernumerary and supplemental
teeth are as follows:
a. They cause noneruption to adjacent teeth.
b. They deflect erupting adjacent teeth into
abnormal location.
c. They can result in crowding and rotation
of adjacent teeth.
d. Unerupted mesiodense is one of the
causes of midline spacing.
e. Unerupted supernumerary teeth are
potential risk factors for cystic
transformation.}
Missing teeth:
• Congenitally missing teeth are far more
Missing teeth:
common than supernumerary teeth.
• Some of the commonly missing teeth in
decreasing order of frequency are as follows:
third molars,
'
sh- '
1 1
'
• Can be unilateral or bilateral

• Spacing in dental arches
• Migration of adjacent teeth - abnormal
location and axial inclination of teeth
• Over-retained deciduous teeth - because of
absence of permanent teeth.
ii. Anomalies of tooth size:
• Increase in size of teeth results in crowding, e.g.
fusion between two adjacent teeth and
between normal tooth and supernumerary
tooth.
• Smaller size teeth result in spacing, e.g.
commonly seen are smaller size ~
Size of teeth is to a large extent genetically

determined.
Most of these conditions show positive family
history.
iii. Anomalies of tooth shape:
Anomalies of tooth size and shape are
interrelated; frequently seen tooth shape
anomalies are
212
• Peg shape I
are accompanied by
spacing and migration of teeth.
• Abnormally large cingulum on a maxillary
incisor tooth, prevents establishment of
normal overbite and overjet and involved
tooth is in labioversion due to forces of
occlusion.
• Additional lingual cusp on

increases MD dimensions of tooth.
• Congenital syphilis causes peg laterals and
mulberry molars.
• Developmental defects like amelogenesis
imperfecta, hypoplasia of teeth, fusion and
gemination causes anomalies of shape.
• Dilaceration is characterized by abnormal
angulation between crown and root of a tooth
or angulation within the root. Dilacerated
teeth fail to erupt to normal level and can
cause malocclusion.
iv. Premature loss of deciduous teeth:
• It refers to loss of a tooth before its permanent
successor is sufficiently advanced in
development and eruption to occupy its place.
• The severity of malocclusion caused due to
early loss of a deciduous tooth depends on
following factors:
a. Premature loss of deciduous molars
predispose to malocclusion due to shifting
of adjacent teeth into the space.
b. The earlier the deciduous teeth are
extracted before successional teeth are
ready to erupt, the greater is the
possibility of malocclusion.
c. In cases of arch length deficiency or
crowding, the early loss of deciduous
teeth worsens the existing malocclusion.
v. Prolonged retention of deciduous teeth:
It is a condition where there is undue retention
of deciduous teeth beyond the usual eruption
age of their permanent successors.
{SN Q.15}
Prolonged retention of deciduous teeth

I
Anteriors Buccal teeth
! Result in ! Result in
Lingual or palatal eruption of Eruption of permanent teeth

their permanent successors either buccally or lingual or
may remain impacted
Aetiology of prolonged retention of deciduous

teeth:
a. Absence of underlying permanent teeth
b. Endocrinal disturbances, e.g.
hypothyroidism
c. Ankylosed deciduous teeth that fail to
resorb
d. Nonvital deciduous teeth that do not
resorb
vi. Delayed eruption of permanent teeth:
Delayed eruption of permanent teeth may be
caused due to the following reasons:
• Congenital absence of permanent tooth
• Supernumerary tooth blocking eruption of
permanent tooth
• Presence of a heavy mucosal barrier
• Premature loss of deciduous tooth (because
of formation of bone over erupting
permanent tooth)
• Endocrinal disorders - Hypothyroidism
delays eruption of teeth
• Presence of deciduous root fragments - These
are not resorbed and can block erupting
permanent teeth
vii. Abnormal eruptive path:
The abnormal path of eruption may be because of
the following reasons:
• Arch length deficiency
• Presence of supernumerary teeth or retained
root fragments
• Formation of bony barrier
3 3
Example: Most often found erupting
in abnormal position as they develop almost
near the floor of the orbit and travel down to
their final position in oral cavity.
B. Trauma to the teeth:
• Trauma to primary teeth may cause displacement
of permanent teeth, defective enamel formation or
dilacerated roots.
• Trauma to permanent teeth may result in ankylosis,
nonvitality and displacement of tooth.
• In ankylosis, a part or whole of the root surface is
directly fused to bone in absence of intervening
periodontal membrane.
• Ankylosed teeth fail to erupt to normal level
(submerged teeth within jaws). Cause migration of
adjacent teeth into the space.
C. Mucosal barriers:
i. Abnormal labial [renal attachment
• Abnormalities of maxillary labial frenum are
quite often associated with maxillary midline
spacing.
• Rarely a heavy fibrous frenum is found attached
to the interdental papilla region. This can
prevent the two maxillary central incisors
1 1
from approximating each other.
• Diagnosed by a positive blanch test.
• A midline IOPA or occlusal radiograph exhibits
notching of the interdental alveolar crest.
ii. Soft tissue impaction:
Thick mucosal tissue covering erupting teeth acts
as a barrier to path of eruption and results in
soft tissue impaction.
{SN Q.13}
D. Dental caries
Dental caries
Premature loss of deciduous/permanent

! teeth
! Causes
Migration of contiguous teeth
!
Abnormal axial inclination and supra-eruption
of opposing teeth)

Improper occlusal restoration:
i. Overcontoured restoration leads to premature
contacts and functional shift of mandibular
during jaw closure.
ii. Undercontoured restoration permits
supraeruption of opposing dentition.
Proximal restoration:
Undercontoured restoration leads to loss of arch
length and food lodgement.
Overcontoured restorations consume more space
leading to irregularity of dentition.
Q.3. Enumerate various postnatal causes of

malocclusion. Elaborate endocrinal factors.
Ans.
Various postnatal causes of malocclusion are
catogerized into:
A. Developmental disturbances:
i. Endocrine disturbances
ii. Nutritional deficiencies
iii. Allergy
iv. Muscular activity
v. TMJ problems
B. Functional disturbances:
i. Head and tongue postures
ii. Various habits like mouth breathing, thumb
sucking, tongue thrusting and abnormal
swallowing.
iii. Functional shifts
C. Environmental interferences:
i. Disturbances of dental development
• Missing teeth
• Malformed teeth
• Supernumerary and supplemental teeth
• Delayed eruption
• Ectopic eruption
• Early loss of primary teeth
ii. Trauma to teeth
iii. Dental caries
iv. Mucosal barrier, e.g. persistent labial frenum
Endocrine disturbances or problems and
their manifestations:
i. Hypopituitarism:
T 1 .. . ' 1 .. •1
Endocrine disturbances or problems and
their manifestations:
i. Hypopituitarism:
• In hypopituitary dwarfism, the eruption
rate and shedding time of teeth are
delayed, as is the growth of the body in
general.
• The dental arch is smaller than normal and
cannot accommodate all the teeth; hence
the malocclusion develops. Development
of maxilla is not as retarded as mandible,
hence results in class II.

• Thickening of dentinal walls at the expense
of pulp chambers. Amelogenesis directly
depends on pituitary hormones but
dentinogenesis and cementogenesis can
proceed at decreased rate without
pituitary hormones.
ii. Hyperpituitarism:
• It results in gigantism and acromegaly.
• Gigantism is due to hypersecretion of GH in
childhood before fusion of epiphysis of
bone with shaft. Acromegaly is due to
hypersecretion of GH in adults.
• Enlargements of bones (especially
mandible), kyphosis (bowing of spine) and
bulldog scalp are important features.
• Gigantism is characterized by a general
symmetric overgrowth of the body.
Skeletal changes include enlarged
supraorbital ridges and prognathic
mandible, enlargement of the tongue and
whole face. Patients may develop class III
malocclusion with interdental spacing.
• Mandibular prognathism, labial or buccaly
tilted teeth and enlarged tongue are the
features of acromegaly.
iii. Hypothyroidism (cretinism):
• Congenital hypothyroidism or cretinism
leads to stunted height, enlargement of
tongue, spaced dentition and delayed
dental age.
• Constant protrusion of enlarged tongue
leads to malocclusion.
• The eruption rate of teeth is delayed and
deciduous teeth are retained beyond
normal shedding time.
iv. Hyperthyroidism:
• This condition is characterized by increase
in the rate of maturation and metabolic
rate.
• The patient exhibits premature eruption of
deciduous teeth, disturbed root resorption
of deciduous teeth and accelerated
eruption of permanent teeth.
• The patient may have osteoporosis, which
contraindicates orthodontic treatment.
• Rare in children.
• Hypertension; wide eyes staring; anxious
looks; very poor dental patients.
Hypoparathyroidism:
• It is associated with changes in
calcium metabolism.
• It can cause delay in tooth eruption,
altered tooth morphology, delayed
eruption of deciduous and
permanent teeth and hypoplastic
teeth. Morphology of teeth is
affected.
Hyperparathyroidism:
• It produces increase in blood
calcium. There is demineralization
of bone and disruption of
trabecular pattern.
• In growing children, tooth
development is interrupted.
• The teeth may become mobile due to
loss of lamina dura, cortical bone
and resorption of the alveolar
process.
Q.4. Discuss the genetic and hereditary factors

contributing towards the formation of malocclusion.
Ans.
• Conditions that are caused due to disturbances in
germ plasma or chromosomes or genes are known as
genetic disorders.
• Genetic disorders can be classified into:
i. Hereditary disorders:
The conditions which are transmitted from one
generation to another are known as hereditary
disorders.
Neel's criteria for considering a problem as
hereditary disorder are as follows:
• Occurrence of disease in definite numerical
proportions among individuals related by
descent.
• Failure of disease to spread to nonrelated
individuals.
• No known precipitation factor.
• Greater concordance of disorder in identical
twins.
ii. Mutational disorders:
• In a previously unaffected individual, the
mutational disorders arise de novo because of
damage to the germ plasma.
• If mutational disorders are transmitted to the
future generation, it becomes hereditary.
Types of transmission of malocclusion:
Malocclusions are transmitted by three ways:
i. Repetitive
ii. Discontinuous
iii. Variable
• Repetitive: Recurrence of a single dentofacial
deformity within the immediate family.
• Discontinuous: Recurrence of tendency for a
malocclusal trait to reappear after few generations.
Some generations will be skipped.
• Variable: Expression of different but related types of
malocclusion within the several generations of the
same family.
Genetic influence:
Malocclusions could be produced by heredity in two
major possible ways:
i. Inherited disproportion between size of teeth
and size of jaws.
ii. Inherited disproportion between size and
shape of upper and lower jaws, which leads to
occlusal malrelationships.
• Genetic disorders seen at the time of birth are
called congenital defects.
• Heredity plays a role in the following
conditions:
a. Congenital deformities
b. Facial asymmetry
c. Cleft lip and palate
d. Mandibular prognathism and
retro gna th ism
e. Micrognathia and macrognathia
f. Variations of tooth shape etc.
• Various modes of inheritance are:
a. Autosomal dominance and recessive
b. X-linked
c. Polygenic
d. Chromosomal
• Contemporary views on aetiology of
malocclusion attribute some of the
malocclusions to hereditary or genetic causes.
i. Dental problem:
a. Crowding- hereditary and
environmental reasons
b. Individual tooth malalignments and
crossbites - pressure environment
ii. Skeletal problem:
Mostly attributed to inherited or genetic cause.
Example:
a. Retrognathic mandible and maxilla
b. Prognathic mandible
c. Skeletal deep bite
Heredity:
It has long been attributed as one of the causes
of real malocclusion.
i. The child inherits conflicting traits from
both parents who have dissimilar genetic
material, resulting in abnormalities of
dentofacial region.
ii. Uncoordinated inheritance of teeth and
jaws is a result of racial, ethnic and
regional intermixture. This is another
reason attributed to genetically
determined malocclusions.
According to Lundstrom, the human traits
influenced by the genes include:
Microdontia
I. Too1h size
{
Macrodont ia
Arch lcnath
Tl. Arch dimension e-
{
Arch width
Ill. Crowding and spacing-.. Uncoordinated inheritance
of arch length and tooth
material
TV. Abnormalitie: of tooth . hape - e.g. peg laterals
(high genetic predisposition)
Anodontia
V. Abnormalities of tooth number
{
Oliaodomia
~
VJ. Overjet - believed 10 be influenced genetically.

VII. Iruerarch variations: Discrepancies in
Transverse Vertical planes

Sagiual
can be inherited
Vlll. Frenum: izc, po ition and shape: genetically influenced.
Example: midline dias terna
According to Harris and Johnson: A number of

craniofacial parameters showed significant
genetic influence.
Example: Sella - gnathion
Sella - point A
Sella - gonion
Nasion - anterior nasal spine
Articulare - pogonion
Bizygomatic width
Anterior facial height
As so many traits show a strong genetic
pattern, a number of malocclusions can be
partly or solely attributed to genetic
factors. These genetic traits can be further
influenced by existing prenatal and
postnatal environmental factors.
Q.5. Explain in detail aetiology of malocclusion.

Ans.
[Same as LE Q.1]
Q.6. Classify the aetiology of malocclusion. Discuss

Q.5. Explain in detail aetiology of malocclusion.
Ans.
[Same as LE Q.1]
Q.6. Classify the aetiology of malocclusion. Discuss

general factors in detail.
Ans.
[Same as LE Q.1]
Q. 7. Role of genetics in malocclusion.

Ans.

[Same as LE Q.4]
Short essays:
Q.1. Supernumerary tooth.

Ans.
[Ref LE Q.2]
Q.2. Importance of genetics in malocclusion.

Ans.
genetic disorders.
• Genetic disorders can be classified into:
i. Hereditary
ii. Mutational
• The conditions which are transmitted from one
generation to another are known as hereditary
disorders.
• According to Lundstrom, the human traits influenced
by the genes include:
Microdoruia
I. Tooth size
{
Macrodontia
Arch length
11. Arch dimensions
{
Arch width
III. Crowding and spacing - Uncoordinated inheritance
of archleugth and tooth
material
JV. Abnormalities of tooth shape. e.g. peg laterals
Anodonria
V. Abnormalities of tooth number
{
Oligodontia
VI. Overjct - believed to be influenced genetically.
VU. lnterarch variations: Discrepancies in
Transverse
!
Sagiua)
Vertical planes
can be inherited
VIII. Frenum: Size, position and shape: influenced genetically.
According to Harris and Johnson: A number of

craniofacial parameters showed significant genetic
influence.
Example: Sella - gnathion, Nasion- anterior nasal
spine, articulare - pogonion, bizygomatic width,
anterior facial height.
A number of malocclusions can be partly or solely
attributed to genetic factors. These genetic traits
can be further influenced by existing prenatal and
postnatal environmental factors.
Q.3. Mention local factors in the aetiology of

malocclusion.
Ans.
Various environmental or local factors that cause
malocclusion are as follows:
A. Disturbances of dental development:
i. Anomalies of number
ii. Anomalies of tooth size
iii. Anomalies of tooth shape
iv. Premature loss of deciduous teeth
v. Prolonged retention of deciduous teeth
vi. Delayed eruption of permanent teeth
vii. Abnormal eruptive path
C. Mucosal barriers
D. Dental caries
i. Anomalies in number of teeth
• Teeth that are extra to the normal
complement are known as supernumerary
teeth. They do not resemble normal teeth
and are usually conical in shape.
Example: mesiodense and paramolars.
• Extra teeth that resemble normal teeth are
called supplemental teeth.
For example, most often seen in

region.
common than supernumerary teeth.
Example: third molars and maxillary
lateral incisors.
ii. Anomalies of tooth size:
• Increase in size of teeth macrodontia
results in crowding, e.g. fusion between
two adjacent teeth and between normal
tooth and supernumerary tooth.
• Smaller size teeth, i.e. microdontia results
. .
in spacing ~
iii. Anomalies of tooth shape:

• Anomalies of tooth size and shape are
interrelated. Frequently seen tooth shape
anomalies are peg shape ~
• Developmental defects like amelogenesis

imperfecta, hypoplasia of teeth, fusion and
gemination cause anomalies of shape.
iv. Premature loss of deciduous teeth:
• It refers to loss of a tooth before its
permanent successor is sufficiently
advanced in development and eruption to
occupy its place.
v. Prolonged retention of deciduous teeth:
Prolonged retention of deciduous teeth

I
Anteriors Buccal teeth
! Result in ! Result in
Lingual or palatal eruption of Eruption of permanent teeth
their permanent successors either buccally or lingually or
may remain impacted
vi. Delayed eruption of permanent teeth:

Delayed eruption of permanent teeth may be
caused due to congenital absence of
permanent tooth, supernumerary tooth
blocking eruption of permanent tooth,
endocrinal disorders like hypothyroidism, etc.
vii. Abnormal eruptive path:
The abnormal path of eruption may be because
of arch length deficiency, presence of
supernumerary teeth or retained root
fragments etc.
• Trauma to primary teeth may cause
displacement of permanent teeth, defective
enamel formation or dilacerated roots.
• Trauma to permanent teeth may result in
ankylosis, nonvitality and displacement of
tooth.
C. Mucosal barriers
• Abnormal labial frenal attachment is quite
often. associated with maxillary midline
spacing.
• Thick mucosa! tissue covering erupting teeth
acts as a barrier to path of eruption, and
results in soft tissue impaction.
D. Dental caries
Dental caries
Premature loss of deciduous/permanent

! teeth
! Causes
Migration of contiguous teeth
!
Abnormal axial inclination and supraeruption
of opposing teeth

• Occlusal restoration:
Overcontoured restoration leads to
premature contacts and functional shift of
mandible during jaw closure, while
undercontoured restoration permits
supraeruption of opposing dentition.
• Proximal restoration:
Undercontoured restoration leads to loss of
arch length and food lodgement, while
overcontoured restorations consume more
space, leading to irregularity of dentition.
Q.4. Graber's classification of aetiological factors in

malocclusion.
Ans.
[Ref LE Q.2]
Q.5. Enumerate the prenatal causes of malocclusion.

Ans.
The various prenatal causes of malocclusion are as
follows:
• The foetus is well protected against injuries and
nutritional deficiencies during pregnancy, but
certain factors can result in abnormal growth of the
orofacial region, thereby predisposing to
malocclusion.
• Abnormal fetal posture during gestation is said to
interfere with symmetric development of the face.
Most of these deformities are temporary and usually
disappear as age advances.
• The other prenatal influences include maternal
fibroids, amniotic lesions, maternal diet and
metabolism.
• Maternal infection such as German measles and use
of certain drugs during pregnancy such as
thalidomide can cause gross congenital deformities,
including clefts.
Q.6. Butler's field theory.

Ans.
• The human dentition is divided into four fields: (i)
incisor (ii) canine, (iii) premolar and (iv) molar
.
regions.
• The most distal tooth in each field is the most
susceptible to changes or variations like absence of
tooth, variation in size, shape and structure.
• Accordingly, lateral incisors, second premolars and
third molars are the most variable tooth in their
group, this is called 'Butler's field theory'.
• Canine is the least variable tooth in the arch.
Butler's field theory does not apply in lower anterior
region, where mandibular central incisor is more
commonly missing than lateral incisor.
Q.7. Teratogens.
Ans.
• Chemical or other agents which cross the placental
barrier and produce embryologic defects are called
teratogens.
• The various teratogens and their effects are as
follows:
Teratogens effect
i. Aspirin, cigarette smoke - cleft lip and palate
dilantin and valium
ii. 6-Mercaptopurine - cleft palate
iii. Aminopterin - anencephaly
iv. Cytomegalovirus - microcephaly, hydrocephaly
v. Ethyl alcohol - central midface deficiency
vi. 13-cis-retinoic acid - retinoic acid syndrome
vii. Rubella virus - microphthalmia, deafness
viii. Thalidomide - hemifacial microsomia-like
viii. Thalidomide - hemifacial microsomia-like
features
ix. Toxoplasma - microcephaly, hydrocephaly
x. Radiation - microcephaly
xi. Vitamin D excess -premature suture closure
Q.8. Genetic malocclusions.

Ans.
[Same as SE Q.2]
Short notes:

Q.1. Ankylosis.
Ans.
i. Ankylosis is a condition wherein a part or whole of the
root surface is directly fused to the bone with the
absence of the intervening periodontal membrane.
ii. It occurs most often as a result of trauma to the tooth
which perforates the periodontal membrane.
iii. It can also be associated with certain infections,
endocrinal disorders and congenital disorders like
cleidocranial dysostosis.
iv. Clinically, these teeth fail to erupt to the normal level
and are, therefore, called submerged teeth.
Q.2. General factors causing malocclusion.

Ans.
General factors causing malocclusion are as follows:
i. Heredity
ii. Congenital
iii. Predisposing metabolic and climatic diseases
iv. Dietary problems (nutritional deficiency)
v. Abnormal pressure habits and functional aberrations,
e.g. thumb/finger sucking, tongue thrust and nail
biting
vi. Posture
vii. Trauma and accidents
Q.3. Prenatal causes for malocclusion.

Ans.
The various prenatal causes of malocclusion are as
follows:
• Abnormal fetal posture during gestation interferes
with symmetric development of the face.
• Prenatal influences include maternal fibroids,
amniotic lesions, maternal diet and metabolism.
• Maternal infections, e.g. German measles.
• Use of certain drugs during pregnancy such as
thalidomide can cause gross congenital deformities,
including clefts.
Q.4. Local factors causing malocclusion.

Ans.
[Ref LE Q.2]
Q.5. Teratogens.
Ans.
• Chemical or other agents which cross the placental
barrier and produce embryologic defects are called
teratogens.
• Examples of various teratogens and their effects are
as follows:
Teratogens effect
i. Aspirin, cigarette smoke, dilantin and valium -
cleft lip and palate
ii. 6-mercaptopurine - cleft palate
iii. Cytomegalovirus - microcephaly, hydrocephaly
iv. Ethyl alcohol - central midface deficiency
v. Radiation - microcephaly
vi. Vitamin D excess -premature suture closure
Q.6. Supernumerarytooth.
Ans.
[Ref LE Q.2]
Q. 7. Dilacerated tooth.
Ans.
• Dilaceration is described as a condition characterized
by an abnormal angulation between the crown and
root of a tooth or angulation within the root.
• It usually occurs due to trauma to a deciduous tooth
and is transmitted to the underlying permanent
tooth bud.
• Dilacerated teeth fail to erupt to normal level and can
thus cause malocclusion.
Q.8. Submerged tooth.

Ans.
i. Clinically, ankylosed teeth fail to erupt to the normal
level and are therefore called submerged teeth.
ii. At times these teeth are totally submerged within the
jaw and therefore cause migration of adjacent teeth
into the space.
Q.9. Supplemental teeth.

Ans.
[Ref LE Q.2]
Q.10. Genetic malocclusions.

Ans.
genetic disorders.
• Genetic disorders can be classified as hereditary and
mutational.
• According to Lundstrom, the human traits influenced
by the genes include, e.g.
Tooth size like microdontia and macrodontia.
Arch dimensions, i.e. arch length and width.
Abnormalities of tooth shape - e.g. peg laterals.
Crowding and spacing because of uncoordinated
inheritance of arch length and tooth material.
Q.11. Enlist causes of midline diastema.

Ans.
• Midline diastema is a form of localized spacing,
where
. . spacing is present between two central
incisors.
• It occurs due to a number of causes:
A. Normal developmental causes:
i. Physiological median daistema
ii. Ethnic and familial
B. Tooth material deficiency:
i. Microdontia
ii. Missing lateral and peg lateral
C. Physical impediment:
i. Retained deciduous teeth
ii. Mesiodens
D. Habits:
Thumb sucking, tongue thrusting etc.
Q.12. Acromegaly.
Ans.
• Hyperpituitarism results in gigantism and
acromegaly.
• Acromegaly is due to hypersecretion of GH in adults.
Gigantism is due to hypersecretion of GH in
childhood before fusion of epiphysis of bone with
shaft.
• Gigantism is characterized by a general symmetric
overgrowth of the body.
• Skeletal changes include enlarged supraorbital ridges
and prognathic mandible, enlargement of the tongue
and whole face. Patients may develop class III
malocclusion with interdental spacing.
• Mandibular prognathism, labial or buccaly tilted
teeth and enlarged tongue are the features of
acromegaly.
Q.13. How dental caries cause malocclusion.

Ans.
[Ref LE Q.2]
Q.14. Aetiology of crowding.

Ans.
• Crowding and spacing of teeth are believed to be of
genetic origin.
• Most of these conditions are believed to be a result of
uncoordinated inheritance of arch length and tooth
material.
• Arch length-tooth material discrepancy leads to
crowding.
Q.15. Prolonged retention of deciduous teeth.

Ans.
[Ref LE Q.2]
Q.16. Blanch test.

Ans.
• High frenal attachment condition is diagnosed by a
positive blanch test.
• A heavy fibrous frenum is found attached to the
interdental papilla region. This type of frenal
attachment can prevent the two maxillary central
incisors from approximating each other, leading to
midline diastema.
• The procedure of blanch test
When the upper lip is stretched for a period, a
noticeable blanching occurs over the interdental
papilla. A midline intraoral periapical radiograph
usually exhibits notching of interdental alveolar
crest.
Q.17. Mention local factors in aetiology of

malocclusion.
Ans.
[Same as SN Q.4]
Topic 9 Oral habits
Long essays:
1. Define habits. Classify and discuss in detail the
features of tongue thrusting habit and its
treatment modalities.

2. Enumerate the aetiological factors causing mouth
breathing in children and discuss the line of
treatment.
3. Define and classify habits. Discuss clinical pictures
and management of thumb-sucking habit.
4. Describe how tongue thrust, mouth breathing and
thumb-sucking habits cause malocclusion.
5. Classify tongue thrust habit. Discuss its aetiology,
clinical features and management. [Same as LE
Q.1]
6. Define abnormal pressure habits. Write in detail
about the classification, clinical findings and
treatment for mouth breathers. [Same as LE Q.2]
7. Mouth breathing habit and its effects on the
development of occlusion. [Same as LE Q.2]
8. Describe various oral habits directly responsible
for causing malocclusion. Discuss management of
one such habit in detail. [Same as LE Q.3]
9. Define a habit. How do you classify habits; discuss
the aetiology, effects and management of thumb
sucking. [Same as LE Q.3]
10. Define preventive and interceptive orthodontics.
Discuss the management of thumb-sucking habit.
[Same as LE Q.3]
Short essays:
1. Thumb-sucking habit.
2. Mouth breathing habit. [Ref LE Q.2]
3. Classify tongue thrust habit. Add a note on its
management. [Ref LE Q.1]
4. Bruxism.
5. Mouth breathing habit and its effects on the
development of occlusion. [Same as SE Q.2]
6. Write briefly about tongue thrust habit. [Same as
SE Q.3]
Short notes:
1. Mouth breathing.
2. Thumb-sucking habit.
3. Lip sucking and lip biting.
4. Define tongue thrusting habit.
5. Adenoid facies.
6. Classify tongue thrust habit. [Ref LE Q.1]
7. Write a note on management of tongue thrust
habit.
8. Habit breaking appliances. [Ref LE Q.3]
9. Lip biting.
10. Bruxism.
11. Management of thumb sucking habit.
12. Pernicious oral habits.
13. Lip bumper.
14. Nail biting.
15. Beta (13) hypothesis.
16. Role of mouth breathing in the aetiology of
17. Aetiology of tongue thrust. [Same as SN Q.4]
Solved answers
Long essays:
Q.1. Define habits. Classify and discuss in detail the

features of tongue thrusting habit and its treatment
modalities.
Ans.
[SE Q.3]
• {Habit can be defined as the tendency towards an act
that has become a repeated performance, relatively
fixed, consistent and easy to perform by an
individual.
• Tongue thrusting is defined as a condition in which
the tongue makes contact with any teeth anterior to
the molars during swallowing.
• This deleterious habit clinically presents with open
bite and anterior proclination.
Aetiology
The factors considered as a cause of tongue thrusting
habit according to Fletcher are as follows:
i. Genetic factors
ii. Learned behaviour (habit)
iii. Maturational factors
iv. Mechanical restrictions
v. Neurological disturbance
vi. Psychogenic factors
i. Genetic factors: Specific anatomic or
neuromuscular variations in orofacial region
can precipitate tongue thrust, e.g. hypertonic
orbicularis oris activity.
ii. Learned behaviour (habit): Tongue thrusting can
be acquired as a habit due to following
predisposing factors:
a. Improper bottle feeding
b. Prolonged thumb sucking
c. Prolonged tonsillar or upper respiratory
tract infections
d. Prolonged duration of tenderness of
gums or teeth tends to change the
swallowing pattern
iii. Maturational factors:
a. Macroglossia
b. Constricted dental arches
c. Enlarged adenoids and tonsils
They cause tongue to be positioned
anteriorly to prevent blocking of the
oropharynx.
iv. Neurological disturbance: Orofacial region can
cause tongue thrust habit, e.g. hyposensitive
palate and moderate motor disability.
v. Psychogenic factors: Tongue thrusting habit may
develop because of forced discontinuation of
other habits like thumb sucking.
{SN Q.6}
Classification of tongue thrusting habit
According to James S. Braner and Holt.
Type I: on-deforming tongue thru t

Type Il: Deforming anterior tongue thrust
i. Anterior open bite
3 subgroups:
-E ii. Antcriorproclination
iii. Posterior cross bite
Type Ill: Deforming lateral tongue thrust
i. Posterior open bite
3 Subgroups
-E ii. Posterior crossbiie
iii. Deep over bite
Type fV: Deforming anterior and lateral tongue thrust
i. Anterior and po terior open bite
3 Subgroups
-E ii. Proclination of anterior teeth
iii. Po terior cro sbite
Moyers classified tongue thrusting into three

types:
i. Simple tongue thrusting: characterized by teeth
together swallow
ii. Complex thrusting: characterized by teeth apart
swallow
iii. Retained infantile swallow
Clinical features:
The clinical features seen in tongue thrusting
condition are dependent on type of tongue
thrusting.
Some common clinical features of tongue thrust
habit are as follows:
• Proclination of anterior teeth
• Bimaxillary protrusion
• Anterior open bite
• In case of lateral tongue thrust, posterior open
bite and posterior crossbite
i. The Simple tongue thrust habit:
• It is also called teeth together swallow. There is
normal tooth contact during swallowing.
• Generalized spacing and proclination may be
seen in the upper and lower anterior teeth.
• Increased overjet, reduced overbite or presence
of anterior open bite may be seen.
• Tongue is thrust forward during swallowing to
help in establishing anterior lip seal.
• Exaggerated perioral musculature during the
swallowing action. Especially hyperactive
mentalis muscle activity is seen.
ii. Complex tongue thrust habit:
• It is defined as tongue thrust with teeth apart
swallow.
• There are two important diagnostic features:
generalized open bite and poor occlusal fit of
teeth which leads to sliding occlusion.
• Absence of temporal muscle constriction
during swallowing, and the mandible is not
stabilized by the elevator muscles.
iii. Retained infantile swallow:
Little is known about the exact aetiology of this
severe problem.
Treatment
• Interception and treatment of tongue thrusting is
age- and severity-dependent. In children
younger than 3 years, no active intervention is
instituted whereas children older than this age
can be trained for tongue swallowing exercises.
• The various modalities of treatment of tongue
thrusting are as follows:
I. Reminder therapy/interception of habit
II. Corrective therapy}
I. Reminder therapy/interception of habit:
• Use of habit breakers both fixed and
removable cribs and rakes. Some of the
commonly used removable appliances
include upper Hawley's plate with tongue
cribs and roller balls for tongue exercise.
• Teaching correct method of swallowing to
child.
II. Corrective therapy:
a. Removal of obstruction
b. Tongue exercises
c. Lip exercises
d. Habit breaking appliance
e. Treatment of malocclusion
a. Removal of obstruction:
• Surgery for adenoids and macroglossia
• Closure of anterior and posterior open bite,
anterior spaces with either fixed or
removable orthodontic appliance.
b. Tongue exercises:
Various muscle exercises of tongue to adapt
it to new swallowing pattern with
removable or fixed orthodontic appliances
are advised after habit is intercepted, they
are as follows:
i. Elastic band swallow exercise: Small
orthodontic elastic band is held up the
tongue tip against the palate during
swallowing and asked to practise. If the
swallow is correct, patient will be able to
hold the elastic, otherwise it falls or will be
swallowed.
ii. Water swallow exercise: Patient is advised
to keep water in mouth and a mirror in the
hand and swallowing is practised daily.
iii. Candy swallow exercise: A fiat, sugarless
candy is placed between tongue and palate
and swallowing is practised.
This exercise reinforces the learning of new
swallowing pattern to be transferred to
the subconscious level.
iv. Speech exercise: Patient practises syllables
like c, g, h, k while keeping an elastic band
between the tongue and the palate.
c. Lip exercises:
Patient practises stretching of lips to achieve
anterior lip seal.
d. Habit breaking appliance:
i. The tongue thrusting appliance has fixed
tongue spikes fabricated with 0.040,,
stainless steel alloy. It is V-shaped with
three or four projections which extend up
to cingulum of lower incisors soldered to
..
d. Habit breaking appliance:
i. The tongue thrusting appliance has fixed
tongue spikes fabricated with 0.040,,
stainless steel alloy. It is V-shaped with
three or four projections which extend up
to cingulum of lower incisors soldered to
molar bands or crowns. It acts as picket
fence, preventing or limiting the tongue.
ii. 5-10 years is the optimum age to use this
appliance.
iii. A modified tongue crib is used in patients
with lateral tongue thrusting habit.

e. Treatment of malocclusion:
Malocclusion is treated with either
removable or fixed orthodontic
appliances.
Q.2. Enumerate the aetiological factors causing

mouth breathing in children and discuss the line of
treatment.
Ans.
[SE Q.2]
{i. Mouth breathing is an altered way of breathing
through mouth and is an adaptation to obstruction in
nasal passages. The obstruction may be temporary or
recurrent. While more often it is partial than
complete. The air way resistance may be enough to
force the subject to breathe through the mouth.
ii. Mouth breathing is usually attributed as an
aetiological factor for malocclusion.
iii. Mouth breathing results in altered jaw and tongue
posture, which, in turn, alters orofacial equilibrium
leading to malocclusion.
Classification of mouth breathers:
Mouth breathers
Three types
.
Obstructive Habitual
! l
Anatomic
Complete or partial Due to deep-rooted Patients with short
obstruction of nasal habit that is upper lip that does
passage results in unconsciously not permit complete
mouth breathing performed mouth closure
Aetiology
A. Obstructive causes:
• Nasal polyps
• Obstructive adenoids
• Congenital enlargement of nasal turbinates
• Chronic inflammation of nasal mucosa
• Benign tumours
• Deviated nasal septum
B. Anatomic causes:
• Short upper lip
• Underdeveloped nasal cavity
C. Obstructive sleep apnoea}
Pathophysiology of mouth breathing
Oral respiration
Three changes in posture
Lowering of Position of tongue Tipping back of

mandible ( downward and forward) head
\..__ ----~)
y
Upset orofacial equilibrium
Unrestricted buccinators activity
Influences position of teeth
and growth of jaws
[SEQ 2]
{Clinical features:
i. The type of malocclusion associated with mouth
breathing is called 'Long Face Syndrome' or
classic adenoid facies or vertical maxillary
excess.
ii. Long and narrow face with short and flaccid
upper lip.
iii. Expressionless, blank face.
iv. Anterior open bite.
v. Contraction of upper arch, narrow V-shaped
upper jaw with a high narrow palate, posterior
crossbite.
vi. r Overjet due to flaring of maxillary anteriors.
vii. Anterior marginal gingivitis and r caries
incidence.
viii. Narrow nose and nasal passage, widely flared
external nares.
ix. Excessive appearance of maxillary anterior
teeth with a 'GUMMY SMILE'.
Diagnosis is based on:
i. History of the patient
ii. Clinical examination
iii. Some simple tests:
• Mirror condensation test
• Water holding test
• Cotton wisp test
iv. Cephalometrics: It helps to assess the
amount of nasopharyngeal space, size of
adenoids and diagnosing long face.
v. Rhinomanometry:
• Study of nasal airflow
characteristics using devices like
flow meter and pressure gauges.
• Estimation of airflow through nasal
passage and amount of nasal
resistance.
Treatment:
• Removal of nasal or pharyngeal obstruction by
ENT surgeon.
• Interception of the habit - vestibular screen
adhesive tapes for lip seal
• Rapid maxillary expansion - causes widening
of arch, resulting in T nasal flow and ! nasal
air resistance}
Q.3. Define and classify habits. Discuss clinical

pictures and management of thumb-sucking habit.
Ans.
Habit can be defined as the tendency towards an act
fixed, consistent and easy to perform by an individual.
Classification:
According to different authors, habits have been
classified as follows:
Author Classification
U eful habits
Jame (1923)
Harmf ul habit
Morri and Pressure habit

Bohanna Nonpre ure habit
(1969) Biting habit
Ernpry habits
Klein ( 1971)
Meaningful habit
Finn (1987)
'-+ Noncompulsive habits
Classification of Habits
Classification of Habits
I. According to James
t t
Useful habits Harmful habits
The habits that are essential for The habits that have deleterious
normal function effect on the teeth and their
supporting structures
Example: Example:
• Proper positioning of tongue • Thumb sucking
• Respiration • Tongue thrusting etc.
• Normal deglutition
II. According to Morris and Bohanna
•
Pressure habits
1
Nonpressure habits
t
Biting habits
Include sucking habits Habits which do not Include various

such as apply direct force on biting habits
• Thumb sucking teeth or its supporting such as
• Lip sucking structures, such as • Nail biting
• Finger sucking • Mouth breathing • Pencil biting
• Tongue thrusting • Lip biting
Ill. According to Klein
I
t
Empty habits Meaningful habits
Habits not associated with any Habits that have a psychological
deep-rooted psychological bearing, e.g. nail biting, lip biting,
problems, e.g. abnormal digit sucking
pillowing, chin propping
IV. According to Finn

I
t
Compulsive habits Noncompulsive habits
i. These are deep-rooted habits 1. Include habits that are easily
that have acquired fixation in learned, and dropped as the
the child to the extent that child matures.
the child retreats to the habit
whenever his security is
threatened by events that
occur around him.
ii. The child tends to suffer
increased anxiety when an
attempt is made to correct
the habits.
Thumb sucking
Digit sucking or thumb sucking is defined as
placement of the thumb or one or more fingers in
varying depths into the mouth.
Aetiology
Causative factors include:
(i) Parents' occupation: Low socioeconomic groups
are more prone to thumb sucking.
(ii) Working mother: Children with insecure
feeling cultivate the habit.
(iii) Number of siblings: More number of children
leads to neglection of child and development of
this habit.
(iv) Order of birth of child: Later the sibling rank
of a child, greater the chances of oral habit.
(v) Social adjustment and stress.
(vi) Feeding practices.
(vii) Age of the child.
Some of the more commonly accepted theories to
explain the thumb-sucking habit are as follows:
i. Freudian theory
ii. Benjamin's theory
iii. Psychological aspects
iv. Oral drive theory
v. Learned pattern theory
i. Freudian theory (1905) - proposed by Sigmund
Freud
• He suggested that a child passes through various
phases of psychological development - of which
oral and anal phases are seen in first 3 years of
life.
The child ha
!
tendency
to place hi finger
or any object into the oral cavity.
!
Prevention of uch habit i believed co re ult in
emotional in ecuriry and po e ri k of child
diver ifying into other habit .
ii. Benjamin's theory- suggests that thumb sucking

arises from rooting or placing reflex seen in all
mammalian infants.
iii. Psychological aspects - feeling of insecurity in
children deprived of parental love and affection is
believed to resort to this habit.
iv. Oral drive theory (1950) - proposed by Sears and
Wise (1982), it stated that prolonged sucking can
lead to thumb sucking.
Phases of development of thumb sucking
Phases of development of thumb sucking
Phase I Phase II Phase III

Normal and Clinical Intractable sucking
subclinically significant
significant sucking
Seen during first 3 Seen during 3-61/2 Persistent beyond
years of life and years of life the fourth or fifth
is considered year of life
quite normal
No treatment Treatment: Dental Treatment:

required, problems Consultation with
usually should be a psychologist is
terminates at solved in this required in this
the end of phase phase phase
I
Clinical effects of thumb sucking:

• Dentofacial changes associated with thumb
sucking can affect - maxilla, mandible, interarch
relationship, lip placement and function, etc.
• The severity of malocclusion caused by thumb
sucking depends on the following factors:
a. Duration - amount of time spent in indulging
in the habit
b. Frequency- number of times habit is
activated/day
c. Intensity - vigour with which the habit is
performed
• The effects of thumb sucking on dental arch and
its supporting structures are as follows:
i. Proclination or labial tipping of maxillary
anterior teeth.
ii. Increasing overjet - due to proclination of
maxillary anterior + lingual tipping of
mandibular incisors.
iii. Anterior open bite ( ! overbite) - restriction of
incisor eruption + supra-eruption of buccal
teeth.
iv. Posterior crossbite - narrow maxillary arch
predisposing to crossbite due to contraction of
cheek muscles during thumb sucking.
v. Tongue thrust - develops because of open bite.
vi. Effects on lip - hypotonic upper lip,
hyperactive lower lip. r Lip incompetence,
hyperactive mentalis activity.
vii. Other effects are psychological health, risk of
malposition of jaws, speech defects, digit
defects.
Diagnosis:
i. History - frequency and duration of habit
ii. Child's emotional status - assessed by enquiring
• Feeding habits
• Parental care of child
• Working parents
iii. Examination of child's fingers - presence of
clean nails and callus on finger
iv. Intraoral clinical examination - proclination,
open bite, etc.
Treatment:
• The child + parent + dentist form a team to assist
child in stopping the habit
• Treatment is mainly of the following three
categories:
A. Psychological therapy
B. Reminder therapy or mechanotherapy -
removable habits breakers, and fixed habit
breakers
C. Chemical approach
A. Psychological treatment:
a. Screening patients for underlying
psychological disturbances and referring to
professionals for counselling.
b. Children between 4 and 8 years age need
only reassurance, positive reinforcement
and friendly reminders to divert child's
attention to other things like play and toys.
c. Dunlap's beta hypothesis
• Forced purposeful repetition of a habit
eventually associated with unpleasant
reactions and habit is abandoned.
• Dunlop's beta hypothesis is especially
practised in older children, i.e. aged 8
years and above.
B. Reminder therapy or mechanical aids:
{SN Q.8}
{The habit breaking appliances are basically
reminding appliances that assist to quit the habit.
Two types of habit breakers
Removable Fixed
i. These are passive and i. This appliance consists of
removable appliances molar bands/crowns on
consisting of a crib first permanent molars
placed palatal to 2112 with palatal assembly
and anchored to oral and soldered spurs made
cavity by means of of either nickel-chrome or
clasps on posterior stainless steel.
teeth. Example:
Example: Tongue spikes, • Quadhelix
• Hay rakes
tongue guard spurs/rake • Maxillary lingual arch with
palatal crib
ii. The best appliance is
heavy gauge stainless
steel wire designed to
form a frame that is
soldered to molar bands
FIG. 9.1 Tongue spike.
FIG. 9.2 Tongue guard.
FIG. 9.3 Fixed habit breaker.
Other mechanical aids used to intercept the

habit include:
• Bandaging of the thumb
• Bandaging of the elbow
C. Chemical approach:
• Use of bitter tasting or foul smelling
preparations placed on thumb that is sucked
can make the habit distasteful.
• Commonly used medicaments are as follows:
a. Pepper dissolved in a volatile medium
b. Quinine
c. Asaf oetida
Q.4. Describe how tongue thrust, mouth breathing

and thumb-sucking habits cause malocclusion.
Ans.
• Habit can be defined as the tendency towards an act
fixed, consistent and easy to perform by an
individual.
• Due to their repetitive nature and longer duration,
the orofacial habits influence the form of orofacial
structures.
The pathophysiology of various habits causing
malocclusion is as follows:
A. Tongue thrusting habit:
The repeated anterior positioning of the tongue leads
to anterior open bite, protruded and spaced
anterior teeth and an incompetent anterior lip
seal, all of these effects lead to tongue thrusting-
like situation.
B. Mouth breathing:
i. A child suffering from nasorespiratory blockage
due to any reason like enlarged tonsils,
recurrent throat infections etc. tends to keep
the tongue low and forward and is unable to
maintain anterior lip seal.
ii. Such patients develop a mouth breathing habit
with consequent mouth open posture. These
children develop a long face known as adenoid
facies.
C. Sucking habits:
i. Development of normal orofacial function is
greatly hindered by continuation of
nonnutritive sucking habits beyond 4-5 years
of age.
ii. During thumb or finger sucking, mouth
remains open and the tongue is positioned
forward and low in the mouth, because of this
an abnormal pressure is generated by
contraction of cheek muscles resulting in
imbalance in intraoral force system.
iii. Exaggerated buccinator activity during sucking
.::inrl c::,,u.::illrn,\Tincr rA<:nltc:: in rnnc::trirtArl rn.::ivill.::i
.......... ,,.,_, _ ,J .
iii. Exaggerated buccinator activity during sucking

and swallowing results in constricted maxilla,
buccal crossbite, lowered and backward
mandibular posture resulting in class II
division 1 malocclusion.
Q.5. Classify tongue thrust habit. Discuss its

aetiology, clinical features and management.
Ans.
[Same as LE Q.1]

Q.6. Define abnormal pressure habits. Write in detail
about the classification, clinical findings and
treatment for mouth breathers.
Ans.
[Same as LE Q.2]
Q.7. Mouth breathing habit and its effects on the

development of occlusion.
Ans.
[Same as LE Q.2]
Q.8. Describe various oral habits directly responsible

for causing malocclusion. Discuss management of
one such habit in detail.
Ans.
[Same as LE Q.3]
Q.9. Define a habit. How do you classify habits;

discuss the aetiology, effects and management of
thumb-sucking.
Ans.
[Same as LE Q.3]
Q.10. Define preventive and interceptive

orthodontics. Discuss the management of thumb-
sucking habit.
Ans.
[Same as LE Q.3]
Short essays:
Q.1. Thumb-sucking habit.

Ans.
• Thumb sucking is defined as placement of thumb or
one or more fingers in varying depths into the
mouth.
• Theories involved in explaining thumb-sucking habit
are
i. Freudian theory
ii. Oral drive theory
iii. Benjamin's theory
iv. Psychological aspects
v. Learned pattern theory
• Phases of development of thumb sucking:
Phase I - normal - seen during the first 3 years of life
Phase II- clinically significant - 3-61/2 years
Phase III - intractable sucking - beyond fourth or
fifth year of life
• Clinical features:
i. Proclination of maxillary anteriors
ii. t Overjet and l overbite
iii. Anterior open bite and posterior crossbite
iv. Tongue thrust, hypotonic upper lip and
hyperactive mentalis muscle
• Diagnosis:
It is based on:
i. History of habit
ii. Child's emotional status
iii. Examination of child's fingers - clean
nails and callus on finger
iv. Intraoral clinical examination
• Treatment of thumb sucking:
i. Psychological therapy
ii. Mechanical aids:
a. Removable
b. Fixed habit breakers
c. Chemical approach
i. Psychological therapy:
• Counselling of parents to provide adequate
love and affection to the child.
• Advice parents to divert the child's attention
to other things like play and toys.
ii. Mechanical aids:
• Habit breaking appliances:
a. Removable, e.g.
i. Tongue spikes
ii. Tongue guard
b. Fixed, e.g.
i. Quad helix
ii. Hay rakes
• Other mechanical aids used to intercept the
habit are bandaging of thumb and elbow
iii. Chemical approach: It is by using bitter tasting
and foul smelling chemicals placed on thumb,
e.g. pepper dissolved in a volatile medium,
quinine, asafoetida.
Q.2. Mouth breathing habit.

Ans.
[Ref LE Q.2]
Q.3. Classify tongue thrust habit. Add a note on its

management.
Ans.
[Ref LE Q.1]
Q.4. Bruxism.
Ans.
Grinding of teeth for nonfunctional purposes is known
as bruxism.
Nocturnal grinding ~ Bruxi m
T,vo type
Day grinding ~ Bruxomania
P iychological and emotional tre c
Occlu al irucrf ere nee or di crcpancy

Aetiology -- between centric relation (CR) and
centric occlusion (CO)
Pericoronitis and periodontal

pain lrigger bruxis m
Clinical features:
i. Occlusal wear facets on teeth
ii. Mobility of teeth
iii. Fractured teeth and restorations
iv. Muscle pain - on waking up in the morning
v. Temporomandibular joint (TMJ) pain and
discomfort
vi. Tenderness and hypertrophy of masticatory
muscles
Diagnosis:
i. History and clinical examination are helpful in
diagnosis of bruxism.
ii. Check for occlusal prematurities using
articulating paper.
iii. Check for hyperactivity of muscles of
mastication, i.e. electromyography
examination.
Treatment:
i. Psychological counselling
ii. Relieving muscle tension by
• Hypnosis
• Relaxing exercises
• Massage
iii. Occlusal adjustments
iv. Night guards or occlusal splints
Q.5. Mouth breathing habit and its effects on the

development of occlusion.
Ans.
[Same as SE Q.2]
Q.6. Write briefly about tongue thrust habit.

Ans.
[Same as SE Q.3]
Short notes:
Q.1. Mouth breathing.

Ans.
i. Mouth breathing is an altered way of breathing
through mouth and is an adaptation to obstruction in
nasal passages.
ii. Mouth breathing results in altered jaw and tongue
posture, which in turn alters orofacial equilibrium
leading to malocclusion.
iii. The type of malocclusion associated with mouth
breathing is called 'Long Face Syndrome' or classic
adenoid facies or vertical maxillary excess.
iv. Anterior open bite and posterior crossbite, narrow V-
shaped upper jaw with a high narrow palate, short
and flaccid upper lip.
v. Treatment of mouth breathing includes removal of
nasal or pharyngeal obstruction by ENT surgeon,
interception of the habit using vestibular screen
adhesive. tapes for lip seal and rapid maxillary
expansion.
Q.2. Thumb-sucking habit.

Ans.
i. Thumb sucking is defined as placement of thumb or
one or more fingers in varying depths into the mouth.
ii. Clinical features: Proclination of maxillary anteriors, t
overjet and ! overbite, anterior open bite and
posterior crossbite, tongue thrust, hypotonic upper lip
and hyperactive mentalis muscle.
iii. It is diagnosed based on history, child emotional
status, examination of child's fingers, i.e. clean nails
and callus on finger and intraoral clinical
examination.
iv. Treatment of thumb sucking includes psychological
therapy, use of mechanical aids like habit breaking
appliances, e.g. tongue spikes, tongue guard, hay
rakes, etc., and chemical approach using bitter tasting
and foul smelling chemicals placed on thumb.
Q.3. Lip sucking and lip biting.

Ans.
i. Lip sucking and lip biting are usually seen in cases of
excessive overj et.
ii. They involve cushioning the lower lip against palatal
surfaces of maxillary incisors, causing them flare
forward.
iii. Due to indirect pressure delivered to labial surface of
mandibular incisors, they move lingually, increasing
the overjet.
iv. Hypertrophied lower lips and associated hyperactive
mentalis activity are seen.
v. Lip bumpers are used to treat upper and lower lip
'Y'l1"'nhlnmt" 'T'l-.;C' ............... 1;,.... ..... ,..,.. 'Y'l1"'nTTn'Y'ltt" "\h'Y'lr>1"'m'\l f',._ .... ,..,..
J
v. Lip bumpers are used to treat upper and lower lip

problems. This appliance prevents abnormal force
acting on the incisors and hyperactivity of mentalis
muscle.
Q.4. Define tongue thrusting habit.

Ans.
• Tongue thrusting is defined as a condition in which
the tongue makes contact with any teeth anterior to
the molars during swallowing.
Aetiology:
The factors considered as a cause of tongue thrusting

habit according to Fletcher are as follows:
i. Genetic factors, e.g. hypertonic orbicularis oris
activity
ii. Learned behaviour (habit) due to improper
bottle feeding, prolonged thumb sucking,
prolonged tonsillar or upper respiratory tract
infections, etc.
iii. Maturational factors, e.g. macroglossia,
constricted dental arches and enlarged
adenoids and tonsils, etc.
iv. Mechanical restrictions
v. Neurological disturbance, e.g. hyposensitive
palate and moderate motor disability.
vi. Psychogenic factors
Q.5. Adenoid facies.

Ans.
i. The type of malocclusion associated with mouth
breathing is called long face syndrome, adenoid
facies.
ii. The term 'adenoid facies' was coined by Tomes in
1872 to describe dentofacial changes associated with
chronic nasal airway obstruction.
iii. These patients have increased lower anterior face
height associated with unfavourable 'clockwise'
rotation of the mandible in a more vertical and
posterior direction, open bite, crossbite and
retrognathia.
iv. In growing patients, following adenoidectomy and
orthodontic treatment, changes would reverse back
to normal.
Q.6. Classify tongue thrust habit.

Ans.
[Ref LE Q.1]
Q.7. Write a note on management of tongue thrust

habit.
Ans.
Management of tongue thrusting habit:
• Interception and treatment of tongue thrusting is age-
and severity-dependent.
• The various modalities of treatment of tongue
thrusting are as follows:
I. Reminder therapy/interception of habit: Use of
habit breakers both fixed and removable cribs
and rakes.
II. Corrective therapy:
a. Removal of obstruction: Surgery for
adenoids and macroglossia.
b. Tongue exercises:
i. Elastic band swallow exercise
ii. Water swallow exercise
iii. Candy swallow exercise
iv. Speech exercise
c. Lip exercises: Patient practises stretching
lips to achieve anterior lip seal.
d. Habit breaking appliance, e.g. tongue
crib.
e. Treatment of malocclusion: Either
removable or fixed orthodontic
appliances.
Q.8. Habit breaking appliances.

Ans.
[Ref LE Q.3]
Q.9. Lip biting.

Ans.
i. Lip biting habit is u ually een in case with exce sive over-jet
Proclincd upper anteriors
ii. Clinical features: -++ Hypertrophic and redundant

lower lip
Cracking of lips
iii. Trcatrncnt : Lip bumper
Q.10. Bruxism.
Ans.
i. Grinding of teeth for nonfunctional purposes is known
as bruxism.
ii. It is mainly due to psychological and emotional
stresses or occlusal interference. Pericoronitis and
periodontal pain triggers bruxism.
ii. Occlusal wear facets are seen on teeth, mobility of
teeth, fractured teeth and restorations.
iii. Muscle pain on waking up in the morning, TMJ pain
or discomfort and tenderness and hypertrophy of
masticatory muscles.
iv. Treatment consists of psychological counselling,
relieving muscle tension by occlusal adjustments and
use of night guards or occlusal splints.
Q.11. Management of thumb-sucking habit.

Ans.
Management of thumb-sucking habit is as follows:
• The child + parent + dentist form a team to assist child
in stopping the habit.
• Treatment is mainly of three categories: Psychological
therapy, reminder therapy or mechanotherapy and
chemical approach.
• Psychological therapy: Forced purposeful repetition
of a habit eventually associated with unpleasant
reactions and habit is abandoned.
• Reminder therapy or mechanical aids: They are habit
breaking appliances that assist to quit the habit and
are of two types: removable and fixed.
Example: removable appliances: tongue spikes,
tongue guard and spurs/rake
Fixed appliances: Quadhelix, hay rakes and
maxillary lingual arch with palatal crib.
• Chemical approach: Use of bitter tasting or foul
smelling preparations placed on the thumb that is
sucked can make the habit distasteful.
Q.12. Pernicious oral habits.

Ans.
i. Pernicious oral habits are one of the factors
influencing the occlusion.
ii. Abnormal oral habits, like sucking habits and tongue
thrusting, alter the equilibrium of buccinators
mechanism.
iii. Various pernicious oral habits, like digit sucking,
tongue thrusting and mouth breathing, can cause
class II, division 1 features.
iv. Median diastema can also be caused due to these
habits.
v. Discontinuation of these habits is required for
correction of acquired malocclusions.
Q.13. Lip bumper

Ans.
i. The lip bumper is a 'combined removable fixed
appliance'.
ii. The appliance can be used in both the maxilla
(Denholtz appliance) and the mandible to shield the
lips away from the teeth.
iii. Typically, it is a vestibular arch carrying an acrylic
pad engaged to lower molar bands with 0.93-mm
diameter wire and it stands 2-3 mm away from the
teeth and gingiva and lies about 4 mm below the
cervical margins of the lower incisors. The lower lip
is thus held forward.
• It prevents the hyperactivity of the mentalis muscle
and
. .
the abnormal force from acting on the
incisors.
• The other effect of lip bumper is that it causes
proclination of the incisors and distalization of
molars.
• It is used in the correction or elimination of lip trap.
Q.14. Nail biting

Ans.
i. Nail biting is one of the deleterious oral habits.
ii. It does not produce gross malocclusion.
iii. It results in minor tooth irregularities similar to nut
notch because of cracking hard nuts.
iv. It is treated with lip bumpers.
Q.15. Beta ((3) hypothesis.

Ans.
i. 'Beta hypothesis' or concept of 'negative practice' was
discovered by Dr. Knight Dunlap (1929).
ii. When the concept of ~ hypothesis or negative practice
is applied to oral habits, it helps as a self-correcting
mechanism.
iii. A child is encouraged to watch himself in front of a
large mirror while sucking the digit, the sight of
oneself sucking thumb will hamper the pleasure
derived from that act and the child will slowly try to
avoid the habit by himself.
Q.16. Role of mouth breathing in the aetiology of

malocclusion.
Ans.
[Same as SN Q.1]
Q.17. Aetiology of tongue thrust.

Ans.
[Same as SN Q.4]
Topic 10 Orthodontic diagnosis

Long essays:
1. Classify diagnostic aids and enumerate all the
essential diagnostic aids.
2. Discuss the importance of intra oral X-rays in

orthodontic diagnosis and treatment planning.
3. Enumerate various diagnostic aids used in
orthodontics. Add a note on study models.
4. What do you understand by diagnostic aids?
Classify them. Describe the role of cephalometrics
in orthodontics.
5. Classify diagnostic aids and write in detail about
case history and clinical examination. [Same as LE
Q.1]
6. What are diagnostic aids used in orthodontics?
Describe any one of them in detail. [Same as LE
Q.1]
7. Discuss in brief the various diagnostic aids used in
orthodontic case analysis. [Same as LE Q.1]
8. Describe your procedure for clinical examination
of face and intraoral tissue. [Same as LE Q.1]
9. What are the diagnostic aids used in orthodontics?
Describe anyone of them. [Same as LE Q.2]
10. Describe the role of X-ray in orthodontic
diagnosis and OPG in detail. [Same as LE Q.2]
11. Enumerate essential diagnostic aids. Describe
study models in detail. [Same as LE Q.3]
12. Classify the diagnostic aids in orthodontics. Write
the importance of study models and enumerate
various types of models used in orthodontics.
[Same as LE Q.3]
13. What are the diagnostics aids? Describe in detail
cephalometrics and its uses in orthodontics.
[Same as LE Q.4]
14. Classify diagnostic aids in orthodontics. Describe
the uses of roentgenographic cephalometry in
orthodontics. [Same as LE Q.4]
Short essays:
1. Electromyography.
2. Diagnostic aids in orthodontics. [Ref LE Q.1]
3. What are the study models and uses of the same in
orthodontics. [Ref LE Q.3]
4. Discuss supplementary diagnostic aids used in
orthodontics.
5. Uses of radiographs in orthodontics. [Ref LE Q.2]
6. Intraoral X-rays in orthodontics. [Ref LE Q.2]
7. Hand-wrist radiographs.
8. Trimming of study model.
9. Advanced diagnostic aids.
10. What are orthodontic diagnostic aids? Enumerate
essential diagnostic aids. [Same as SE Q.2]
11. Essential diagnostic aids. [Same as SE Q.2]
12. Study models. [Same as SE Q.3]
13. Role of X-rays in orthodontics. [Same as SE Q.5]
Short notes:
1. Diagnostic aids. [Ref LE Q.1]
2. Study models.
3. Occlusal X-ray. [Ref LE Q.2]
4. CT or CAT.
5. Orthopantomogram (OPG). [Ref LE Q.2]
6. Classify X-rays in orthodontics. [Ref LE Q.2]
7. Head types/facial types.
8. Path of closure. [Ref LE Q.1]
9. Electromyograms. [Ref SE Q.1]
10. Intraoral periapical radiograph uses. [Ref LE Q.2]
11. Hand-wrist X-rays.
12. Cephalometric radiography. [Ref LE Q.2]
13. Facial forms. [Ref LE Q.1]
14. Bite-wing radiographs. [Ref LE Q.2]
15. Kesling set-up.
16. Carpal bones.
17. Gnathostatic models.
18. Incompetent lips.
19. Facial profile.
20. Evaluation of smile.
21. Facial divergence.
22. Lateral cephalogram.
23. Sheldon's body type.
24. Uses of study models. [Same as SN Q.2]
25. Occlusal radiograph. [Same as SN Q.3]
26. OPG. [Same as SN Q.5]
27. Panoramic radiograph. [Same as SN Q.5]
28. Electromyogram as diagnostic aid. [Same as SN
Q.9]
29. Hand-wrist radiographs. [Same as SN Q.11]
Solved answers
Long essays:
Q.1. Classify diagnostic aids and enumerate all the

essential diagnostic aids.
Ans.
(SN Q.1 and SE Q.2)
{(Diagnosis involves development of a comprehensive
database of pertinent information. The data are derived
from both essential and nonessential diagnostic aids.
Orthodontic diagnostic aids are of two types, namely
A. Essential diagnostic aids: They are considered very
important for all the cases. They are simple and do
not require expensive equipment.
B. Nonessential or supplemental diagnostic aids:
They are not essential in all cases and require
specialized equipment.)
Orthodontic Diagnostic Aids

I
Essential diagnostic aids Nonessential diagnostic aids
(supplemental diagnostic aids)
i.
Case history i. Supplemental radiographs
ii.
Clinical examination a. Occlusal films (intraoral)
iii.Study models b. Lateral jaw views
iv. Certain radiographs: c. Coneshifl technique
• IOPA radiograph d. Cephalomteric radiographs
• Bite-wing ii. EMG (electromyographic
• Orthopantomogram examination of muscle activity)
(OPG) iii. Hand-wrist radiographs
v. Facial photographs iv. Endocrine tests
v. Estimation of BMR
vi. Diagnostic set-up
vii. Occlusograms
i. Case history: Includes the information collected

from the patient and parent or guardian to aid
in the overall diagnosis of the case. Case history
includes certain personal details, the chief
complaint, past and present dental as well as
medical history and associated family history.
A. Personal details:
(a) Name
• The patient's name should be
recorded for the purpose of not
only communication and
identification but also addressing a
patient by name which has a
positive beneficial psychological
effect on the patient.
(b) Age
• The chronological age of the patient
helps in diagnosis as well as
treatment planning.
• Certain treatment protocols are
dictated by the age of the patient,
like growth modification
procedures using functional and
orthopaedic appliances are best
carried out during growth period,
whereas surgical respective
procedures are better carried out
after the cessation of growth.
(c) Sex
• It is important in treatment
planning as the timing of growth
events differs in males and
females.
(d) Address and occupation
• These are important for
communication and evaluation of
socioeconomic status of the
patient.
• It helps in selection of appropriate
appliance.
B. Chief complaint:
• It should be recorded in patients' own
words.
• This helps the clinician in identifying the
priorities and desires of the patients,
which helps in setting treatment
objectives that can satisfy the patient as
well as their family in general.
C. Medical history:
• A very few medical conditions
contraindicate the use of orthodontic
appliances.
• Most of the medical conditions require
certain precautionary measures to be
taken prior to or during orthodontic
therapy, e.g. antibiotic coverage may be
required in patients with rheumatic fever
or cardiac anomalies even for molar band
placement and removal.
D. Dental history:
• Past dental history helps in assessing the
patient's and parent's attitude towards
dental health and dental treatment.
• Dental history should include information
on the age of eruption of deciduous and
permanent teeth, history of extraction,
decay restoration and trauma to the
dentition.
E. Prenatal and postnatal history:
• Prenatal history includes the information
on the condition of the mother during
pregnancy and type of delivery.
• The use of certain teratogenic drugs like
thalidomide and some infections like
German measles during pregnancy result
in congenital deformities of the child.
• Forceps delivery predisposes to TMJ
injuries and associated mandibular
growth retardation.
F. Postnatal history:
• Type off eeding
• Presence of habits, e.g. digit/thumb
sucking
• Milestones of normal development are
included in the postnatal history
G. Family history:
• Records the details of malocclusion
existing in other members of the family,
which gives a hint of inherited conditions,
e.g. skeletal class II and class III
malocclusions and congenital conditions
like cleft lip and palate.
ii. Clinical examination
Clinical examination of a patient includes the
following:
A. General examination
B. Extraoral examination
C. Intraoral examination
D. Functional examination
A. General examination:
Comprises general assessment of the patient,
and usually begins as soon as the patient
enters the clinic, and includes:
• Gait
• Posture
• Body built
Gait: It is the way the person walks. Any
abnormality in the gait suggests
neuromuscular disorders, which have a
dental correction.
Posture: It is the way the person stands. Any
abnormality in posture can predispose to
malocclusion due to alteration in
maxillomandibular relationship.
Bodv built: Sheldon has classified the general
,.
Body built: Sheldon has classified the general
body built into three types:
• Ectomorphic - tall and thin physique
• Mesomorphic - average physique
• Endomorphic - short and obese
physique
B. Extraoral examination:
It includes the following:
(a) Type of the head: Mesocephalic, i.e.
average shape head.
Dolicocephalic, i.e. long and narrow head.
Brachycephalic, i.e. broad and round head.

{SN Q.13}
(b) Facial form: Mesoproscopic (average facial form)
Euryproscopic (broad and short facial form)
Leptoproscopic (long and narrow facial form)
(c) Facial profile: Straight, convex and concave
(d) Facial divergence: It is defined as inclination
of lower face relative to forehead.
Anterior divergent: class III cases
Posterior divergent: class II cases
Straight or orthognathic: class I cases
(e) Assessment offacial symmetry and
proportions:
• For assessment of symmetry, the face is
examined in the frontal and lateral views.
• In the frontal plane, intercanthal distance
equals width of the nose, and interpupillary
distance equals width of the mouth.
• Vertical height of the midface should equal
the height of lower face. The height of the
forehead is measured from hairline to
glabella, it measures one-third of the total
facial height.
• In normally balanced face, upper facial
height, middle face and lower facial height
should be equal.
(f) Examination of lips:
• Competent lips: Lips which are in slight
contact when the musculature is relaxed.
• Incompetent lips: Anatomically short lips
which do not contact each other when the
musculature is relaxed.
• Everted lips: They are hypertrophied lips
with redundant tissue exhibiting weak
muscular tonicity.
(g) Examination of nose: Includes examination of
size, contour and nostrils.
(h) Examination of chin: Mentolabialsulcus,
mentalis activity, chin position as well as
prominence should be examined.
(i) Nasolabial angle:
• It is the angle formed by tangent to base of
the nose and a tangent to upper lip.
• Normal angulation is 110°. In cases of
proclination of upper incisors, NLA is acute
or decreased and NLA is obtuse or increased
in retroclination of incisors.
(j) Clinical FMA:
• The inclination of mandibular plane angle to
Frankfort horizontal plane should be noted
clinically by placing measuring scales on
patient's face corresponding to respective
planes.
• In average FMA cases, the angle meets
behind the occiput.
• In a high angle case, the posterior ends of the
angle meet behind the auricle or within the
occiput.
• Steep mandibular plane angle is seen in
patients with long face and open bites, while
flat mandibular plane angle is seen in short
faces and skeletal deep bite cases.
• In a low angle case, the two lines are parallel
and meet very far away.
The examination of profile, divergence,
vertical facial proportions, lip posture,
incisor protrusion and clinical FMA
constitute the facial profile analysis. It is
also called 'poor man's cephalometric
analysis'.
(k) Chin:
• Chin is examined for height, width and
contour.
• Mentolabialsulcus: It is shallow in
bimaxillary protrusion, while deep in class
II, division 1 malocclusion.
• Hyperactive mentalis activity is also seen
along with lip habits like lip sucking and
thrusting.
(1) Chin and soft tissues:
Throat form
Throat length
Chin-throat angle
C. Intraoral examination:
a. Mouth opening
• Intraoral examination starts with
measuring of mouth opening.
• Normal mouth opening is 45-55 mm for
adults and less than 45 mm for children.
b.Tongue
• The size, colour and configuration of
tongue should be assessed.
c. Palate
• Palate is assessed for contour.
• Palatal mucosa is examined for ulcerations,
indentations, clefts or pathologic
swellings.
d. Gingiva
• The gingiva is examined for signs of
inflammation, hypertrophy or recession.
e. Frenal attachments
• Midline diastemas may arise due to thick
maxillary labial frenum.
• High attachment of mandibular labial
frenum leads to gingival recession.
f. Adenoid and tonsils
They are examined for enlargement and
inflammation.
g. Dentition
• Number of deciduous and permanent
teeth.
• Size, shape and form of teeth.
• Presence of supernumerary or missing
tooth, caries, attrition, erosion, fractures,
etc.
h. Intra-arch examination
• Assessment of shape, symmetry and
alignment of arch.
• Location of midlines, rotations of teeth,
crowding, spacing and contact areas are
checked.
i. Interarch examination
• Midline shift between the maxilla and
mandible recorded.
• Sagittal relations: Molar relationship,
canine relationship, overjet and anterior
crossbite are recorded.
• Vertical relation: Deep bite, open bite.
• Transverse relation: Posterior crossbites.
D. Functional examination:
• The dynamic nature of the stomatognathic
system for optimal function is studied in
functional examination. It helps in identifying
the aetiology of malocclusion and therefore
helps in planning the type of orthodontic
treatment to be initiated.
Detailed functional examination includes the
following:
i. Examination of postural rest position and
maximum intercuspation.
ii. Examination of path of closure.
iii. Examination of temporomandibular joint.
iv. Examination of orofacial dysfunctions.
i. Postural rest position:
• The position of mandible where the
synergistic and antagonistic muscular
components are in dynamic equilibrium
with their balance being maintained by
basic muscle tonus is known as postural
rest position.
• In true deep bite cases, increased
freeway space is seen where there
is infra occlusion of posteriors. In
such conditions, bite opening by
molar extrusion can be attempted.
• Pseudo-deep bite with normal
freeway space has normal
eruption of posteriors. Bite
opening by intrusion of incisors is
recommended.
ii. Path of closure:
{SN Q.8}
The path of closure of mandible from the postural
rest position to maximum intercuspation is
evaluated in sagittal, vertical and transverse
planes.
Patient is examined for the presence of functional
shifts in anterior, posterior or lateral directions.
Examples: Upward and forward - normal.
Upward and backward - class II, division 2
Upward and forward - pseudo-class III and anterior
crossbites.
iii. Examination of temporomandibular joint:
• Palpation: The TMJ is palpated for tenderness
and synchrony of action.
• Auscultation: The joint is checked for clicking
or crepitus using a stethoscope.
• Functional analysis ofTMJ: The opening and
closing movements of the mandible as well
as its protrusive, retrusive and lateral
excursions are examined clinically.
iv. Examination of orofacial dysfunctions:
Examination of orofacial dysfunctions
includes analysis of the functions like
swallowing, speech, respiration and
actions of tongue and lips.
a. Examination of swallowing pattern:
• The normal swallowing pattern exhibits
contraction of mandibular elevators, the
tongue is enclosed in the oral cavity, teeth
occlude momentarily, dorsum of the
tongue approaches the palate.
• Infants swallow in a different manner.
Retained infantile swallow leads to
malocclusion.
• Signs of infantile swallow: Jaws are apart,
while in swallowing, tongue is placed
between the teeth, mandible is stabilized
by contraction of lips and tongue, muscles
of facial expression are involved, anterior
mandibular thrust, caving in of cheeks.
b. Examination of tongue: The size, shape,
posture and function of the tongue are
assessed.
Tongue size and shape: Abnormal tongue size
like microglossia, i.e. small tongue and
collapsed arch, macroglossia exhibits
spaced dentition and crenations in lateral
border of tongue.
Tongue position/posture:
~
Tongue position/posture:
• Position of tongue is a very important
factor in the development of
malocclusion.
• Normal resting position of tongue is
retracted, tip just behind the lower
incisors and lateral border resting on the
linguo-occlusal surfaces of lower
posterior teeth.
• In cases of class II malocclusion, tongue tip
is more retruded in rest position, while it
lies far forward in class III cases.

Tongue function (thrust):
The various types of tongue thrust are
present like anterior, lateral, complex,
endogenous, habitual and adaptive tongue
thrust.
Anterior tongue thrust is associated with
anterior open bite. Lateral open bite is
seen in lateral tongue thrust. Complex
tongue thrust patient occludes teeth only
in the molar region.
c. Examination of lips:
• Examination of lips consists of
assessment of configuration, functioning
and presence of any dysfunctions.
• The common lip dysfunctions include lip
sucking, lip thrust and lip insufficiency.
d. Examination of respiration:
• The mode of respiration is examined to
establish any impediment in nasal
breathing.
• Mouth breathing results due to
prolonged difficulty in nasal breathing.
This type of breathing results in disturbed
orofacial musculature, which leads to
long face syndrome or adenoid facies.
e. Examination of speech:
• In structural defects involving the
palate, tongue, lips and dentition, etc. the
speech is affected and the area of
abnormality is identified by observing
pronunciations of different consonants.
Example: Patients having tongue thrust
habit tend to lisp while cleft palate
patients may have a nasal tone.
Q.2. Discuss the importance of intraoral X-ray in

orthodontic diagnosis and treatment planning.
Ans.
Diagnosis involves development of a comprehensive
Orthodontic diagnostic aids are of two types, namely:
A. Essential diagnostic aids: They are considered very
important for all the cases and are simple and do not
require expensive equipment.
B. Nonessential or supplemental diagnostic aids: They
are not essential in all cases and require specialized
equipment.
[SE Q.5]
{Role of radiographs in orthodontic diagnosis:
The uses ofradiographs in orthodontics are as
follows:
• To assess general development of the dentition,
presence, absence and state of eruption of the
teeth.
• To determine the extent of root resorption of
deciduous teeth and the extent of root
formation of permanent teeth.
• To confirm the diagnosis of any supernumerary
teeth, teeth that are morphologically
abnormal, extent of pathological and
traumatic conditions.
• To study the character of alveolar bone.
• They are a valuable aid in craniodentofacial
analysis.}
Various radiographs used in orthodontics are
{SN Q.6}
I. Based on the location of radiographic film
a. Intraoral radiographs:
i. Intraoral periapical (IOPA) radiographs
ii. Bite-wing radiographs
iii. Occlusal radiographs
b. Extraoral radiographs:
i. Panoramic radiographs
ii. TMJ radiographs
iii. Cephalograms
II. Based on the area of interest
iv. Panoramic radiographs
v. Radiographs to assess facial skeleton
a. Lateral cephalometric radiographs
b. Frontal cephalometric radiographs
c. Oblique cephalometric radiographs
III. Based on importance in diagnosis
Essential diagnostic radiographs:
iii. Panoramic radiographs
Supplementary diagnostic radiographs:
i. Occlusal radiographs
ii. Cephalometric radiographs
iii. Hand-wrist radiographs
iv. TMJ radiographs
a. Role of intraoral radio graphs in orthodontics:
[SE Q.6]
• {Intraoral radiographs are called so as they are taken
with the film placed inside the patient's mouth.
• They provide vital information about the teeth and
their supporting structures.
• Commonly, there are three types of intraoral
radiographs used in orthodontics:
i. Intraoral periapical radiographs
i. Intraoral periapical (IOPA)radiographs
Most commonly used radiographs in dentistry to
visualize the teeth and the supporting alveolar
bone.
{SN Q.10}
Uses of IOPA radio graphs are as follows:
• To examine the amount of demineralization in
carious tooth.
• To assess the height of alveolar bone crest around the
tooth.
• To study the extent of root resorption and root
formation in the deciduous and permanent teeth
respectively.
• To visualize the root for any fractures or external
resorption.
• To examine any calcific changes or internal
resorption in the dental pulp.
• To visualize the apical area of teeth to rule out
pathology.
• To view the size, location and angulation of impacted
teeth.
• To study quality of alveolar bone and periodontal
ligament space.
• To confirm the congenital absence of teeth or
presence of supernumerary tooth.}
Advantages of IOPA are as follows:
• The area of interest can be visualized in high detail.
• Minimal radiation exposure to patient.
• Easy to store and transport.
Disadvantages of IOPA are as follows:
• While placing the film, pain and gagging may occur.
• Many radiographs are required for full mouth
survey.
• Exposure to radiation increases when used for full
mouth examination.
There are two methods of obtaining IOPA radio graphs:
a. Paralleling technique
b. Bisecting angle technique
Paralleling technique
• In this technique, the X-ray film is placed
parallel to the long axis of the teeth and the
central ray of the collimated X-ray beam is
passed perpendicular to long axis of the tooth
and the film.
• In this technique there is reduced geometric
distortion.
• Morphological limitations imposed by oral
cavity in the correct placement of the film.
Bisecting angle technique
• This technique uses Cieszynski's rule of
isometry, which is a geometric theorem.
• According to the rule of isometry, two triangles
are equal when they share a complete side and
two equal angles.
• In this technique, the central ray is directed at
right angles to a plane bisecting the angle
between the long axis of the teeth and the film.
• This technique is convenient to the operator
and the film is placed close to lingual surfaces
of the tooth.
• The disadvantage of this technique is that
faulty X-ray beam angulation results in fore
shortening or elongation of the image.
(SN Q.14 & SE Q.6)
{(ii. Bite-wing radiographs
• Bite-wing radiographs give information about the
tooth and the supporting alveolar bone up to
half the length of the root.
Uses of bite-wing radio graphs are as follows:
Bite-wing radio graphs are used for detecting
i. Interproximal caries at an early stage and
secondary caries under restorations.
ii. Bone loss at the alveolar crest.
iii. Calculus deposits and overhangs in the
restoration at the interproximal areas.
iv. Occlusal pattern.)
Advantages of bite-wing radiographs:
• No geometric distortions and
magnifications
• Convenient to the operator and
comfortable for the patient
• When compared to periapical films, it is
more easier to use in children.
iii. Occlusal radiographs:
(SN Q.3 & SE Q.6)
• {(When there is a need to visualize a large
segment of the dental arch with reasonable
extent of adjacent structures, occlusal
radiograph is indicated.
The radiographic film 3 x

2tinches in
size is placed between the occlusal surfaces of
the teeth in the plane of occlusion.)
Classification of occlusal radio graphs based on
the projection of the X-ray is as follows:
i. Maxillary occlusal radiographs
• Topographical maxillary occlusal
projection
• Cross-sectional maxillary occlusal
projection
ii. Mandibular occlusal radiographs
_ .,, 1..: __ 1 .J:1.. .. 1--- ---1----1
Q.4. What do you understand by diagnostic aids?
Classify them. Describe the role of cephalometrics in
orthodontics.
Ans.
Diagnosis involves development of a comprehensive
Orthodontic diagnostic aids are of two types, namely:
a. Essential diagnostic aids: They are considered very
important for all the cases. They are simple and do
not require expensive equipment.
b. Nonessential or supplemental diagnostic aids:

They are not essential in all cases and require
specialized equipment.

I
Essential diagnostic aids Nonessential diagnostic aids
(supplemental diagnostic aids)
i.
Case history i. Supplemental radiographs
ii.
Clinical examination a. Occlusal films (intraoral)
iii.
Study models b. Lateral jaw views
iv.Certain radiographs: c. Coneshift technique
IOPA radiograph d. Cephalomteric radiographs
Bite-wing ii. EMG (electromyographic
(OPG) examination of muscle activity)
v. Facial photographs iii. Hand-wrist radiographs
iv. Endocrine tests
v. Estimation of BMR
vii. Occlusograms
Cephalometrics
• In 1931, Holly Broadbent of the USA and Herbert
Hofrath of Germany introduced the
roentgenographic cephalometric technique to
orthodontics.
• 'Cephalo' means head and 'metric' means
measurement. The measurement of the head
from the shadows of the bony and soft tissue
landmarks on the radiographic image is known
as roentgenographic cephalometry.
• Cephalometric radiographs have become an
integral part of orthodontic practice and enable
the clinicians to quantify facial and dental
relationships.
• They provide information about the spatial
relationship of superficial and deep structures.
Various types of cephalograms are as follows:
i. Lateral cephalogram
ii. Frontal or anteroposterior cephalogram
iii. Oblique cephalogram
Technique of cephalometric radiography:
• An apparatus that consists of an X-ray
source and a head-holding device called
cephalostatis is used to take a
cephalometric radiograph.
• The cephalostat prevents the movement
of the head in the horizontal plane.
Vertical stabilization of the head is
brought about by an orbital pointer that
contacts the lower border of the left orbit.
The upper part of the face is supported by
the forehead clamp positioned above the
region of the nasal bridge.
• The equipment helps in standardizing
the radiographs by use of constant head
position and a fixed source film distance
(5 feet) so that serial radiographs can be
compared.
Uses of cephalograms are as follows:
i. Cephalometrics is one of the valuable
tools in treatment planning and follow-up
of patients undergoing orthodontic
treatment.
ii. Cephalogram is used to elucidate the
skeletal, dental and soft tissue
relationships of the craniofacial region
and helps in identification and
classification of skeletal and dental
anomalies.
iii. They are useful in estimating the facial
type.
iv. They help in treatment planning and
evaluation of the treatment results for an
individual.
v. Serial cephalograms help in assessment of
growth of facial skeleton and are also
used in growth prediction.
vi. They help in predicting the growth-
related changes and changes associated
with orthognathic surgical treatment and
also help to distinguish changes produced
by natural growth and orthodontic
treatment.
vii. Cephalograms also help to carry out
functional analysis.
viii. Cephalograms are relatively
nondestructive and noninvasive,
producing a high yield of information at
relatively economical cost.
ix. Cephalograms are relatively permanent
records and are easy to store, transport
and reproduce.
x. Cephalometrics is a valuable aid in
research work involving the cranio-dento-
facial region.
Limitations/drawbacks of cephalogram:
i. It should be used only when it is diagnostically
and therapeutically desirable, as patient is
exposed to ionizing radiation, which is harmful.
ii. Due to lack of anatomical references which
remain constant with time, it is a serious
disadvantage when clinicians wish to compare
cephalograms taken at different times.
iii. Some reference landmarks and planes do not
agree with the anatomical landmarks.
iv. The processes of image acquisition as well as
measurement procedures are not well
standardized.
v. It is difficult to locate landmarks and surfaces
on the X-ray image as the image lacks hard
edges and well-defined outlines.
vi. The radiographic image is a two-dimensional
picture of three-dimensional structures being
imaged.
vii. Anatomical structures lying at different planes
within the head undergo projective
displacement.
viii. There could be a mandibular shift from
centric relation as the patient is made to bite in
maximum intercuspation while taking the
cephalogram.
ix. A cephalometric analysis makes use of means
obtained from different population samples.
They have only limited relevance when applied
to individual patient.
x. The composite of lines and angles used in the
cephalometric analysis yields limited
information about the patient's dento-skeletal
patterns.
xi. An orthodontic diagnosis cannot be made
solely on the basis of cephalometric analysis.
Q.5. Classify diagnostic aids and write in detail about

case history and clinical examination.
Ans.
[Same as LE Q.1]
Q.6. What are diagnostic aids used in orthodontics?

Describe any one of them in detail.
Ans.
[Same as LE Q.1]
Q.7. Discuss in brief the various diagnostic aids used

in orthodontic case analysis.
Ans.
[Same as LE Q.1]
Q.8. Describe your procedure for clinical

examination of face and intra oral tissue.
Ans.
[Same as LE Q.1]
.
Q.9. What are the diagnostic aids used m
orthodontics? Describe anyone of them.
Ans.
[Same as LE Q.2]
Q.10. Describe the role of X-ray in orthodontic

diagnosis and OPG in detail.
Ans.
[Same as LE Q.2]
Q.11. Enumerate essential diagnostic aids. Describe

study models in detail.
Ans.
[Same as LE Q.3]
Q.12. Classify the diagnostic aids in orthodontics.

Write the importance of study models and
enumerate various types of models used in
orthodontics.
Ans.
[Same as LE Q.3]
Q.13. What are the diagnostics aids? Describe in

detail cephalometrics and its uses in orthodontics.
Ans.
[Same as LE Q.4]
Q.14. Classify diagnostic aids in orthodontics.

Describe the uses of roentgenographic cephalometry
in orthodontics.
Ans.
[Same as LE Q.4]
Short essays:
Q.1. Electromyography.
Ans.
{SN Q.9}
• The procedure that is used for recording the electrical
activity of the muscles when they are excited is
known as electromyography (EMG). The instrument
used is called electromyograph and the output is
called electromyogram.
• The electromyograph is a machine which is used to
receive, amplify and record the action potential
during muscle activity. The record obtained by such
a procedure is known as electromyogram.
• The surface membrane of the muscle cells is
positively charged on the external surface and
negatively charged on the internal surface. The
action potential reverses the charge on the muscle
membrane. A series of changes that occur will bring
about muscle contraction.
• Recording of the electrical charges from the muscle
are accomplished by means of surface electrodes or
• Recording of the electrical charges from the muscle
are accomplished by means of surface electrodes or
needle electrodes.
a. Surface electrodes: These electrodes are used
when the muscle is superficially placed just
below the skin.
b. Needle electrodes: They are used when the
muscle is placed deep inside, e.g. pterygoid
muscles.
• The action potential is picked up by surface or needle
electrodes and recorded either with the help of a
moving pen in the form of a graph or recorded in the

form of sound with the help of a magnetic tape
recorder.
• Permanent paper record is obtained with a pen
writing device. Electromyogram can be displayed on
an oscilloscope.
{SN Q.9}
Uses ofEMG
• The role of musculature in craniofacial growth can
be studied with the help of EMG.
• In mouth breathers, EMG is used to study the
activity of mandibular elevators and depressors.
• EMG is used to assess the aberrant muscular
activity associated with various habits.
• Abnormal muscle activity associated with certain
forms of malocclusion can be detected with the
help of EMG.
Examples: Abnormal buccinator activity in class II,
division 1.
The hypo-functional upper lip in severe class II,
division 1 malocclusion.
• Following orthodontic therapy, EMG can be carried
out to see whether muscle balance is achieved.
Disadvantages of EMG
• Unknown levels of muscular fatigue or pain may
compromise EMG readings.
• Muscle activity varies at different periods even
during the day time.
• Measures of EMG activity during clenching,
swallowing, etc. vary considerably between
subjects.
Q.2. Diagnostic aids in orthodontics.

Ans.
[Ref LE Q.1]
Q.3. What are the study models and uses of the same
in orthodontics.
Ans.
[Ref LE Q.3]
Q.4. Discuss supplementary diagnostic aids used in

orthodontics.
Ans.
Supplemental diagnostic aids are certain aids which are
not essential in all cases. They may require specialized
equipment that an average dentist may not possess.
The supplemental diagnostic aids are as follows:
i. Specialized radiographs
Examples:
a. Cephalometric radiographs
b. Occlusal intraoral films
c. Selected lateral jaw views
d. Cone shift technique
ii. Electromyographic examination of muscle activity
iii. Hand-wrist radiographs to assess bone age or
maturation age
iv. Endocrine tests
v. Estimation of basal metabolic rate
vii. Occlusograms
Q.5. Uses of radiographs in orthodontics.

Ans.
[Ref LE Q.2]
Q.6. Intraoral X-rays in orthodontics.

Ans.
[Ref LE Q.2]
Q.7. Hand-wrist radiographs.

Ans.
i. Among the various skeletal maturity indicators, hand-
wrist radiographs are commonly used in
orthodontics.
ii. The numerous small bones in the hand-wrist region
show a predictable and scheduled pattern of
appearance, ossification and union from birth to
maturity.
Thus, by comparing patients hand-wrist radiograph
with standard radiographs that represent different
skeletal ages, the skeletal maturation status of the
individual can be determined.
iii. Among various methods described to assess skeletal
maturity using hand-wrist radiographs, the most
commonly used ones are as follows:
a. Atlas method by Greulich and Pyle
b. Bjork, Grave and Brown method
c. Fishman's skeletal maturity indicators
d. Hagg and Taranger method
a. Atlas method by Greulich and Pyle
• Greulich and Pyle published an atlas which
contains pictures of the hand-wrist for
different chronological ages for both the sexes.
• The patients radiographs are matched with one
of the photographs in the atlas which is
representative of a particular skeletal age.
b. Bjork, Grave and Brown method
• According to Bjork, the skeletal development in
the hand-wrist area is divided into eight
stages, each of them represents a particular
level of skeletal maturity.
c. Fishman's skeletal maturity indicators
• Leonard S. Fishman proposed a system for
evaluation of skeletal maturation by making
use of anatomical sites located on the thumb,
third finger, fifth finger and radius.
• Covering entire period of adolescent
development, 11 descrete skeletal maturity
indicators have been described.
d. Hagg and Taranger method
• Hagg and Taranger noted that skeletal
development in hand and wrist can be
analysed from assessment of ossification of
ulnar sesamoid of metacrpo-phalangeal joint
of the first finger (S) and certain specified
stages of three epiphyseal bones: the middle
and distal phalanges of the third finger (MP3
and DP3) and the distal epiphysis of the radius
(R) by taking annual radiographs between 6
and 18 years of age.
Indications of hand-wrist radio graphs are as
follows:
• It is indicated when there is a major
discrepancy between the dental age and the
chronological age of the patient.
• For determination of skeletal maturity status to
assess the potential for growth prior to
treating the patient with skeletal class II or
• To predict the pubertal growth spurt.
• To assess the skeletal age in a patient whose
growth is affected by infections or neoplasms
or traumatic conditions.
• To evaluate growth status prior to orthognathic
surgery in young adults so that the chances of
relapse linked to postsurgical growth can be
minimized.
• Serial assessment of skeletal age is used for
studying growth of an individual.
• It is a valuable aid in research aimed at
studying the effect of heredity, environment,
nutrition, etc. on the skeletal maturation
pattern.
Q.8. Trimming of study model.

Ans.
Basing and trimming of the cast
• The rubber base formers are readily available to
pour the art portion or base. They serve to confine
the plaster and are fabricated to shape the base in
artistically pleasing contours.
• The various types of base formers are used, e.g.
Broussard case former, the Columbia anterior
segment single unit study cast former.
• The trimming of the orthodontic model is carried
out on an electric plaster trimming machine
having a medium-grit carborundum wheel.
Guidelines for trimming of orthodontic casts are as
follows:
Step 1: Orientation of the tray is done in such a way
that the anatomic portion is in the centre of the
rubber mould with the occlusal plane parallel with
the cast base of the base former.
The lower model is inverted over a 'T'-shaped
piece of rubber, and a marking is circumscribed
all around the base of the model using a marker
mounted on a vertical stand. Once the marking is
made, the base of the cast is trimmed up to the
marking.
Step 2: The back of the mandibular model is
trimmed perpendicular to the midline leaving 5
mm of the plaster base distal to the most posterior
teeth.
• The back of the model should be at 90° to the base
of the model.
Step 3: Occlude both upper and lower models
together and trim the maxillary back surface so
that it is in flush with the mandibular back.
Step 4: The upper and lower models are occluded
together and placed on model trimmer with their
backs.
• The base of the maxillary cast is trimmed so that
it is parallel to the base of the lower model.
• At the end of this step, the backs of both upper
and lower casts are at right angles to the bases.
• The bases of the maxillary and the mandibular
casts are parallel to each other and to the
occlusal plane.
Step 5: The buccal cuts are made on the mandibular
cast 5-6 mm away from the buccal surface of the
posterior teeth and at an angulation of 60° to the
back of the model.
Step 6: The anterior portion of the lower arch is
trimmed into a curve that follows the curvature of
the lower anterior teeth and is 5-6 mm away from
the labial surface of the anterior teeth.
Step 7: The posterior cuts of the mandibular model
measuring 13-15 mm are trimmed at an angle of
approximately 115° to the back of the model.
Step 8: The buccal cuts are made at an angle of 65° to
the back of the maxillary cast at a distance of 5 mm
away from the buccal surface of the most posterior
teeth.
Step 9: On the maxillary cast, the anterior cuts are
made at an angle of 30° to the back of the cast. The
cuts on either side should be of equal length and
should be 5-6 mm away from the labial surface of
the anterior teeth. . ., . , , ,, . ' .,
The anterior cuts on either side should meet at the
rnidline of the cast and should extend till the
midline of the canine.
Step 10: The posterior cuts of the maxillary cast are
made in such a way that they are in flush with the
posterior cuts of the mandibular cast.
This is done by occluding the models and trimming
the maxillary posterior cuts till they are in line
with the mandibular posterior cuts.
After trimming, the study casts should be
symmetrical. Upper study cast should have
seven sides and lower study cast should have six

sides when viewed from occlusal plane.
Q.9. Advanced diagnostic aids.

Ans.
The advanced diagnostic aids or the newer techniques
used in orthodontic diagnosis are as follows:
i. Xeroradiography
ii. MRI
iii. Computed tomography (CT) scan
iv. Computerized cephalornetric systems
v. Photocephalornetry
vi. Cinefluororadiography
vii. Laser holography
i. Xeroradiography:
• Xeroradiography was invented by Chester Carlson
for copying purposes.
• Xeroradiography is a radiographic method which
works in a manner similar to xerox machines. No
radiographic film is employed, rather a printout is
taken on paper.
Method:
•Alight-tight cassette with a photoreceptor is
placed intraorally and X-ray exposed like film.
• On exposure to X-rays, selective discharge occurs
from the areas of photoreceptors proportional to
the density of the rays.
• The latent image is formed together from the
areas with discharge and without discharge and
is converted to visible image by exposing it to
charged powder particles in toner.
• The toner image is then transferred from the
photoreceptor and fixed to a white plastic
substrate for viewing.
• The photoreceptor is available for reuse after
cleaning.
Uses:
• Xerox radiography is a valuable alternative to
conventional radiography for detecting all
pa tho lo gies.
• It is also useful in interpreting periapical
structures.
Advantages:
• Wide exposure latitude, high edge enhancement
and good detail.
• Choice of positive and negative displays.
• Compared with conventional radiographs, it
requires only about one-third of the radiation
dose.
ii. Magnetic resonance imaging (MRI) in
orthodontics
• Magnetic resonance imaging is a nonradiographic
method used to visualize the craniofacial
structures.
• The major constituent of the body is water which
has two hydrogen atoms, each one has a single
proton.
• The hydrogen protons behave like small magnets
when they are placed in magnetic field, and they
will move around the magnetic field inducing a
minute current which is amplified and displayed
on an oscilloscope.
Uses of MRI:
• Useful in studying internal derangements of the
articular disc of TMJ.
• Used to evaluate the position of the articular disc
before and after treatment with functional and
orthopaedic appliances.
• Examination of tongue movements during
deglutition.
Advantages of MRI:
• No radiation exposure.
• Compared with CT scanning, greater tissue
characterization and a better spatial resolution.
• Any choice of sectional view can be created in
any desired direction in the human body.
Disadvantages:
• Not useful to visualize bony lesions.
• Contraindicated in patients with cardiac
pacemakers.
• Compared with CT scanning, it is more time-
consurning and expensive.
iii. CT in orthodontics
• CT is the radiographic examination of section or
slice of body structures in the cross-sectional form.
• Digital data are produced by using scanners that
measure the extent of X-ray transmission
through the object.
Uses of CT:
• Useful to examine TMJ.
• Evaluation of amount of cortical bone for
orthodontic implants.
• Diagnosis and treatment planning in maxillary
canine impactions.
• To study the effects of rapid maxillary expansion
and distraction osteogenesis devices.
Advantages:
• Large amount of useful information secured in
very short period with high geometric precision.
• Very well discriminates between objects with
minor difference in density.
• Images can be manipulated by highlighting or
accentuating areas of interest.
Disadvantages:
• Radiation exposure.
• Procedure is very expensive.
Q.10. What are orthodontic diagnostic aids?

Enumerate essential diagnostic aids.
Ans.
[Sarne as SE Q.1]
Q.11. Essential diagnostic aids.

Ans.
[Sarne as SE Q.1]
Q.12. Study models.

Ans.
[Sarne as SE Q.3]
Q.13. Role of X-rays in orthodontics.

Ans.
[Sarne as SE Q.5]
Short notes:
Q.1. Diagnostic aids.

Ans.
[Ref LE Q.1]
Q.2. Study models.

Ans.
• Study models are accurate reproduction of teeth and
their surrounding soft tissues that provide a
reasonable 'facsimile' of the occlusion of the patient
(Graber).
• Parts of study model:
i. Anatomic portion
ii. Artistic portion
• Uses of study casts are as follows:
i. They are one of the essential
diagnostic aids in orthodontic
diagnosis and treatment planning.
ii. They enable the study of the
occlusion from all aspects and help
in assessing the nature and
severity of malocclusion.
iii. They are valuable aids in patient
education, motivation and
assessment of treatment progress.
iv. They help in communication
between orthodontists.
Q.3. Occlusal X-ray.

Ans.
[Ref LE Q.2]
Q.4. CT or CAT.
Ans.
• Computed axial tomography (CAT) or CT is the
radiographic examination of section or slice of body
structures in the cross-sectional form.
• Digital data are produced by using scanners that
measure the extent of X-ray transmission through
the object.
Uses of CT:
• Useful to examine TMJ.
• Evaluation of amount of cortical bone for
orthodontic implants.
• Diagnosis and treatment planning in maxillary
canine impactions.
• To study the effects of rapid maxillary expansion
and distraction osteogenesis devices.
Q.5. Orthopantomogram (OPG).

Ans.
[Ref LE Q.2]
Q.6. Classify X-rays in orthodontics.

Ans.
[Ref LE Q.2]
Q. 7. Head types/facial types.

Ans.
Head type is determined based on the anthropometric
determination of maximum skull width and maximum
skull length.
Head types are classified as follows:
i. Mesocephalic: average shape head
ii. Brachycephalic: broad and round head
iii. Dolichocephalic: long and narrow head
Q.8. Path of closure.

Ans.
[Ref LE Q.1]
Q.9. Electromyograms.
Ans.
[Ref SE Q.1]
Q.10. Intraoral periapical radiograph- uses.

Ans.
[Ref LE Q.2]
Q.11. Hand-wrist X-rays.

I\ ...,. c.-
Q.11. Hand-wrist X-rays.
Ans.
i. The hand-wrist radiographs are commonly used
among the various skeletal maturity indicators in
orthodontics.
ii. The numerous small bones in the hand-wrist region
maturity.
Thus, by comparing patients hand-wrist radiograph
with standard radiographs that represent different
skeletal ages, the skeletal maturation status of an

individual can be determined.
iii. They are indicated when there is a major
discrepancy between the dental age and the
chronological age of the patient for determination of
skeletal maturity status.
iv. Serial assessment of skeletal age is used in studying
growth of an individual.
v. It is a valuable aid in research aimed at studying the
effect of heredity, environment, nutrition, etc. on the
skeletal maturation pattern.
Q.12. Cephalometric radiolography.

Ans.
[Ref LE Q.2]
Q.13. Facial forms.

Ans.
[Ref LE Q.1]
Q.14. Bite-wing radiographs.

Ans.
[Ref LE Q.2]
Q.15. Kesling set-up.

Ans.
• The diagnostic set-up was first proposed by H.D.
Kesling. The Kesling diagnostic set-up is made from
an extra set of trimmed and polished study models.
• The cast is cut using a fretsaw blade to separate
individual teeth. A horizontal cut is made 3 mm
apical to the gingival margin. Vertical cuts are made
to separate individual teeth.
• The individual teeth and their associated alveolar
processes are sectioned off and replaced on the
model base in the desired positions using red wax.
Uses of diagnostic set-up:
• It helps in simulating various tooth movements that
are planned for patients.
• The patients can be motivated by simulating
various corrective procedures on the cast.
• Tooth size-arch length discrepancies can be
visualized by means of a set-up.
Q.16. Carpal bones.

Ans.
• Carpal bones were first named by Lyser in 1683.
• Each hand-wrist area has 8 carpals, 5 metacarpals
and 14 phalanges.
• The carpal bones are arranged in two rows.
a. Distal row: trapezium, trapezoid, capitate,
hamate
b. Proximal row: scaphoid, lunate, triquetral,
pisiform
• These small irregular bones lie in-between the long
bones of forearm and the metacarpals.
Q.17. Gnathostatic models.

Ans.
Gnathostatic models are orthodontic study models
where the base of the maxillary cast is trimmed to
correspond to the Frankfort horizontal plane.
Q.18. Incompetent lips.

Ans.
• Competency of lips can be defined as the ability to
approximate the lips without any strain.
• Lips which are in slight contact when the
musculature is relaxed and 2 mm of incisal edges of
upper incisors showing at rest is considered normal
competent lips.
• Anatomically, lips which do not contact each other
when the musculature is relaxed are known as
incompetent lips.
• They are morphologically short lips which do not
form a lip seal in a relaxed state. The lip seal can
only be achieved by active contraction of the perioral
and mentalis muscles.
• Potentially incompetent lips are the normal lips that
fail to form a lip seal due to proclined upper incisors.
Q.19. Facial profile.

Ans.
• The facial profile is examined by viewing the patient
from the side.
• The facial profile is assessed by joining the two
reference lines:
i. A line joining the forehead and the soft tissue
point A
ii. A line joining point A and the soft tissue
.
po gonion
• Three types of profiles exist based on the relationship
between these two lines:
a. Straight profile: The lines form a straight line.
b. Convex profile: The lines form an angle, which
is pointed away from the face, e.g. class II
skeletal pattern.
c. Concave profile: The lines form an angle which
is pointed towards the face, e.g. class III skeletal
pattern.
• The facial profile helps in diagnosing gross deviations
in the maxillomandibular relationship.
Q.20. Evaluation of smile.

Ans.
• One of the important aspects of orthodontic treatment
is creation of pleasing smile.
Evaluation of smile:
Smile is evaluated by its vertical, transverse and
oblique characteristics.
Vertical characteristics:
• Incisor and gingival displays are two main features
of vertical characteristics of smile.
• Inadequate incisor display can be due to vertical
maxillary deficiency, restricted lip mobility and
short clinical crown.
• Gummy smile will be associated with vertical
maxillary excess.
Transverse characteristics:
There are three important features: buccal corridor
width, arch form and transverse cant.
Buccal corridor width:
• Buccal corridor is represented by a ratio of
intercommissure width divided by the distance
from one maxillary first premolar to opposite
side first premolar.
• Excessively wide buccal corridor is referred to as
'negative space'.
Arch form:
• Arch form plays an important role in the form of
smile.
•Inpatients with collapsed arch or narrow
maxilla, smile also is narrow.
Transverse cant:
• Asymmetric vertical growth of the arches or
differential eruption of teeth can cause
appearance of transverse cant or tilt of the smile
line.
• Ideally, there should not be any transverse cant.
Oblique characteristics:
• Maxillary occlusal plane from premolar to
premolar should be in consonant with the
curvature of the lower lip on smile.
• Downward tilt of the posterior maxilla or upward
tilt of anterior maxilla can result in deviation.
Q.21. Facial divergence.

Ans.
Facial divergence is defined as an inclination of lower
face relative to forehead. It is influenced to a large
extent by the patient's ethnic and racial background.
Facial divergence can be off allowing three types:
i. Anterior divergent: A line drawn between the forehead
and chin is inclined anteriorly towards the chin, e.g.
class III cases.
ii. Posterior divergent: A line drawn between the
forehead and chin slants posteriorly towards chin,
e.g. class II cases.
iii. Straight or orthognathic: The line between the
forehead and chin is straight or perpendicular to the
floor, e.g. class I cases.
Q.22. Lateral cephalogram.

Ans.
• The measurement of the head from the shadows of
the bony and soft tissue landmarks on the
radiographic image is known as roentgenographic
cephalometry.
• Cephalometric radiographs are of two types:
a. Lateral cephalogram
b. Posteroanterior cephalogram
• Lateral cephalogram: This provides a lateral
view of the skull. It is taken with the head in a
standardized reproducible position at a
specified distance from the source of the X-ray.
Q.23. Sheldon's body type.

Ans.
Sheldon's classification of body type or build-up is as
follows:
i. Ectomorphic: Tall and thin body tissue is made of
primarily skin and neural elements.
ii. Mesomorphic: Average body tissue is made of
primarily mesodermal tissue: muscular and robust
individuals.
iii. Endomorphic: Short and obese body tissue is made of
primarily fat tissues.
Q.24. Uses of study models.

Ans.
[Same as SN Q.2]
Q.25. Occlusal radiograph.

Ans.
[Same as SN Q.3]
Q.26. OPG.
Ans.
[Same as SN Q.5]
Q.27. Panoramic radiograph.

Ans.
[Same as SN Q.5]
Q.28. Electromyogram as diagnostic aid.

Ans.
[Same as SN Q.9]
Q.29. Hand-wrist radiographs.

Ans.
[Same as SN Q.11]
Topic 11 Cephalometrics

Long essays:
1. Discuss cephalometrics as a diagnostic aid.
2. Write in detail about any one cephalometric
analysis of your choice used in orthodontics.

3. Describe the role of cephalometric radiography in
orthodontics. Give various planes and angles used
in cephalometric analysis.
4. Classify diagnostic aids. Discuss the uses of
cephalometrics. [Same as LE Q.1]
5. Classify the diagnostic aids. Define caphalometric
landmarks and planes. [Same as LE Q.1]
6. What is standardization in cephalometrics?
Discuss Steiner's cephalometric analysis. [Same as
LE Q.2]
7. Enumerate cephalometric analysis and elaborate
on Steiner's analysis. [Same as LE Q.2]
8. Discuss in detail the clinical implications of
growth and development enumerating the use of
cephalometrics to study the same. [Same as LE
Q.3]
Short essays:
1. Uses of cephalometrics. [Ref LE Q.1]
2. Tweed's triangle.
3. Down's analysis.
4. Enumerate five horizontal planes used in
cephalometrics and give their uses and
significance. [Ref LE Q.1]
5. What is conventional cephalometrics? Give its
drawbacks.
6. Visual treatment objective (VTO).
7. Steiner's skeletal analysis. [Ref LE Q.2]
8. Write the skeletal measurements of Down's
analysis. [Same as SE Q.3]
Short notes:
1. y-axis.
2. Key ridge.
3. Limitations of cephalogram.
4. Enumerate horizontal planes in cephalometry.
5. Interincisal angle. [Ref LE Q.2]
6. S-N plane.
7. ANB angle. [Ref LE Q.2]
8. FMA angle.
9. SNA angle. [Ref LE Q.2]
10. Two uses of cephalometrics in orthodontia.
11. Tweed's diagnostic triangle.
12. Occlusal plane angle.
13. Steiner's soft tissue analyses.
14. Registration point.
15. Facial divergence.
16. Angle SNB. [Ref LE Q.2]
17. Mandibular plane angle.
18. Cephalostat.
19. The Wits appraisal.
20. Frankfort horizontal plane.
21. Define cephalometric points.
22. 'E' plane or aesthetic plane.
23. Computerized cephalometric system.
24. Nasolabial angle.
25. Advantages of computerized cephalometric
system.
26. Significance of ANB angle. [Same as SN Q.7]
27. Uses of cephalometrics. [Same as SN Q.10]
28. Tweed's triangle. [Same as SN Q.11]
29. Occlusal plane. [Same as SN Q.12]
30. Mandibular plane. [Same as SN Q.17]
31. Name some data management programmes in
computerized cephalometric system. [Same as SN
Q.23]
Solved answers
Long essays:
Q.1. Discuss cephalometrics as a diagnostic aid.

Ans.
• Diagnostic aids are means by which a comprehensive
database of pertinent information is derived.
The orthodontic diagnostic aids are of two types

I
I. Essential diagnostic aids 11. Nonessential diagnostic aids
Or Supplemental diagnostic aids.
For example For example
i. Case history i. Supplemental radiographs
ii. Clinical examination a. Occlusal films
iii. Study models b. Lateral jaw views
iv. Certain radiographs: c. Cephalomteric radiographs
a. IOPA ii. EMG
b. Bite-wing iii. Hand-wrist radiographs
c. OPG iv. Endocrine tests
v. Facial photographs v. Estimation of BMR
vii. Occlusograms
• In 1931, Holly Broad Bent (USA) and Herbert Ho Frath

(Germany) simultaneously presented a standardized
cephalometric technique.
• Cephalometrics is used to describe the analysis and
measurements made on the cephalometric
radio graphs.
Cephalograms are of two types

I
(i) Lateral cephalogram (ii) Frontal cephalogram
(Lateral view of skull) (AP view of skull)
[SE Q.1]
{Uses of cephalometrics:
Cephalometrics is a valuable tool in treatment
planning and follow-up of orthodontic patients.
Cephalometrics helps in:
i. Orthodontic diagnosis (by studying
skeletal + dental and supporting
structures)
ii. Classification of facial type (skeletal +
dental)
iii. Treatment planning
iv. Evaluation of treatment results
v. Prediction of growth-related changes and
changes associated with surgical
treatment
vi. Research works involving
craniodentofacial region.}
Technical aspects of cephalometrics Fig 11.1 :
The standard apparatus used to take cephalograms
consists of the following:
i. An X-ray source
ii. Acephalostat (head-holding device)
iii. A cassette holder
• Cephalostat stabilizes the head of the patient
with the help of ear rods, orbital pointer and
forehead clamp.
• The distance between the X-ray source and the
midsagittal plane of the patient is fixed at 5
feet.
Cephalometric landmarks:
• Certain landmarks or points on the skull are used
by cephalometrics for quantitative analysis and
measurements.
• The landmarks used in cephalometrics should be
easily visible on radiographs, uniform in outline
and easily reproducible, permitting valid
quantitative measurements of lines and angles
projected from them.
• Cephalomteric landmarks are of the following
types:
...
'
J=----:x-rayfilm cassette
--Film
plane
X-ray source
SFeeL
FIG. 11.1 A standard cephalometric

arrangement.
A11ato111ic landmarks - Represent actual

I. anatomic tructure of kull
Derived landmarks -They are obtained

econdarily from anatomic tructure
I lard tis ue landmarks
II.
Soft tis uc landmark
Some of the important points and landmarks described in lateral cephalometric

projection are as follows.
Unilateral landmarks Bilateral landmarks include

i. Sella i. Orbital
ii. Nasion ii. Porion
iii. Anterior nasal spine ill. Bolton point
(ANS) iv. Gonion
iv. Posterior nasal spine v. Pogonion
(PNS) vi. Articulare
v. Point A vii. Condylion
vi. Point B viii. The key ridge
vii. Basion ix. Broadbent registration
viii. Gnathion point
ix. Menton x. Glabella
x. Prosthion xi. Chelion
xi. Infradentale
xii. Ptm point
xiii. Sub-nasal
xiv. Glabella
The definitions of each of the above points or

landmarks used in cephalometric are as follows:
Unilateral landmarks
i. Sella: The point representing the midpoint of the
pituitary fossa or sella turcica.
ii. Nasion: The intersection of internasal suture
with the nasofrontal suture in the midsagittal
plane.
iii. Anterior Nasal Spine (ANS): It is the tip of the
anterior nasal spine seen on the X-ray film from
normal ateralis.
p
~
0
--- - Bo
Ba
p g
G
---i ........
Me
FIG. 11.2Lateral cepha lometric

landmarks.
iv. Posterior Nasal Spine (PNS): It is the tip of the

posterior spine of the palatine bone in the hard
palate.
v. Point A (sub-spinale): It is the deepest point in
the midline between the anterior nasal spine
and (alveolar crest between two central
incisors) prosthion.
vi. Point B (supramentale): It is the deepest point
in the midline between the alveolar crest of the
mandible and the mental process.
.
vi. Point B (supramentale): It is the deepest point
in the midline between the alveolar crest of the
mandible and the mental process.
vii. Basion: The lower most point on the anterior
margin of the foramen magnum in the
midsagittal plane.
viii. Gnathion: The most anteroinferior point in
the contour of the chin.
ix. Menton: The lower most point on the
mandibular symphysis.
x. Prosthion (supra-dentale): The lowest and the
most anterior point on the alveolar bone in the

midline between the upper central incisors.
xi. Infradentale: The highest and the most anterior
point on the alveolar process, in the median
plane between mandibular central incisors.
xii. Ptm point: It is the intersection of the inferior
border of the foramen rotund um with the
posterior wall of the pterygomaxillary fissure.
xiii. Subnasale: The point where the lowest border
of the nose meets the outer contour of the
upper lip.
xiv. Glabella: It is the most prominent point of the
forehead in the midsagittal plane.
Bilateral cephalometric landmarks
i. Orbitale: The lowest point on the inferior bony
margin of the orbit.
ii. Porion: The highest bony point on the upper
margin of external auditory meatus.
iii. Bolton point: The highest point in the upward
curvature of the retrocondylar fossa
(Broadbent).
iv. Gonion: Is a constructed point at the junction of
ramal and mandibular planes. It is the most
inferiorly, posteriorly and outwardly directed.
v. Pogonion: It is the most anterior point in the
contour of the chin.
vi. Articulare: It is a point at the junction of the
posterior border of ram us and the inferior
border of the basilar part of the occipital bar.
vii. Condylion: The most superior point on the
head of the condyle.
viii. Thekey ridge: The lower most point on the
contour of the anterior wall of the
infratemporal fossa.
ix. Broadbent registration point: It is the midpoint
of the perpendicular from the centre of
sellatursica to the Bolton plane.
x. Glabella: Is the most prominent point of the
forehead in the midsagittal plane.
xi. Che lion: Is the lateral terminus of the oral slit
on the outer corner of the mouth.
Lines and planes in cephalometrics
These lines and planes are obtained by connecting
two landmarks. Based on their orientation, they
are classified as horizontal and vertical planes.
[SE Q.4)
{Horizontal planes:
i. S-N plane
ii. Frankfort horizontal plane
iii. Occlusal plane
iv. Mandibular plane
v. Basion-nasion plane
vi. Bolton's plane
(i) S-N plane
It represents anterior cranial base. It is the
cranial line between the sella and nasion.
-------------·------
FIG. 11.3 S-N Plane (Sella-Nasion plane).
(ii) Frankfort horizontal plane

This plane connects the orbitale and porion.
p
o--~---------- - ----------~,, .
0
FIG. 11.4 Frankfort horizontal plane.
(iii)Occlusal plane
It is a denture plane bisecting the posterior
occlusion of permanent molars and
premolars and extends anteriorly.
FIG. 11.s Occlusal Plane.
(iv) Mandibular plane:

According to Down, mandibular plane is a
line connecting gonion and menton.
(v) Basion-nasion plane:

It is a line connecting the Basion and Nasion
and represents cranial base.
(vi) Bolton's plane: It is a plane that

connects Bolton's point posterior to the
occipital condyles and nasion.}
Vertical planes:
Various commonly used vertical planes in
cephalometrics are as follows:
i. A-pog line
ii. Facial plane
iii. Facial axis
iv. Aesthetic plane
(i) A-pog line
It is a line extending from point A
on the maxilla to pogonion on the
mandible.
FIG. 11.6 A-Pogonion plane.
(ii) Facial plane

It is a line
. from the nasion to
pogoruon.
I
I
I
I
I
I
I
I
I
I
....._.-Pog
FIG. 11. 7 Facial Plane.
(iii) Facial axis

It is a line from ptm point to
cephalometricgnathion.
Ptm

r-,.._J\
\
\
r-r--:« \
\
\
\
\
\
\
\
\
FIG. 11.s Facial axis.
(iv) 'E' plane or aesthetic plane

It is a line between the most
anterior point of the soft tissue
nose and soft tissue chin.
With all the above-mentioned
standard points and measurable
planes and angles, cephalometric
aids in skeletal, dental and soft
tissue analysis and classification of
various malocclusions.
I
I
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I
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I
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I
I
FIG. 11. 9 Aesthetic plane.
Q.2. Write in detail about any one cephalometric

analysis of your choice used in orthodontics.
Ans.
Various cephalometric analyses are as follows:
A. Methodological classification
1. Angular analyses-SNA, SNB, ANB, Tweeds
analysis
2. Linear analyses - MacNamara analysis, COGS
B. According to area of analysis
1. Skeletal analysis - SNA, SNB, ANB
2. Dentoalveolar analysis - upper central incisor
to NA
3. Soft tissue analysis - 'E' plane
[SE Q.7]
{Steiner's analysis
Cecil c. Steiner in 1930 developed this analysis. The
idea is to provide maximum clinical information
with the least number of measurements.
The Steiner's analysis is divided into three parts.
I. Skeletal analysis
II. Dental analysis
III. Soft tissue analysis
I. Skeletal analysis
The Steiner's skeletal analysis considers
the following parameters:
a. SNA angle
b. SNB angle
c. ANB angle
d. Mandibular plane angle
e. Occlusal plane angle
The mean values of parameters considered in Steiner's skeletal analysis are as
follows:
SNA argle SNB argle AND ~ 1'ia11P.1lar plane~ Oa lusaJ plane ~

s2° 80° 20 320 14$1
(SN Q.9 and SE Q.7)

(a) {(SNA angle:
• The angle formed between S-N plane and line
joining nasion to point A is SNA angle.
• It indicates anteroposterior positioning of maxilla
in relation to cranial base.
• The mean value is 82°.
SNA > 82° - maxillary prognathism
SNA < 80° - retrognathism of maxilla)
(SE Q.7 and SN Q.16)
{((b) SNB angle:
The angle formed between S-N plane and line joining
nasion and point B.
• SNB angle indicates anteroposterior positioning
of mandible in relation to cranial base.
• The mean value of SNB angle is 80°.
SNB > 80° - mandibular retrognathism (class
III).
SNB < 80° - mandibular retrognathism (class
II).)}
{SN Q.7}
(c) ANB angle:
• Angle formed by intersection of line joining
nasion to point A and nasion to point B is known
as ANB angle.
• ANB angle indicates relative position of maxilla
and mandible to each other.
• The mean value of ANB angle is 2°.
ANB > 2° ..... class II tendency.
ANB < 2° - class III relationship.)
[SE Q.7]
{(d) Mandibular plane angle:
• Mandibular plane angle is the angle between S-N
plane and mandibular plane (Go-Gn).
• It indicates the growth pattern of an individual:
Average value is 32°.
<32° suggests horizontally growing face.
>32° suggests vertically growing face.
...<,
<,
<,
<,
<,
...... ...
<,
Go ', <,
<,
<,
<,
<,
<,
<,
...,
FIG. 11.1 o Mandibular plane angle.
(e) Occlusal plane angle:

• It is the angle formed between occlusal plane and S-
N plane.
• It indicates the relation of occlusal plane to cranium
and face the growth pattern of an individual.
It has a mean value of 14.5°.
r occlusal plane angle - clockwise rotation of
occlusal plane.
! occlusal plane angle - counterclockwise rotation
of occlusal plane.}
------- ---- ....

--- -·-- ---- .....
----
FIG. 11.11 Occlusal plane angle.
Steiner's dental analysis

The mean values of parameters considered in
Steiner's dental analysis are as follows:
r...- lff'ff..-lONA(upl i.w,,..-toNA{- LoMr..-10"1llu,p) ~-loNI(- b<fflripJu,p
,.._.,...._122" I •nm I :is- I •rnn I 131•
I
I
I
I
I
I
: NA line
FIG. 11.12 Upper incisor to NA (angle).
(a) Upper incisor to NA angle:

• Angle formed by intersection of the long axis of
upper central incisors and the line joining
nasion to point A.
• The mean value is 22°. It indicates relative I
inclination of the upper incisors.
r upper incisor to NA angle - upper incisor
proclination, e.g. class II, division I.
i upper incisor to NA angle - upper incisor
retroclination.
(b) Upper incisor to NA linear: It is the lineal
measurement between labial surface of central
incisor and the line joining nasion to point A.
• It is the linear measurement between labial
surface of central incisor and line joining
nasion to point A.
• This helps to determine upper incisor position:
Mean value is 4 mm.
• r value seen in upper incisor proclination.
Q.7. Enumerate cephalometric analysis and
elaborate on Steiner's analysis.
Ans.
[Same as LE Q.2]
Q.8. Discuss in detail the clinical implications of

growth and development enumerating the use of
cephalometrics to study the same.
Ans.
[Same as LE Q.3]
Short essays:

Q.1. Uses of cephalometrics.
Ans.
[Ref LE Q.1]
Q.2. Tweed's triangle.

Ans.
Long axis of lower

central incisor
FIG. 11.17 Tweed analysis.
The objectives of Tweed's analysis are as follows:

• Determination of lower incisor position
• Evaluation of prognosis of a case
I. The planes used in Tweed's analysis that form a
diagnostic triangle are as follows:
• Frankfort horizontal plane
• Mandibular plane
• Long axis of lower incisor
II. The significance of angles formed from these
three planes is as follows:
(a) Frankfort mandibular plane angle
(FMA): The angle formed by the Frankfort
horizontal plane with the mandibular
plane.
The average value is 25°
If FMA is 16-28° - prognosis is good.
If FMA is 28-35° - prognosis is fair.
If FMA is >35° - prognosis is bad.
Extractions frequently complicate the
problems.
(b) Incisor mandibular plane angle (IMPA):
Angle formed between long axis of lower
incisor with mandibular plane. Mean
value is 90°.
If IMPA > 110° - proclined lower incisors
IMPA < 85° - retroclined lower incisors
(c) Frankfort mandibular incisor angle
(FMIA): Angle formed between long axis
of lower incisor and Frankfort horizontal
plane. Mean value is 65°.
Tweed's diagnostic triangle is used in
diagnosis, classification, treatment
planning as well as for prognosis of
orthodontic cases.
Q.3. Down's analysis.

Ans.
• Down's analysis is one of the most frequently used
cephalometric analysis which measures the skeletal
and dental pattern of the patients to define the
underlying facial type and establish the relation of
dentition to the underlying bony structures.
• Down's analysis consists of following skeletal and
dental parameters, five each.
Skeletal parameters Dental parameters

a. Facial angle a. Cant of occlusal plane
b. Angle of convexity b. Interincisal angle
c. A-B plane angle c. Incisor mandibular plane
d. Mandibular plane angle
angle d. Incisor mandibular plane
e. y-axis (growth axis) angle
e. Upper incisor to A-pog
Skeletal Parameters:
(a) Facial angle:
• Facial angle is the inside inferior angle formed
by the intersection of FH plane and nasion-
pogonion plane.
• This angle indicates anteroposterior positioning
of the mandible in relation to the upper face.
• The average value is - 87.8° with a range of
82-95°.
r Facial angle - skeletal class III with
prominent chin.
1 Facial angle - skeletal class II.
I
I
-~---------------
ol-t----- ----
H--1-- Nasion-pogonion
plane
Pog
FIG. 11.1 a Facial angle.
(b) Angle of convexity:

• Angle of convexity is formed by intersection of
a line from nasion to point A and a line from
point A to pogonion.
• This angle reveals the convexity or concavity of
skeletal profile.
• Average value is - 0° with a range of -8.5 to
10°.
• Positive or t angle of convexity - prominent
maxillary denture base relative to mandible.
Negative or l angle of convexity-prognathic
profile.
(N-A Line) nasion---

to point line
Ai'---'~- Point A to pogonion

line (A-Pog line)
FIG. 11.19 Angle of convexity.
(c) A-B plane angle:

• A-B plane angle is formed between a line
connecting point A to point B and N-pog line.
• This angle is indicative of maxillomandibular
relationship in relation to facial plane.
Mean value is -4.6° with range of-9 to 0°.
Usually A-B plane angle is negative.
In class III cases A-B plane angle is positive.
I I
I I
I I
,,
II
II
,,
~
:,
A
~-t--Pog
FIG. 11.20 A-B plane angle.
(d) Mandibular plane angle:

• Mandibular plane angle is formed between FH
plane and mandibular plane.
• Mean value is 21.9° with range of 17-28°.
• t Mandibular plane angle suggests vertical
growth with hyper divergent facial pattern.
p FH plane
----~--
FIG. 11.21 Mandibular plane Angle.
(e) y-axis (growth axis)

• y-axis or growth axis is an acute angle formed by
the intersection of Frankfort horizontal plane
with a line from sella turcica to gnathion. I
• y-axis indicates the growth pattern of the
individual; mean value is 59.4° with a range of
53-66°.
y-axis > normal - indicates greater vertical
growth of mandible.
y-axis < normal - indicates greater horizontal
growth of mandible.
• This angle is greater in class II than in class III
facial patterns.
\
-----~--
v
-----'-\-,,-,r-=r---f------.::....--: ------- ---.
------ ------ FH
plane

Gn
FIG. 11.28 y-axis (growth axis).
• y-axis indicates the growth pattern of the individual.

• Mean value is 59.4° with a range between 53 and 66°.
y-axis > normal - indicates greater vertical growth of
mandible.
y-axis < normal - indicates greater horizontal growth
of mandible.
• This angle is greater in class II than in class III facial
patterns.
• During orthodontic treatment:
Increase in y-axis suggests - vertical growth pattern
or open bite.
Decrease in y-axis suggests - horizontal growth
pattern or deepening of bite.
Q.2. Key ridge.

Ans.
• Key ridge is the lower most point on the contour of
the anterior wall of the infra temporal fossa. Or
• It is the inferior most point of the anterior border of
zygoma as seen in lateral cephalogram.
• In his concept of normal occlusion, Angle related
maxillary first molar to key ridge position, normally
the mesiobuccal root of maxillary permanent first
molar is in line with the key ridge.
Q.3. Limitations of cephalogram.

Ans.
• Cephalogram is a cephalometric radiography
introduced to orthodontics by Holly Broadbent and
Herbert Hofrath in 1931.
• These are used in orthodontics to elucidate the
skeletal, dental and soft tissue relationships.
• Limitations of cephalogram are as follows:
i. Exposure of patient to harmful ionizing
radiation.
ii. A serious disadvantage is the absence of
anatomical references which remain constant
with time.
iii. The process of image acquisition and
measurement procedures are not well
standardized.
iv. The structures being imaged are three-
dimensional whereas the radiographic image is
two-dimensional. So, anatomical structures
lying at different planes within the head
undergo projective displacement.
v. The cephalometrics make use of means
obtained from different population samples;
hence they have only limited relevance when
applied to individual patient.
Q.4. Enumerate horizontal planes in cephalometry.

Ans.
In cephalometrics, various lines and planes are
obtained by connecting two landmarks. Based on their
orientation, they are classified as horizontal and vertical
planes.
Various horizontal planes are as follows:
i. S-N plane
ii. Frankfort horizontal plane
iii. Occlusal plane
iv. Mandibular plane
v. Basion-nasion plane
Q.5. Interincisal angle.

Ans.
[Ref LE Q.2]
Q.6. S-N plane.

Ans.
i. S-N plane represents the anterior cranial base.
ii. It is a horizontal cephalometric plane between the
centre of sellatursica (S) and the most anterior point
of the frontonasal suture (N), i.e. nasion.
FIG. 11.29 Sella-Nasion plane.
Q.7. ANB angle.

Ans.
[Ref LE Q.2]
Q.8. FMA angle.

Ans.
• FMA is an angle formed at the intersection of the
Frankfort horizontal plane with the mandibular
plane.
• Mean value of FMA is 25°.
• The Tweed's analysis makes use of FMA angle in a
diagnostic triangle to determine position of lower
incisor and evaluation of prognosis of a case.
FMA------
'-...,
'
IMP
FIG. 11.30Tweed's diagnostic triangle

showing FMA angle.
Q.9. SNA angle.

Ans.
[Ref LE Q.2]
Q.10. Two uses of cephalometrics in orthodontia.

Ans.
i. Cephalometrics is a nonessential or supplemental
diagnostic aid in orthodontic diagnosis.
ii. In 1931, a standardized cephalometric technique was
simultaneously presented by Holly Broadbent (USA)
and Herbert Ho Frath (Germany).
iii. Cephalometrics helps in:
• Orthodontic diagnosis
• Classification
• Treatment planning
• Evaluation of treatment results
Hence, it forms a valuable tool in treatment planning
and follow-up of orthodontic patients.
Q.11. Tweed's diagnostic triangle.

Ans.
i. Tweed's diagnostic triangle is used in diagnosis,
classification, treatment planning as well as for
prognosis of orthodontic cases.
• The significance of angles formed from the three
planes, i.e. Frankfort horizontal plane, mandibular
plane and long axis of lower incisor that form
three sides of the diagnostic triangle is as follows:
a. Frankfort mandibular plane angle (FMA): The
angle formed by the Frankfort horizontal plane
with the mandibular plane.
The average value is 25°. If FMA is 16-28° -
prognosis is good; FMA is 28-35° - prognosis is
fair; FMA > 35° - prognosis is bad. Extractions
frequently complicate the problems.
b. Incisor mandibular plane angle (IMPA): Angle
formed between long axis of lower incisor with
mandibular plane.
Mean value is 90°. If IMPA >110° - proclined
lower incisors, IMPA < 85° - retroclined lower
. .
incisors.
c. Frankfort mandibular incisor angle (FMIA):
Angle formed between long axis of lower incisor
and Frankfort horizontal plane. Mean value is
65°.
-=------ _
]
....',,,, FMA
FH plane
~------------
O
____ L
<, F~Y I
Long axis of
lower central
incisor
FIG. 11.31 Tweed analysis.
Q.12. Occlusal plane angle.

Ans.
Occlusal plane
It is a denture plane bisecting the posterior occlusion
of permanent molars and premolars and extends
anteriorly.
Significance:
• The angle formed between occlusal plane and S-N
plane is known as occlusal plane angle.
• It indicates the relation of occlusal plane to
cranium and face, i.e. the growth pattern of an
individual.
• It has a mean value of 14.5°.
r Occlusal plane angle - clockwise rotation of
occlusal plane
! Occlusal plane angle - counterclockwise
rotation of occlusal plane
FIG. 11.32 Occlusal plane.
Q.13. Steiner's soft tissue analyses.

Ans.
i. Cecil C. Steiner in 1930 developed a cephalometric
analysis. The idea is to provide maximum clinical
information with least number of measurements.
ii. The Steiner's analysis consisted of three parts, namely
skeletal analysis, dental analysis and soft tissue
analysis.
... ...... . . ,.
r. . • ' .... . .
.,
iii. Steiner's soft tissue analysis: According to Steiner, in
a well-balanced face, lips should touch the line
extending from soft tissue contour of chin to midline
of an 'S' formed by the lower border of nose.
• Lips located beyond this line indicates ..... protrusive
(convex profile).
• Lips located behind this line ..... retrusive (concave
profit).

I
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I
S-Line
FIG. 11.33 S-line.
Q.14. Registration point.

Ans.
The Broadbent registration point (R point) is the
midpoint of the perpendicular from the centre of
sellatursica to the Bolton-nasion plane.
Broad bent
FIG. 11.34 Registration point.
Q.15. Facial divergence.

Ans.
i. Facial divergence was described by Milo Hellmann as
the inclination of lower face relative to forehead.
ii. It determines the position of lower part of the face
relative to the forehead using soft tissue landmarks,
i.e. soft tissue nasion and pogonion.
iii. Based on a line drawn between the forehead and the
chin in the natural head position, the facial
divergence is of the following types:
a. Posterior divergent face: When the line is
inclined posteriorly in the chin region, it is
known as posterior divergent face, seen in class
II cases.
b. Straight or orthognathic face: When the line is
perpendicular to the floor, it is known as
straight or orthognathic face, seen in class I
cases.
c. Anterior divergent face: When the line is
inclined anteriorly in the chin region, it is
known as anterior divergent face, seen in class
III cases.
Q.16. Angle SNB.

Ans.
[Ref LE Q.2]
Q.17. Mandibular plane angle.

Ans.
Mandibular plane angle is one of the parameters used
in Steiner's skeletal analysis.
• Mandibular plane angle is formed between S-N plane
and mandibular plane.
• This angle gives an indication of the growth pattern of
an individual.
• The average value is 32°.
A lower angle indicates ..... horizontal growing face.
An increased angle indicates -. vertical growing
face.
SN plane
I _
Mandibular --- ----------
,'-+e1-------
plane angle
., ...
.........
,,
', ...,
,Go,,
...
', ,, ,,
... , ., ,,
,,
Mandibular plane~ c-,
~,._.....
Ga
FIG. 11.35 Mandibular plane angle.
Q.18. Cephalostat.
Ans.
i. Cephalostat is a head holder device, one of the
components of standard apparatus used to take
cephalograms.
ii. A cephalostat consists of ear rods, orbital pointer and
forehead clamp to stabilize the head of the patient
and position it in three dimensions to receive X-ray
beam.
iii. It positions the patient's head so that distance
between the X-ray source and midsagittal plane of
patient is at a fixed distance of 5 feet.
Q.19. The Wits appraisal.

Ans.
The Wits appraisal is a measure of the
maxillomandibular relation in the anteroposterior or
sagittal plane.
i. A functional occlusal plane is drawn and
perpendiculars are dropped from points A and B on
it. The points of contact of these perpendiculars on
the occlusal plane are termed as AO and BO.
ii. The distance between AO and BO gives the
anteroposterior relation between the maxilla and the
mandible.
iii. Usually in males, point BO is ahead of AO by 1 mm.
In females, points AO and BO coincide.
In skeletal class II tendency, BO is behind AO
(positive reading)
In skeletal class III pattern, point BO is located ahead
of AO (negative reading)
Bo _____ .,._ I
Ao
FIG. 11.36 Wits appraisal.

The Wits appraisal is mainly used in cases where the
ANB angle is considered not reliable due to abnormal
position of nasion and rotation of jaws.
Q.20. Frankfort horizontal plane.

Ans.
Frankfort horizontal plane
• This is a horizontal plane connecting the orbitale
and porion.
• It is one of the cephalometric planes used in the
Down's analysis.

• It is used as a reference plane in measuring both
skeletal and dental patterns of patient.
FIG. 11.37 Frankfort horizontal plane.
Q.21. Define cephalometric points.

Ans.
i. Point S: The point representing the midpoint of the
pituitary fossa or sella turcica is known as point S.
ii. Point Me: Point Me is the inferior most point in the
contour of the chin.
Q.22. 'E' plane or aesthetic plane.

Ans.
• 'E' plane is a line between the most anterior point of
the soft tissue nose and soft tissue chin.
• With all the above-mentioned standard points and
measurable planes and angles, cephalometric aids in
skeletal, dental and soft tissue analysis and
classification of various malocclusions.
I
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/
I
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I
I
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I
I
FIG. 11.38 Aesthetic plane.
Q.23. Computerized cephalometric system.

Ans.
There are two basic components of computerized
cephalometric system:
a. Data acquisition
b. Data management
• Data acquisition: It is done by either regular
radiographs or digital radiographs.
• Data management: Various commercially available
data management programmes are as follows:
i. Rocky mountain orthodontics (RMOs): Jiffy
orthodontic evaluation
ii. Pordios
iii. Dentofacial planner
iv. Quickceph image
v. Digi graph
Q.24. Nasolabial angle.

Ans.
i. It is one of the soft tissue measurements considered in
McNamara analysis.
ii. Nasolabial angle is formed by drawing a line tangent
to the upper lip.
iii. Average value is 102+8°.
iv. An acute nasolabial angle indicates dentoalveolar
protrusion. It may also be due to upturned
orientation of the base of the nose.
Q.25. Advantages of computerized cephalometric

system.
Ans.
• In orthodontics, computerized cephalometric systems
are employed for the purpose of diagnosis, prognosis
and treatment evaluation.
• The advantages of computerized cephalometric
system are as follows:
i. Less time-consuming
ii. Easy to store
iii. Easy to retrieve old records
iv. Combined evaluation of patient's photographs,
casts and cephalogram is possible
v. Efficient in research application
Q.26. Significance of ANB angle.

Ans.
[Same as SN Q.7]
Q.27. Uses of cephalometrics.

Ans.
[Same as SN Q.10]
Q.28. Tweed's triangle.

Ans.
[Same as SN Q.11]
Q.29. Occlusal plane.

Ans.
[Same as SN Q.12]
Q.30. Mandibular plane.

Ans.
[Same as SN Q.17]
Q.31. Name some data management programmes in

computerized cephalometric system.
Ans.
[Same as SN Q.23]
Topic 12 Skeletal maturity indicators

Long essays:
1. Enumerate various methods available to assess the
skeletal maturity of an individual and its
implications in orthodontic diagnosis and
treatment planning. Explain in detail about hand-
wrist x-rays.

Short essays:
1. Hand-wrist radiography. [Ref LE Q.1]
2. Compare skeletal age and dental age.
3. Cervical vertebrae as skeletal maturity indicators.
4. Implant radiography in orthodontics.
5. How hand-wrist x-rays are useful in orthodontic
diagnosis and treatment planning? [Same as SE
Q.1]
6. Dental versus skeletal age. [Same as SE Q.2]
Short notes:
1. Carpals.
2. Hand-wrist X-ray. [Ref LE Q.1]
3. Skeletal age.
4. Vital staining.
5. Dental age.
6. Carpal index. [Same as SN Q.1]
7. Hand-wrist radiography. [Same as SN Q.2]
Solved answers
Long essays:
Q.1. Enumerate various methods available to assess

the skeletal maturity of an individual and its
implications in orthodontic diagnosis and treatment
planning. Explain in detail about hand-wrist x-rays.
Ans.
Various skeletal maturity indicators commonly used in
orthodontics are as follows:
i. Hand-wrist radiographs
ii. Evaluation of cervical vertebrae using cephalogram
iii. Clinical and radiographical examination of different
stages of tooth development, especially canine
calcification.
Clinical implications of skeletal maturity
assessment status on diagnosis and treatment
planning in orthodontics are as follows:
i. The skeletal maturity status of an individual helps in
knowing whether the patient will grow appreciably
during the treatment period. This has important
implications on the treatment planning and response
to treatment.
ii. While planning orthopaedic therapy, functional
appliance therapy and orthognathic surgery, the
knowledge of position of patient in the facial growth
curve is important.
During the periods of accelerated growth, the
orthopaedic or functional appliance treatment can
contribute significantly to correction of dentofacial
deviations, leading to an improvement in facial
appearance.
iii. The skeletal maturity or skeletal age is accurate in
assessing the physical maturity. The other
parameters, like peak height velocity, secondary
sexual changes and dental age, are inferior to skeletal
age in estimating physical maturity.
The bones mature at different rates and follow a
reasonable sequence; hence, the developmental
status of a child can be estimated by determination
of degree of completion of facial skeleton.
(SE Q.1 and SN Q.2)
{(Hand-wrist radiographs:
• Numerous small bones in the hand-wrist region
maturity.
Thus, by comparing patient's hand-wrist
radiograph with standard radiographs that
represent different skeletal ages, the skeletal
maturation status of an individual can be
determined.
• The left hand-wrist is used by convention and a PA
view is taken to register the hand-wrist region.
• Among various methods described to assess skeletal
maturity using hand-wrist radiographs, the most
commonly used ones are as follows:
i. Atlas method by Greulich and Pyle
ii. Bjork, Grave and Brown method
iii. Fishman's skeletal maturity indicators
iv. Hagg and Taranger method)}
Anatomy of hand-wrist region:
• Each hand-wrist area has 8 carpals, 5 metacarpals
and 14 phalanges, which make a total of 27 bones.
• Distal ends of radius and ulna also appear in the
hand-wrist radiograph. Radius and ulna are the
long bones of the forearm. When the palm is facing
front, ulna lies in the medial aspect and radius in
the distal aspect.
• Carpal bones were first named by Lyser, these are
eight irregularly shaped small bones arranged in
two rows:
a. Proximal row - scaphoid, lunate, triquetral and
pisiform
b. Distal row - trapezium, trapezoid, capitates and
hamate
These small irregular bones lie in-between the long
bones of forearm and the metacarpals.
• Metacarpals are small long bones and are
numbered 1-5 starting from thumb to little finger.
Each of the five metacarpals has a base, shaft and
head. These lie between the carpals and phalanges,
forming the skeletal framework of the palm.
• Phalanges are small bones forming the fingers.
Each finger has three phalanges - proximal,
middle and distal phalanx. Middle phalanx is
absent in the thumb.
• The phalanges have a pattern of ossification, which
occurs in three stages:
Stage 1: The epiphysis and diaphysis are equal.
Stage 2: The epiphysis caps the diaphysis by
surrounding it.
Stage 3: The epiphysis and diaphysis are fused.
• Sesamoid bone is a small nodular bone, mostly
embedded in the tendons of thumb region.
[SE Q.1]
{i. Atlas method by Greulich and Pyle
• Greulich and Pyle published an atlas containing
pictures of hand-wrist for different
chronological ages for both the sexes.
• Patients' radiographs are matched with one of the
photographs in the atlas which is a
representative of particular skeletal age.
ii. Bjork, Grave and Brown method
• According to Bjork, skeletal development in the
hand-wrist area is divided into eight stages, each
of them represents a particular level of skeletal
maturity.}
According to Bjork, stages of skeletal development in hand-wrist region
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[SE Q.1]
{iii. Fishman's skeletal maturity indicators
• Leonard S. Fishman proposed a system for the
evaluation of skeletal maturation by making use of
anatomical sites located on the thumb, third finger,
fifth finger and radius.
• Covering the entire period of adolescent
development, 11 descrete skeletal maturity
indicators have been described, which are as
follows:
i. Width of epiphysis and diaphysisare equal
in proximal phalanx of third finger
ii. Width of epiphysis equal to that of
diaphysis in the middle phalanx of third
finger
iii. Width of epiphysis equal to that of
diaphysis in the middle phalanx of fifth
finger
iv. Appearance of adductor sesmoid of the
thumb
v. Capping of epiphysis seen in the distal
phalanx of third finger
vi. Capping of epiphysis seen in the middle
phalanx of third finger
vii. Capping of epiphysis seen in the middle
phalanx of fifth finger
viii. Fusion of epiphysis and diaphysis seen
in the distal phalanx of third finger
ix. Fusion of epiphysis and diaphysis seen in
the proximal phalanx of third finger
x. Fusion of epiphysis and diaphysis seen in
the middle phalanx of third finger
xi. Fusion of epiphysis and diaphysis seen in
the radius
iv. Hagg and Taranger method
• Hagg and Taranger noted that skeletal development
in hand and wrist can be analysed from the
assessment of ossification of ulnar sesamoid of
metacrpophalangeal joint of the first finger (S) and
certain specified stages of three epiphyseal bones:
the middle and distal phalanges of the third finger
(MP3 and DP3) and the distal epiphysis of the
radius (R) by taking annual radiographs between 6
and 18 years of age.}
A. Sesamoid:
It is usually attained during the acceleration
period of the pubertal growth spurt, i.e.
onset of peak height velocity (PHV).
B. Stages of ossification of middle phalanx of
third finger (MP3):
They follow pubertal growth spurt. The stages
of ossification are outlined from stage F to
stage I as follows:
i. Stage F
The epiphysis is as wide as the metaphysis.
About 40°/o of individuals are before PHV.
Very few are at PHV.
ii. Stage FG
The epiphysis is as wide as the metaphysis,
and there is a distinct medial or lateral (or
both) border of the epiphysis forming a
line of demarcation at right angles to the
border. About 90°/o of individuals are one
year before or at PHV.
iii. Stage G
-
iii. Stage G
The sides of the epiphysis are thickened,
and there is capping of the metaphysis,
forming a sharp edge distally at one or
both sides. About 90°/o of individuals are at
or one year after PHV.
iv. Stage H
Fusion of the epiphysis and metaphysis
has begun. About 90°/o of girls and all boys
are after PHV but before the end of the
pubertal growth spurt.
v. Stage I

Fusion of epiphysis and metaphysis is
completed. All individuals except a few
girls have ended the pubertal growth
spurt.
C. Distal phalanx of third finger:
DP3-I: Fusion of the epiphysis and metaphysis is
completed.
This stage signifies the fusion of the epiphysis
and metaphysis and is attained during the
deceleration period of the pubertal growth
spurt (i.e. end of PHV) by all subjects.
D. Radius:
R-I:
Beginning of fusion of the epiphysis and
metaphysis.
In about 80°/o of the girls and 90°/o of the boys,
this stage is attained 1 year before or at the
end of growth spurt.
R-IJ:
Fusion is almost completed but there is still a
small gap at one or both margins.
R-J:
Fusion of the epiphysis and metaphysis
occurred.
None of the subjects had attained these stages
before the end of PHV.
Short essays:
Q.1. Hand-wrist radiography.

Ans.
[Ref LE Q.1]
Q.2. Compare skeletal age and dental age.

Ans.
Skeletal age Dental age

It is based on the The formation of teeth or
ossification of eruption of the teeth is the
endochondral bone. basis for calculating the
dental age.
It is assessed based on the Assessed based on the number
skeletal maturity of teeth at each chronological
indicators like hand- age or on stages of formation
wrist radiographs and of crowns and roots of the
cervical vertebrae. teeth.
It helps in assessing It has no role in physical
physical maturity of an maturity assessment.
individual.
It is helpful in treatment It can reflect an assessment of
planning and tracking physiologic age comparable
response to treatment. to age based on the skeletal
development, weight or
height.
There is a correlation When the last tooth has
between the dental age completed its development, it
and skeletal age. is an indication that the
skeleton is approaching
complete maturation.
Q.3. Cervical vertebrae as skeletal maturity

indicators.
Ans.
• A system of skeletal maturation determination using
cervical vertebrae was introduced by Hassel and
Farman.
• The shapes of the cervical vertebrae were seen to
differ at each level of skeletal development which
provided a means to determine the skeletal maturity
of a person and thereby estimate whether the
possibility of potential growth existed.
• The six stages put forward by Hassel and Farman in
assessing skeletal growth are named as follows:
Stage 1: initiation
Stage 2: acceleration
Stage 3: transition
Stage 4: deceleration
Stage 5: maturation
Stage 6: completion
Changes observed in various stages are as follows:
i. Stage 1: Initiation
• Marks the beginning of adolescent growth with
80°/o-95°/o of adolescent growth expected.
• Inferior borders of C2, C3 and C4 were flat, and
superior borders were tapered from posterior
to anterior and vertebrae were wedge-shaped.
ii. Stage 2: Acceleration
• Acceleration of growth begins at this stage with
• Concavities are seen in the lower borders of C2
and C3 and the lower border of C4 will be flat.
• The bodies of C3 and C4 were nearly
rectangular in shape.
iii. Stage 3: Transition
• Corresponds to acceleration of growth to peak
height velocity with 25°/o-65°/o of adolescent
growth expected.
• Marked concavities are seen in the lower
borders of C2 and C3 and a concavity was
beginning to develop in the lower border of
C4.
• The bodies of C3 and C4 were rectangular in
shape.
iv. Stage 4: Deceleration
• Deceleration in adolescent growth spurt with
• Marked concavities are seen in C2, C3 and C4 in
their lower borders.
• Vertebral bodies of C3 and C4 are square in
shape.
v. Stage 5: Maturation
• Final maturation of vertebrae took place during
this stage with 5°/o-10°/o of adolescent growth
expected.
• More accentuated concavities are seen in the
lower borders of C2, C3 and C4.
• The bodies of C3 and C4 are square in shape.
vi. Stage 6: Completion
• This stage corresponds to completion of
growth. Little or no adolescent growth is
expected.
• More accentuated concavities are seen in the
lower borders of C2, C3 and C4.
• The body shapes of C3 and C4 were square or
were greater in vertical dimension than in
horizontal dimension.
Q.4. Implant radiography in orthodontics.

Ans.
i. Implant radiography is an experimental method for
studying physical growth.
ii. Professor Bjork introduced human implant
radiograph for growth measurement.
iii. Procedure:
• Inert metal pinseg: Tantalum pins, 1.5 mm long and
0.5 mm in diameter, were placed in the mandible.
• These metal pins get osseo-integrated and serve as
reference points.
• Serial cephalometric radiographs are taken
repeatedly over a period of time, and compared.
• Only implant radiography can estimate rotation of
jaw bones.
iv. Information obtained from implant radiography:
It gives very accurate information about the site of
growth, amount of growth and direction of growth,
and a relatively accurate information about the
rate of growth.
v. Drawbacks:
• It is a two-dimensional study of three-dimensional
process.
• Radiation hazard.
Q.5. How hand-wrist x-rays are useful in orthodontic

diagnosis and treatment planning?
Ans.
[Same as SE Q.1]
Q.6. Dental versus skeletal age.

Ans.
[Same as SE Q.2]
Short notes:
Q.1. Carpals
Ans.
i. Carpals are the bones of hand-wrist region.
ii. They were first named by Lyser.
iii. They are eight irregularly shaped small bones
arranged in two rows:
(a) Proximal row-scaphoid, lunate, triquetral and
pisiform.
(b) Distal row-trapezium, trapezoid, capitate and
hamate.
These small irregular bones lie in-between the
long bones of forearm and the metacarpals.
iv. Each carpal bone ossifies from one primary centre,
which appears in a predictable pattern.
Q.2. Hand-wrist X-ray?

Ans.
[Ref LE Q.1]
Q.3. Skeletal age.

Ans.
i. The skeletal maturity or skeletal age is more superior
and accurate in assessing the physical maturity than
the other parameters like peak height, velocity,
secondary sexual changes and dental age.
ii. Skeletal age is based on the ossification of
endochondral bone.
iii. It can be assessed based on the various skeletal
maturity indicators like hand-wrist radiographs,
evaluation of cervical vertebrae and clinical and
radiographic examination of different stages of tooth
development.
iv. Assessing the skeletal maturity is helpful in diagnosis,
treatment planning and response to treatment in
orthodontics.
v. The dental and skeletal ages correlate with each
other.
Q.4. Vital staining.

Ans.
i. Vital staining is one of the experimental methods of
measuring growth introduced in the eighteenth
century by John Hunter.
ii. It consists of injecting dyes that stain and get
deposited in the mineralizing tissues like bones and
teeth.
Example: Commonly used dyes for vital staining are
alizarin s, radioactive tracers, fluorochrome,
tetracycline and trypan blue.
iii. Animals are sacrificed and tissues are studied
histologically.
iv. This cross-sectional study elicits information
regarding detailed analysis of site and the amount of
growth and as well as the rate of growth.
v. Disadvantage: It is not a longitudinal study, i.e.
repeated data of the same individual cannot be
obtained.
Q.5. Dental age.

Ans.
i. Dental age usually correlates with chronological age
and is assessed based on the fallowing:
(a) Amount of root resorption of primary teeth
(b) Teeth which have erupted
(c) Amount of permanent teeth development
ii. Dental age is assessed on the basis of the number of
teeth at each chronological age or on the stages of
formation of crowns and roots of the teeth.
iii. Dental age can reflect an assessment of physiologic
age comparable to age based on the skeletal
development, weight or height.
iv. Complete formation of the last tooth is an indication
that the skeleton is approaching complete
maturation.
Q.6. Carpal index.

Ans.
[Same as SN Q.1]
Q.7. Hand-wrist radiography.

Ans.
[Same as SN Q.2]
Topic 13 Model analysis
Long essays:
1. Enumerate the various diagnostic aids used in
orthodontics and add a note on study models.
Short essays:

1. Pont's analysis.
2. Korkhau's analysis.
3. Carey's analysis.
4. Ashley Howe's index.
5. Mixed dentition analysis. Explain one in detail.
6. Radiographic method of mixed dentition analysis.
7. Bolton's tooth size ratio.
8. Kesling tooth positioning.
9. Pont's index. [Same as SE Q.1]
10. Carey's analysis or arch perimeter analysis.
[Same as SE Q.3]
11. Ashley Howe's index. [Same as SE Q.4]
12. Assessment of tooth mass discrepancy. [Same as
SE Q.4]
13. Moyer's mixed dentition analysis. [Same as SE
Q.5]
14. Bolton's analysis. [Same as SE Q.7]
15. Kesling's diagnostic set-up. [Same as SE Q.8]
Short notes:
1. Pont's analysis. [Ref SE Q.1]
2. Model analysis.
3. Carey's analysis.
4. Peck and Peck ratio.
5. Name few model analysis for mixed dentition. [Ref
SE Q.5]
6. Linderhearth's ratio.
7. Radiographic method of mixed dentition analysis.
8. Study models - uses. [Ref LE Q.1]
9. Bolton's analysis. [Ref SE Q. 7]
10. Tanaka-Johnston analysis.
11. Korkhau's analysis.
12. Gnathostatic models.
13. Kesling's diagnostic set-up. [Ref SE Q.8]
14. Ashley Howe's index. [Ref SE Q.4]
15. Pont's index. [Same as SN Q.1]
16. Arch perimeter analysis. [Same as SN Q.3]
17. Bolton's tooth size ratio. [Same as SN Q.9]
18. Bolton index. [Same as SN Q.9]
Solved answers
Long essays:
Q.t. Enumerate the various diagnostic aids used in

orthodontics and add a note on study models.
Ans.
The various diagnostic aids used in orthodontics are as
follows:

I
Essential diagnostic aids Nonessential or supplemental
diagnostic aids
C.Jery important for all cases (Are not essential in all cases
and are simple, and do not and require special equipment)
require expensive equipment)
Examples: Examples:
a. Case history and clinical a. Specialized radiographs
examination b. EMG
b. Study models c. Hand wrist X-ray
c. Certain basic radiographs d. Endocrine tests
d. Facial photographs e. Estimation of BML
f. Diagnostic set-up
g. Occlusograms
{SN Q.8}
• (Study models are one of the essential orthodontic
diagnostic aids) that make it possible to study the
arrangement of teeth and occlusion from all three
planes, i.e. sagittal, vertical and transverse planes of
space.
{SN Q.8}
Uses of study models are as follows:
i. They allow study of occlusion from all aspects.
ii. They enable accurate measurements to be made in
dental arch such as arch length, arch width and
tooth size.
iii. Assessment of treatment progress by both
patients and dentist.
{SN Q.8}
iv. They help in assessing the nature and severity of
malocclusion as well as motivation of the patient
to orthodontic therapy.
v. They are useful to explain treatment plan as well
as progress of treatment to the patient and parents.
vi. They make it possible to simulate treatment
procedures on cast called mock surgery.
{SN Q.8}
vii. In case the patient is to be treated by another
dentist, they make it easy to transfer records of the
patient.
Ideal requirements of a study model:
• The study models should accurately reproduce the
teeth and surrounding soft tissues without any
distortion.
• They should not only depict the teeth but also
reproduce as much of alveolar process as possible,
with a clean, smooth and nodule-free surface.
• They should be trimmed in such a way that they are
symmetrical and pleasing to the eye. When placed
on their backs, they should accurately reproduce
the occlusion and enable instant identification of
asymmetries in the arch form.
Parts of a study model:
• The orthodontic study model consists of the
following parts (Fig. 13.1):
(a) Anatomic portion
(b) Artistic portion
• The anatomic portion of study model is the actual
impression of the dental arch and its surrounding
structures.
• Usually this portion is made of stone plaster. The
artistic portion of study model consists of a plaster
base that supports the anatomic portion.
In a well-fabricated set of study models, the ratio
of anatomic portion to artistic portion should be
3:1.
Anatomic
portion
Artistic
portion
FIG. 13.1 Orthodontic study model.
Construction of study models:

The steps involved in the construction of study
models are as follows:
i. Impression making
ii. Disinfection of the impression
iii. Casting the impression
iv. Basing and trimming of the cast
v. Finishing and polishing
i. Impression making:
It is an important step in making orthodontic
study models, as they should accurately
reproduce as much of supporting structures
as possible. The ideal trays should be
selected such that they include last erupted
molars and should have a clearance of
around 3 mm between the teeth and the
tray. The irreversible hydrocolloids or
alginates are widely used materials for
making impressions.
ii. Disinfecting the impression:
This can be done by soaking the impression in
a disinfectant solution such as biocide, 2°/o
glutaraldehyde, for a specified duration of
time.
iii. Casting the impression:
Impressions obtained are usually casted in
orthodontic stone or model stone.
iv. Basing and trimming of the cast:
Rubber base formers are available to help in
making the base (i.e. the artistic portion of
the study cast) over the anatomic portion.
The trimming of orthodontic model is a
meticulous process which is done on electric
plaster trimming machine.
v. Finishing and polishing
The final polishing of casts is done by placing
them in soap solution for 1 hour and then
removing and rinsing under cold water. The
casts are then allowed to dry and buffed to
acquire smooth and shining appearance.
They can be polished using fine-grained
sandpaper.
The finished study models can be stored in
boxes for the future reference.
Short essays:
Q.1. Pont's analysis.

Ans.
Font's analysis was presented by Pont in 1909.
{SN Q.1}
• Pont's index or Pont's analysis is a method of
predetermining the ideal arch width based on
mesiodistal width of crowns of maxillary incisors.
• By this analysis, the width of arch in premolar and
molar regions can be established by measuring the
greatest width of maxillary incisors.
• The parameters considered in this analysis are as
follows:
(i) Determination of sum of incisors (SI) (Fig. 13.2)
The summed up values of mesiodistal width of
four maxillary incisors is known as the sum of
incisors (SI).
(ii) Determination of measured premolar value
(MPV) (Fig. 13.3)
The MPV is the arch width of premolar region
from the distal pit of one upper first premolar
to the distal pit of the opposite first premolar.
(iii) Determination of measured molar value
(MMV) (Fig. 13.4)
The MMV is the arch width of the molar region
from the mesial pit of one upper first molar to
the mesial pit of the opposite first molar.
(iv) Determination of calculated premolar value
(CPV)
The expected arch width in the premolar region
or the calculated premolar value is
determined by the following formula: SI x
100/80.
(v) Determination of calculated molar value (CMV)
• The expected arch width of the molar region or
the calculated molar value is determined by
the following formula: SI x 100/64.
• Inference:
If the measured value is less than the
calculated
. value, it indicates the need for
expansion.
Whether dental arch is

narrow/normal.
Uses of Pont's Index
Analysis: It helps - Need for lateral expansion of arch.
you to determine
How much expansion is possible at
premolar and molar regions?
I
I
- I
-: I 1-............
~c-1~1:UJ~
2 1 11 2 A
I
I
2 1 1 2

FIG. 13.2 Sum of incisors (SI).
FIG. 13.3 Measured premolar value

(MPV).
1st Molar
-
1st Molar
FIG. 13.4 Measured molar value (MMV).
Q.2. Korkhau's analysis.

Ans.
Korkhau in 1938 proposed a study model analysis which
reveals anteroposterior malpositioning of incisors in
maxillary and mandibular arches (Fig. 13.5).
Method:
i. Sum of upper incisors (Siu) = Added
measurement
. .
of mesiodistal width of maxillary
incisors.
ii. Available anterior arch length (AAAL) =
Measurement made from the midpoint of the
interpremolar line to the point between two
maxillary incisors.
iii. The ideal anterior arch length (IAAL) is
determined by using the Korkhau's formula:
,..
('/)
':....)
ffJ FIG. 13.5 Korkhau's analysis.
Siu
-- x 100
160
iv. If the AAAL > IAAL, it indicates that maxillary
central incisors are malpositioned anteriorly.
Example: labioversion of anteriors, bimaxillary
protrusion
v. If the AAAL < IAAL, it indicates that maxillary central
incisors are malpositioned posteriorly.
Example: linguoversion of anteriors, class II division
2 malocclusion
vi. The AAAL is measured in the mandibular arch in a
similar manner, whereas the arch width at the
premolar region is taken from contact areas of first
and second premolars.
vii. According to Korkhau's formula, for a given width of
upper incisors, a specific value of distance should
exist between the midpoint of interpremolar line to
the point between two maxillary incisors.
An increase in this measurement denotes proclined
upper anterior teeth, while a decrease in this value
denotes retroclined upper anterior teeth.
Q.3. Carey's analysis.

Ans.
The main cause of most of malocclusions is the arch
length and tooth material discrepancy. This discrepancy
can be calculated with the help of Carey's analysis.
Carey's analysis is usually done in the lower arch (cast).
The same analysis if performed on the upper arch (cast),
it is known as arch perimeter analysis.
Method:
i. Determination of arch length
ii. Determination of tooth material
iii. Determination of discrepancy
i. Determination of arch length
It is carried with a soft brass wire. Arch length is
measured from mesial surface of the first
permanent molar of one side to the first
permanent molar of the opposite side. If the
anterior teeth are well aligned, the brass wire
passes over the incisal edges of anteriors; if
they are retroclined, the brass wire in anterior
segment passes labial to the teeth; in the case
of proclined anteriors, the wire is passed along
the cingulum of anterior teeth.
ii. Determination of tooth material
The tooth material is measured by summing up
the mesiodistal width of individual teeth
anterior to the first molars, i.e. second
premolar to second premolar.
iii. Determination of discrepancy
The discrepancy refers to the difference between
the arch length and the tooth material.
Inference:
If the discrepancy is
0-2.5 mm - It indicates minimum tooth material
excess, and suggests proximal stripping to reduce
tooth material.
2.5-5 mm - It indicates the need to extract second
premolar.
>5 mm - It indicates the need to extract first
premolars.
Q.4. Ashley Howe's Index.

Ans.
{SN Q.14}
• Ashley Howe's analysis is a model analyses to study
the relationship of tooth size to the size of supporting
structures.
• Ashley Howe considered that tooth crowding is due to
deficiency in arch width rather than arch length.
• He found that a relationship exists between the total
width of 12 teeth anterior to the second molars and
the width of dental arch in the 1st premolar region.
• Parameters considered are as follows:
i. Determination of total tooth material (TTM)
ii. Determination of premolar diameter (PMD)
iii. Determination of premolar basal arch width
(PMBA)
(i) Total tooth material (TTM)
The mesiodistal width of all teeth mesial to second
permanent molars is measured and summed up.
This value is called the total tooth material (Fig.
13.6).
(ii) Determination of premolar diameter (PMD)
The premolar diameter is the arch width measured
from the tip of buccal cusp of the first premolar to
the opposite first premolar (Fig. 13.7).
(iii) Determination of premolar basal arch width
(PMBA)
The measurement of width from canine fossa of one
side to other gives the width of dental arch at the
apical base. If canine fossa is not clear, then
measurement is made from a point about 8 mm
below the crest of the interdental papilla distal to
carune.
1 1
2 - ,- 2
,,. ......
4 4
(
1st PM 5
)
2nd PM
( ,C \5
1st M \.,}) )
FIG. 13.6 Total tooth material.
FIG. 13. 7 Premolar diameter.
{SN Q.14}
Inference:
PMBAWand PMD are compared.
If PMBAW > PMD - It is an indication that arch
expansion is possible.
If PMAW < PMD -The arch expansion is not possible.
According to Ashley Howe, the ratio between the
apical base width at the premolar region and the total
tooth material is called the premolar basal arch width
percentage.
PMBAW% = PMBAWX 100

TTM
Inference is as follows:
• If PMBAW0/o is 37°/o or less - It indicates need for
extraction.
• If PMBAW0/o is 44°/oor more - Case can be treated
without extracting any teeth.
• If PMBAW0/o is 37°/o-44°/o - The case is a borderline
case.
Q.5. Mixed dentition analysis. Explain one in detail.

Ans.
{SN Q.5}
Various mixed dentition analyses to study the
relationships of tooth size and available space during
mixed dentition period are as follows:
(a) Moyer's mixed dentition analysis
(h) T::in::i'k-::i-Tnhnc:tnn ::in::il,,c:ic:
.l
(a) Moyer's mixed dentition analysis

(b) Tanaka-Johnston analysis
(c) Staley and Kerber analysis
(d) Radiographic method
Moyer's mixed dentition analysis
(i) The purpose of Moyer's analysis is to evaluate
the amount of space available in the arch for
succeeding permanent canines and premolars.
(ii) Moyer's mixed dentition analysis predicts the
combined mesiodistal width of 3, 4 and 5 based
on the sum of widths of four lower permanent

· ·
incisors, ·
i.e. 21 21
(iii) The mesio distal width of

measured and added. The amount of space
is *1
available for 3, 4 and 5 after incisor alignment
is determined by measuring distance between
distal surface of
2 and mesial
surface of
6
(iv) Based on mesiodistal width of 21 21 , I
the expected width of 3, 4 and 5 is predicted by
referring to the probability chart; 75°/o level of
probability is considered reliable.
(v) To determine discrepancy, the predicted tooth
size of 3, 4, 5 is compared with the arch length
available. If predicted value is greater than the
arch length, then crowding is expected.
Q.6. Radiographic method of mixed dentition

analysis.
Ans.
(i) The radiographic method of mixed dental analysis
makes use of both radiograph and study cast to
determine the width of unerupted tooth to
compensate
. for the enlargement of radiographic
image.
(ii) A simple proportionality relationship can be set up
to determine the measurement of unerupted teeth by
studying the teeth that have already erupted in a
radiograph and on cast by the following formula:
True width of tooth that bas erupted and

measured on cast X width of unerupted
Apparent width
tooth on radiograph
of unerupied - --------=---'----
tooth Width of tooth that has erupted and
measured on the radiograph
(iii) Undistorted radiographic image is usually achieved

with individual periapical radiographs. Accuracy of
this method is fair to good, depending on the quality
of radio graphs.
(iv) This technique can be used in maxillary and
mandibular arches for all ethnic groups.
Q.7. Bolton's tooth size ratio.

Ans.
{SN Q.9}
• Bolton's analysis evaluates maxillary and mandibular
teeth for tooth size discrepancies.
• According to Bolton, a ratio exists between
mesiodistal widths of maxillary and mandibular
teeth. Abnormalities in tooth size are responsible for
the occurrence of many malocclusions.
• Bolton's analysis helps in determining disproportion
in size between maxillary and mandibular teeth.
• The parameters considered are as follows:
(i) Sum of mandibular 12 teeth - measured and
summed up value of mesiodistal widths of all
teeth mesial to 7 7 +
(ii) Sum of maxillary 12 teeth - measured and
teeth mesial to 7T 7
(iii) Sum of mandibular 6 teeth - measured and
(iv) Sum of maxillary 6 teeth - measured and
{SN Q.9}
Determination of overall ratio:
.
Sum of mandibular 12 X 100
O vcra U ratio= -----------
Sum of maxillary 12
According to Bolton, sum of mesiodistal width of

mandibular teeth anterior to 7 7 should be -+
91.3°/o of mesiodistal width of maxillary teeth mesial to
7 7
If overall ratio is
<91.3°/o >91.3o/o indicates

Maxillary tooth material excess Mandibular teeth material excess
Calculated by formula
l
Calculated by formula
Mandibular 12 x 100 Maxillary 12 x 91.3
Maxillary 12- ----- Mandibular 12- ----
91.3 100
Determination of anterior ratio:
. . Sum of mandibular 6 X 1000

A ntenor rauo = -----------
Sum of maxillary 6
According to Bolton, sum of mesiodistal width of

mandibular anteriors should be 77.2°/o of mesiodistal
width of maxillary anteriors.
If anteriors ratio is
<77.2o/o >77.2o/o
Indicates maxillary Indicates mandibular
anterior excess anterior excess
l
Calculated as
l
Calculated as
Sum of mandibular Sum of maxillary
Sum of 6x100 Sum of 6 x 77.2
maxillary 6 ----- mandibular 6 -----
77.2 100
Q.8. Kesling tooth positioning.

Ans.
{SN Q.13}
• H.D. Kesling (1956) proposed a diagnostic set-up
which helps clinician to estimate arch length
discrepancy.
• Procedure:
i. Patients maxillary and mandibular study casts
revealing supporting structures to the depth of
sulcus are prepared with their bases parallel to
occlusal plane.
ii. Using a fretsaw blade, horizontal cuts are made
in mandibular cast 3 mm below the gingival
margin, and vertical cuts are made between
individual teeth so that we are able to remove
all teeth except second and third molars.
ill. Mesial and distal ends of the roots of teeth are
trimmed to facilitate seating in a new position.
The mandibular incisors are arranged at 65°
angle to the Frankfort horizontal plane, while
canines and premolars are placed in correct
contact relationship.
iv. If the remaining space is inadequate to receive
the 1st molars, the extractions are indicated so
first premolars are eliminated from the set-up
and 2nd premolars are placed in contact with
canine.
v. Maxillary teeth are cut and repositioned,
articulating with mandibular set-up.
Uses:
• The tooth size-arch length discrepancies can be
directly visualized on the diagnostic set-up.
• Serves as a guide in including extractions and
visualizing complex orthodontic tooth movements
on the study casts.
• It also helps in estimating whether only uprighting
of 2nd molars could solve the problem of arch
length discrepancy.
• Patients can be motivated by simulating tooth
movements on the study casts.
Q.9. Pont's Index.

Ans.
[Same as SE Q.1]
Q.10. Carey's analysis or arch perimeter analysis

Ans.
[Same as SE Q.3]
Q.11. Ashley Howe's index.

Ans.
[Same as SE Q.4]
Q.12. Assessment of tooth mass discrepancy.

Ans.
[Same as SE Q.4]
Q.13. Moyer's mixed dentition analysis.

Ans.
[Same as SE Q.5]
Q.14. Bolton's analysis.

Ans.
[Same as SE Q.7]
Q.15. Kesling's diagnostic set-up.

Ans.
[Same as SE Q.8]
Short notes:
Q.1. Pont's analysis.

Ans.
[Ref SE Q.1]
Q.2. Model analysis.

Ans.
• Evaluation of maxillary and mandibular teeth and
their supporting structures using study casts is
known as model analysis.
• Model analyses can be classified as follows:
i. Analyses to study the size relationships of
groups of teeth
Examples: Bolton's analysis, Peck and Peck ratio
ii. Analyses to study the relationship of teeth size
to the size of supporting structures
Examples: Ashley Howe's analysis, Pont's
analysis
ill. Analyses to study mixed dentition
Examples: Moyer's analysis, Tanaka-Johnston
analysis
iv. Analyses to study the relationship of tooth size
and available space in permanent dentition
Examples: Carey's analysis, Arch perimeter
analysis
Q.3. Carey's analysis.

Ans.
• The arch length and tooth material discrepancy can
be calculated with the help of Carey's analysis.
Carey's analysis is usually done in the lower arch
(cast).
• The same analysis if performed on the upper arch
(cast), it is known as arch perimeter analysis.
• It involves determination of arch length, tooth
material and discrepancy.
• Arch length is measured from mesial surface of the
first permanent molar of one side to the first
permanent molar of the opposite side.
,. .,
• Arch length is measured from mesial surface of the
first permanent molar of one side to the first
permanent molar of the opposite side.
• The tooth material is measured by summing up the
mesiodistal width of individual teeth anterior to the
first molars, i.e. second premolar to second
premolar.
The discrepancy refers to the difference between arch
length and tooth material.
Inference:
If the discrepancy is
0-2.5 mm - It indicates minimum tooth material

excess and suggests proximal stripping to reduce
tooth material.
2.5-5 mm - It indicates need to extract the second
premolar.
>5 mm - It indicates need to extract first premolars.
Q.4. Peck and Peck ratio.

Ans.
i. Chief rationale of Peck concept is stability of rotational
corrections of lower incisors rather than tooth size
considerations.
ii. Calculated as:
. Mesiodistal width X
Peck an d pee k ratio = ------- 100
Faciolingual diameter
iii. Normal ratio for central incisors is 88°/o-92°/o, and for

lateral incisors the ratio is 90°/o-95°/o.
iv. Peck and Peck ratio is used to determine whether
lower incisor teeth are excessively wider
mesiodistally, if so, then proximal slicing is
recommended.
Q.5. Name few model analysis for mixed dentition?

Ans.
[Ref SE Q.5]
Q.6. Linderhearth's ratio.

Ans.
• Linder hearth's ratio is a method of predetermining
the ideal arch width based on mesiodistal width of
crowns of maxillary incisors similar to Pont's Index.
• According to Linderhearth, the ratio of combined
incisor to transverse arch width as measured from
the centre of the occlusal surface of teeth is ideally
0.85 in the first premolar area and 0.65 in the first
molar area.
• The sum of mesiodistal widths of maxillary incisors is
measured and added (SI).
• The calculated premolar value is determined by the
formula: SI/85 x 100.
• The calculated molar value is determined by the
formula: SI/64 x 100.
• Inference is that if the measured value is less than the
calculated value, it indicates the need for expansion.
Q.7. Radiographic method of mixed dentition

analysis.
Ans.
(i) The radiographic method of mixed dental analysis
makes use of both radio graph and study cast.
(ii) A simple proportionality relationship can be set up
to determine the measurement of unerupted teeth by
studying the teeth that have already erupted in a
radiograph and on cast by the following formula:
True width of tooth that has erupted and

measured on cast X width of unerupted
Apparent width
tooth on radiograph
ofunerupled - -----------
tooth Width of tooth that has erupted and
measured on the radiograph
(iii) Accuracy of this method is fair to good, depending

on the quality of radio graphs.
(iv) This technique can be used in maxillary and
mandibular arches for all ethnic groups.
Q.8. Study models - uses.

Ans.
[Ref LE Q.1]
Q.9. Bolton's analysis.

Ans.
[Ref SE Q.7]
Q.10. Tanaka-Johnston analysis.

Ans.
• Tanaka-Johnston analysis is a mixed dentition
analysis.
• It predicts the widths of unerupted canines and
premolars
. . based on the sum of widths of lower
incisors.
Method:
i. Measure the total arch length.
ii. Measure the mesiodistal widths of lower
four incisors and sum it up.
iii. Divide the value obtained by 2 and
• add 10.5 mm to obtain the sum of width
of mandibular canines and premolars in
one quadrant.
• add 11 mm to obtain the sum of widths of
maxillary canines and premolars in one
quadrant.
iv. Formula to calculate the space available
in the arch after the eruption of canines
and premolars is as follows:
Space available = Total arch length - (Sum of
the lower incisors + 2 x calculated width of
canine and premolar).
v. Advantages: It is simple and practical,
requires neither radiographs nor
reference tables, and shows reasonably
good accuracy.
Q.11. Korkhau's analysis?

Ans.
i. Korkhau in 1938 proposed a study model analysis
which reveals anteroposterior malpositioning of
incisors in maxillary and mandibular arches.
ii. A measurement is made from the midpoint of
interpremolar line to a point between the two
maxillary incisors.
iii. According to Korkhau, for a given width of upper
incisors, a specific value of distance between the
midpoint of interpremolar line and the point between
two maxillary incisors should exist.
iv. An increase in this measurement denotes proclined
Q.12. Gnathostatic models?

Ans.
i. Gnathostatic models or gnathostatic casts reproduce
inclination of the occlusal plane with reference to the
Frankfort plane.
ii. Paul Simon developed an instrument called
gnathometer (1928-1934).
Gnathostatics is a diagnostic medium relating teeth
and their base to each other and to the craniofacial
structures.
iii. Simon tried to orient and relate dentition and jaws
with the help of dental study models to cranium. His
effort was to give orthodontist a real insight into the
I
orientation of dentition to facial skeleton in three
planes of space, thereby helping to modulate
two maxillary incisors should exist.
iv. An increase in this measurement denotes proclined
Q.12. Gnathostatic models?

Ans.
i. Gnathostatic models or gnathostatic casts reproduce
inclination of the occlusal plane with reference to the

Frankfort plane.
ii. Paul Simon developed an instrument called
gnathometer (1928-1934).
Gnathostatics is a diagnostic medium relating teeth
and their base to each other and to the craniofacial
structures.
iii. Simon tried to orient and relate dentition and jaws
with the help of dental study models to cranium. His
effort was to give orthodontist a real insight into the
orientation of dentition to facial skeleton in three
planes of space, thereby helping to modulate
treatment plan in the direction of restoration of facial
balance.
Q.13. Kesling's diagnostic set-up.

Ans.
[Ref SE Q.8]
Q.14. Ashley Howe's index.

Ans.
[Ref SE Q.4]
Q.15. Pont's index.

Ans.
[Same as SN Q.1]
Q.16. Arch perimeter analysis.

Ans.
[Same as SN Q.3]
Q.17. Bolton's tooth size ratio?

Ans.
[Same as SN Q.9]
Q.18. Bolton index.

Ans.
[Same as SN Q.9]
III 0 <
Topic 14 Biology and mechanics of
tooth movement
Long essays:
1. Define optimal orthodontic force. Discuss tissue
changes subsequent to light and heavy forces.
2. What are the theories of tooth movement? What

factors affect the tooth movement?
3. What are the different types of tooth movement?
4. Discuss the biochemical principles involved in
orthodontic tooth movement and add a note on
undermining resorption.
5. Describe the tissue changes subsequent to
orthodontic force application. [Same as LE Q.1]
6. Discuss the histological changes during
orthodontic tooth movement. [Same as LE Q.1]
7. Describe the various histological tissue changes
during active orthodontic treatment. [Same as LE
Q.1]
8. What are different theories of tooth movement?
Discuss the pressure-tension theory in detail.
[Same as LE Q.2]
9. Describe the blood flow theory of tooth movement.
[Same as LE Q.2]
10. What are the various theories that are involved
in the biology of orthodontic tooth movement?
Discuss in detail. [Same as LE Q.2]
Short essays:
1. Explain frontal resorption.
2. Response of bone and periodontium to orthodontic
force at tension zone.
3. Enumerate the various types of tooth movements.
4. Undermining resorption.
5. Enumerate various phases of tooth movements.
6. What is bodily tooth movement? [Same as SE Q.3]
Short notes:
1. Ideal orthodontic force.
2. Name theories of tooth movement.
3. Types of orthodontic force.
4. Piezoelectric theory.
5. Undermining resorption. [Same as SE Q.4]
6. Explain frontal resorption. [Ref SE Q.1]
7. Interrupted force.
8. Physiologic tooth movement.
9. Centre of resistance.
10. Root resorption.
11. Blood flow theory to explain tooth movement.
12. Intrusion.
13. Bodily movement.
14. Define force.
15. Name various types of tooth movements. [Ref SE
Q.3]
16. Force and couple.
17. Write three advantages of optimum orthodontic
force.
18. Optimum orthodontic force. [Same as SN Q.1]
Solved answers
Long essays:
Q.1. Define optimal orthodontic force. Discuss tissue

changes subsequent to light and heavy forces.
Ans.
• Optimum orthodontic force is the one which moves
teeth most rapidly in the desired direction with least
possible damage to tissue and with minimum patient
discomfort.
• Optimum orthodontic force = capillary pulse
pressure, i.e. 20-26 gm/cm2 of root surface area.
Characteristics of optimum orthodontic force from

I
a. Clinical point of view b. Histological point of view
i. Produces rapid tooth i. Vitali~ of tooth and
movement supporting PL is
ii. Minimum patient maintained
discomfort ii. Initiates maximum
iii. Minimum lag phase cellular response
of tooth movement iii. Produced direct frontal
iv. No marked mobili~ resorption
of teeth being moved
Tissue changes subsequent to orthodontic force

application:
When force is applied on a tooth to bring about
orthodontic movement, it results in formation of:
i. Areas of pressure (in the direction of tooth movement)
- Bone subjected to pressure reacts by bone
resorption.
ii. Areas of tension (in the opposite direction) - Bone
subjected to tension exhibits bone deposition.
iii. When tooth is moved due to application of
orthodontic force, there is bone resorption on
pressure side and new bone formation on tension
side.
iv. Histological changes during tooth movements are
studied under two headings:
Changes following application of:
i. Mild force
ii. Extreme force
i. Changes following application of mild force are
as follows:
Changes on pressure side (tooth movement side):
• Periodontal ligament compressed to one-third
of its original thickness.
• Marked t in vascularity of periodontal ligament
due to t capillary blood supply - mobilization
of cells fibroblasts and osteoclasts.
• Osteoclasts lie in shallow depressions of bone
called Howship's lacunae - They start
resorbing bone.
• When the forces applied are within
physiological limits, the resorption is seen in
the alveolar plate immediately adjacent to the
ligament. This kind of resorption is called
frontal resorption.
• Change in orientation of bony trabeculae is
seen several weeks after continued
orthodontic force application.
• The trabeculae are usually parallel to long axis
of teeth and they become horizontally
oriented, i.e. parallel to direction of
orthodontic force.
• The trabecular pattern reverts to normal
during retention phase of treatment.
Changes on tension side (area of tooth opposite to
direction off orce):
• Periodontal ligament gets stretched - Distance
between alveolar bone and tooth is widened.
• t Vascularity is seen (just as on pressure side) -
Mobilization of cells, fibroblasts, osteoblasts.
• In response to this traction, osteoid is laid down
by osteoblasts in periodontal ligament
immediately adjacent to the lamina dura. This
lightly calcified bone in due course matures to
form woven bone.
Secondary remodelling changes:
• When the force is applied to move teeth, the
bone immediately adjacent shows osteoclastic
and osteoblastic activities on the pressure and
tension sides, respectively.
• In addition, bony changes also take place else
where to maintain the width or thickness of
the alveolar bone.
These changes are called secondary
remodelling changes, e.g. if a tooth is being
moved in labial direction, there is
compensatory deposition of new bone on
the outer side of labial alveolar bony plate
and a compensatory resorption on the
lingual side of lingual alveolar bone.
Tooth moved in -
labial direction
• Secondary remodelling changes seen following

application of bodily force in labial direction.
• These compensatory structural alterations maintain
the thickness of supporting alveolar process even
though tooth may be moved over a distance several
times greater than thickness of alveolar bony plates.
ii. Changes following application of extreme forces:
• When extreme forces are applied to teeth -
............. - o- - _ - - - - J .["" _
ii. Changes following application of extreme forces:

• When extreme forces are applied to teeth -
Crushing or total compression of periodontal
ligament occurs.
• On pressure side - Root closely approximated
lamina dura, compresses periodontal ligament and
leads to occlusion of blood vessels.
• Ligament is deprived of its nutritional supply,
leading to regressive changes called hyalinization.
• In this case, bone cannot resorb in the frontal
portion adjacent to the teeth, rather bone
resorption occurs in adjacent marrow spaces and

in the alveolar plate below, behind and above the
hyalinized zones. This kind of resorption is called
as undermining resorption or rearward
resorption.
• On tension side - Periodontal ligament is
overstretched, leading to tearing of Blood vessels
(BVs) and ischaemia.
• When extreme force is applied during orthodontic
tooth movement, there is a net t in osteoclastic
activity as compared to bone formation, with the
result that the tooth becomes loosened in its
socket.
• Pain and hyperemia of the gingiva may occur.
• Hyalinization: It is a form of tissue degeneration
characterized by formation of a clear, eosinophilic,
homogenous substance.
Conventional process of hyalinization is an
irreversible process whereas hyalinization of
periodontal ligament is a reversible process.
During almost all the forms of orthodontic tooth
movement, hyalinization of periodontal
ligament on the pressure side occurs in some
areas. These areas are wider when force is
applied in extreme.
Changes observed during formation of hyalinized
zones are as follows:
i. There is a gradual shrinkage of
periodontal ligament fibres.
ii. Cellular structures become indistinct;
some nuclei become smaller (pycnotic),
while some nuclei disappear.
iii. Compressed collagenous fitness
gradually unites into a more or less cell-
free mass.
iv. Certain changes occur in ground
substance.
v. There is a breakdown of blood vessel
walls leading to spilling of their contents.
vi. Osteoclasts formed in marrow spaces
and adjacent areas of inner bone surface
after a period of 20-30 h.
Presence of hyalinized zone:
• Periodontal ligament nonfunctioning and bone
resorption cannot occur.
• Tooth is not capable of further movement until
local damaged tissue is removed and adjacent
alveolar bone wall resorbs.
Elimination of hyalinized zone:
• The two mechanisms involved are:
i. Resorption of bone by
osteoclasts differentiating in
peripheral intact periodontal
ligament and in adjacent
marrow spaces.
ii. Invasion of cells and blood
vessels from the periphery
of compressed zone by
which necrotic tissue is
removed by enzymatic
action and phagocytosis.
• Greater the force - wider the areas of
hyalinization - large areas of periodontal
ligament become functionless, thereby
showing large areas of rearward resorption.
• Light forces - hyalinized zones are smaller -
large areas of functional ligament available
and frontal resorption predominates in case of
lighter forces.
Nature of tooth movement and location of hyalinized
tissue:
Tipping tooth movement - hyalinization close to

alveolar crest
Bodily tooth movement - hyalinization close to mid-
portion of root
Excessive forces applied during tipping - two areas of
hyalinization: one in apical and another in marginal
area
Areas of bony prominences and spicules usually result
in areas of hyalinization.
Q.2. What are the theories of tooth movement? What

factors affect the tooth movement?
Ans.
Certain theories have been put forward to explain
mechanism of movement of a tooth by an orthodontic
force.
Accepted theories are as follows:
i. Pressure tension theory- Schwarz (1932)
ii. Fluid dynamic theory/blood flow theory - Bein
iii. Bone bending piezoelectric theory- Farrar (1876)
Pressure tension theory:
• According to Schwarz - Whenever tooth is
subjected to orthodontic force, it results in areas of
pressure and tension.
• The area of periodontium in direction of tooth
movement -+ is under pressure -+ shows bone
resorption.
• The area of periodontium opposite to tooth
movement -+ is under tension -+ shows bone
deposition.
Fluid dynamic theory:
• This theory is also called blood flow theory as
proposed by Bein.
• According to this theory - tooth movement occurs
as a result of alterations in fluid dynamics in
periodontal ligament.
• Periodontal ligament - occupies periodontal space
between tooth and alveolar socket.
• Periodontal space -+ consists of fluid system -+
made of interstitial fluid, cellular elements and
blood vessels viscous ground substance, in
addition to periodontal fibres.
• When force of greater magnitude and direction is
applied during orthodontic tooth movement __, the
interstitial fluid in periodontal ligament squeezes
out and moves towards apex and cervical margins
and results in decreased tooth movement -+ called
Squeeze Film Effect by Bien.
• When orthodontic force is applied, it results in -+
compression of periodontal ligament.
• Blood vessels of periodontal ligament are trapped
between principal fibres -+ results in their
'stenosis' __, The vessel above stenosis then
balloons, resulting in formation of 'aneurysm'
(which are minute walled sacs of fluid).
• Bien suggested that there is alteration in the
chemical environment at the site of vascular
stenosis due to decreased 02 level in compressed
area as compared to tension side.
• The formation of these aneurysms and vascular
stenosis causes blood gases to escape into the
interstitial fluid, thereby creating a favourable
local environment for resorption.
Bone bending and piezoelectric theories of tooth
movement: Farrar (1876)
• Farrar (1876) first noted deformation or bending of
interseptal alveolar walls.
• He was first to suggest that bone bending may be a
possible mechanism for bringing about tooth
movement.
• Peizoelectricity is a phenomenon observed in many
crystalline materials in which a deformation of
crystal structure produces a flow of electric
current because of displacement of electrons from
one part of the crystal lattice to the other. A small
electric current is generated when bone is
mechanically deformed.
• The possible sources of electric current are:
a.Collagen
b. Hydroxyapatite
c. Collagen hydroxyapatite interface (the junction
between the collagen and hydroxypatite crystals
when bent can be a source of piezoelectricity).
d. Mucopolysaccharide fraction of ground
substance is not crystalline but it may also
possess the ability to generate electric current
when deformed.
• When crystal structure is deformed, the electrons
migrate from one location to another -+ resulting
in electric charge.
• When force is released, the crystals return to their
original shape and a reverse flow of electrons is
observed.
• Two unusual characteristics:
i. Quick decay rate - This piezoelectric signal
quickly dies away to zero even though the force
is maintained.
ii. When the force is released, electron flow in the
opposite direction is seen.
• On application of force on a tooth, the adjacent
alveolar bone bears:
Areas of concavity in bone associated with
negative charge __, evoke bone deposition.
Areas of concavity associated with positive
charge __, evoke bone resorption.
On application of force __, alveolar and
medullary cortical plates of bone move
together closely - bone becomes less concave
-+ electrical signal associated with resorption
is established
• The bone which is deformed by stress becomes
electrically charged. Concave surfaces attain
negative polarity and convex surfaces a positive
polarity.
• As a result of these electrical signals, a
remodelling response is evoked; bone is added to
concave surfaces and resorbed from convex
surfaces.
Q.3. What are the different types of tooth

movement?
Ans.
Different types of orthodontic tooth movements are as
follows:
i. Tipping
ii. Pure translation
iii. Root movement
iv. Rotation
i. Tipping
• Tipping is the simplest type of tooth movement that
can easily be carried out with application of a
i. Tipping
• Tipping is the simplest type of tooth movement that
can easily be carried out with application of a
single force to the crown.
• It is of two types:
a. Uncontrolled tipping
b. Controlled tipping
a. Uncontrolled tipping
• Uncontrolled tipping is produced when a single
force is applied to the crown of a tooth, where
the crown moves in one direction and the root
moves in opposite direction.

• In uncontrolled tipping, the centre of rotation is
in-between the centre of resistance and apex
of the root.
• Force required: 35-60 g.
• The distribution of load is such that the
periodontal ligament is stressed near the apex
on the same side as the applied force and at
the crest of the alveolar bone on the opposite
side.
• It is useful when incisors have to be proclined.
b. Controlled tipping
• This is a desirable tooth movement as
compared to uncontrolled tipping.
• Centre of rotation is at the root apex and crown
moves in one direction and there is minimal or
no movement of the root in opposite direction.
• Force required is the same as that of
uncontrolled tipping in the range of 35-60 g.
• Minimum stress of the periodontal ligament at
root apex. This prevents root movement.
• It is useful in retraction of excessively
proclined incisors when roots are normally
positioned.
ii. Pure translation
• In translation, crown and root move in the same
direction to the same distance.
• When two forces are applied simultaneously to the
crown of the tooth, the applied force passes
through the centre of resistance, and translation of
a tooth occurs.
• Pure translation is of three types:
a. Bodily movement
b. Intrusion
c. Extrusion
a. Bodily movement
• This is the most desirable type of tooth
movement.
• In bodily movement, crown and root move to
the same distance in the same direction, either
lingually or labially.
• The force applied is 70-120 g and the centre of
rotation is at infinity.
• Uniform stress pattern is seen in the
b. Intrusion
• It is defined as the axial movement of the tooth
along the long axis towards the apex of the
root.
• This tooth movement requires minimum force,
and the centre of rotation passes through the
centre of resistance.
• 10-20 g of force is required and the periodontal
ligament at the apex is compressed over a
small area and no areas of tension exist.
c. Extrusion
• Extrusion is defined as the axial movement of
the tooth along the long axis towards the
coronal part.
• 35-60 g of the force is required.
• No areas of compression in periodontal
ligament, only stretched areas are seen.
iii. Root movement
• This is the opposite of crown tipping, and crown of
a tooth is kept stationary, while the root moves
labiolingually or mesiodistally.
• Root movement is mainly used to torque the incisor
and upright the tipped teeth.
• There are two types of root movements:
a. Torque
b. Uprighting
a. Torque
• Labiolingual root movement is known as
torque.
b. Uprighting:
• This is nothing but mesiodistal root movement
with centre of rotation at incisal edge.
• 50-100 g of force is required.
• The stress is greatest at the apex and decreases
gradually to the cervical level.
iv. Rotation:
• Spinning of the tooth around its long axis.
Or
A displacement of the body, produced by a couple,
characterized by the centre of rotation
coinciding with the centre of resistance is known
as rotation.
• Pure rotations can be divided into two types:
a. Transverse rotation: The tooth displacement
during which the long-axis orientation changes
is known as transverse rotation, e.g. tipping and
torquing.
b. Long-axis rotation: In this type of tooth
displacement, the angulation of the long axis is
not altered, e.g. rotation of a tooth around its
long axis.
Generalized rotation:
• Any movement that is not pure translation or
rotation can be described as a combination of
both translation and rotation and can be termed
as generalized rotation. This type of movement
can be seen during routine clinical practice.
Q.4. Discuss the biochemical principles involved in

orthodontic tooth movement, and add a note on
undermining resorption.
Ans.
• When orthodontic force is applied onto a tooth, it
results in a number of biophysical events such as
compression of periodontal ligament, bone
deformation and tissue injury.
• Decreased vascularity and overstretching of
periodontal ligament induces chemical changes and
inflammatory type of response is elicited.
• The biophysical events in turn lead to certain
biochemical reactions at a cellular level which brings
about the release of some extracellular signalling
molecules called first messengers.
• They include hormones such as parathormone (PTH),
local chemical mediators, such as prostaglandins,
and neurotransmitters such as substance P and
vasoactive intestinal polypeptide (VIP).
First messengers:
• Prostaglandin becomes the first messengers.
Prostaglandin E plays a major role in the cellular
differentiation.
• Other first messengers are PTH, substance P,
vasoactive peptides.
• They bind to the cell surface receptors and activate
the extracellular signals.
Second messengers:
• Conversion of extracellular signal into an
intracellular signal is the next step in cellular
differentiation.
• The first messengers bind to receptors present on
the cell surface of target cells and initiate a process
of intracellular signalling.
• The conversion of extracellular into intracellular
signal takes place by two pathways.
i. Conversion of ATP into cyclic AMP.
ii. Opening of calcium ion channel and activate
ca++.
• The intracellular signalling results in formation of
second messengers, which include cAMP, cyclic
GMP and calcium.
• The formation of second messengers inside the cells
is believed to initiate formation of bone cells,
namely osteoclasts and osteoblasts, which are
responsible for bone remodelling.
• It takes nearly 4 h of sustained pressure to produce
second messengers; hence any appliance has to be
worn for a minimum period of 4-6 h to produce
effects.
Third messengers:
• Within the cells, the cAMP and Ca" act on the
protein kinase enzymes, which are the third
messengers.
• Protein kinase causes phosphorylation of the cells.
• Phosphorylation results in differentiation and
activation of osteoclasts and osteoblast, which
ultimately produce bone remodelling.
As the remodelling of bony socket starts, the tooth
movement begins.
Q.5. Describe the tissue changes subsequent to

orthodontic force application.
Ans.
[Same as LE Q.1]
Q.6. Discuss the histological changes during

orthodontic tooth movement.
Ans.
[Same as LE Q.1]
Q.7. Describe the various histological tissue changes

during active orthodontic treatment.
Ans.
[Same as LE Q.1]
Q.8. What are different theories of tooth movement?

Discuss the pressure-tension theory in detail.
Ans.
[Same as LE Q.2]
Q.9. Describe the blood flow theory of tooth

movement.
Ans.
[Same as LE Q.2]
Q.10.What are the various theories that are involved

in the biology of orthodontic tooth movement?
Discuss in detail.
Ans.
[Same as LE Q.2]
Short essays:
Q.1. Explain frontal resorption.

Ans.
{SNQ.6}
• Frontal resorption is a type of tissue change at
pressure zone in orthodontic tooth movement
following application of light force.
• Frontal resorption is also called periosteal resorption
or direct resorption or forward resorption.
Changes on pressure side (tooth movement side) are as
follows:
• Periodontal ligament compressed to one-third of its
ortzinal thickness.
Changes on pressure side (tooth movement side) are as
follows:
• Periodontal ligament compressed to one-third of its
original thickness.
• Marked t in vascularity of periodontal ligament due
to t capillary blood supply - mobilization of cells
fibroblasts and osteoclasts.
• Osteoclasts lie in shallow depressions of bone called
Howship's lacunae - they start resorbing bone.
{SN Q.6}
• When the forces applied are within physiological
limits, the resorption is seen in the alveolar plate

immediately adjacent to the ligament. This kind of
resorption is called frontal resorption.
• In frontal resorption, the resorption process is
initiated from the periodontal ligament side of
the alveolar bone.
{SN Q.6}
• Frontal resorption usually takes place after two
days following orthodontic force application.
Q.2. Response of bone and periodontium to

orthodontic force at tension zone.
Ans.
The response of bone and periodontium at tension zone
on application of orthodontic force is as follows:
• As compared to pressure zone, the cellular activity is
delayed in areas of tension.
It takes around 30 h for increased cellular activity to
be seen in tension zone.
• The stretched periodontal fibres are reconstructed by
changes of the original fibrils.
• In the areas of tension, macrophages are found in
great numbers and there is inflammatory type
change like breakdown and rebuilding of fibrous
elements.
• Around the parts of the fibres that are close to the
alveolar wall, new unmineralized matrix is laid
down.
• After some time, osteoid is laid on the whole of the
alveolar wall on the tension side.
• Osteoblasts synthesize the osteoid. Subsequently,
mineralization of osteoid takes place.
• Rate of bone deposition is about 30 microns/day.
Q.3. Enumerate the various types of tooth

movements.
Ans.
{SN Q.15}
Various types of orthodontic tooth movements are as
follows:
i. Tipping:
a. Controlled tipping
b. Uncontrolled tipping
ii. Pure translation:
a. Bodily movement
b. Intrusion
c. Extrusion
iii. Root movement
a.Torque
b. Uprighting
iv. Rotation
Bodily movement:
• Bodily movement is a type of pure translation.
• In translation, crown and root move in the same
direction to the same distance.
• When two forces are applied, simultaneously to the
crown of the tooth, the applied force passes
through the centre of resistance and translation of
a tooth occurs.
• This is the most desirable type of tooth movement.
• In bodily movement, crown and root move to the
same distance in the same direction, either
lingually or labially.
• Uniform stress pattern is seen in the periodontal
ligament.
Q.4. Undermining resorption.

Ans.
{SN Q.5}
• Undermining resorption is also known as indirect
resorption.
• The term 'undermining resorption' was coined by
Sandstedt.
• This is a type of tissue change at pressure zone in
orthodontic tooth movement following application of
heavy force.
• When extreme forces are applied to teeth - crushing
or total compression of periodontal ligament occurs.
• On pressure side, root closely approximates lamina
dura, compresses periodontal ligament and leads to
occlusion of blood vessels.
• Ligament is deprived of its nutritional supply, leading
to regressive changes called hyalinization.
• Once hyalinization occurs in periodontal ligament,
frontal resorption is not possible.
• In this case, bone cannot resorb in the frontal portion
adjacent to the teeth; rather bone resorption occurs
in adjacent marrow spaces and in the alveolar plate
below, behind and above the hyalinized zones. This
kind of resorption is called undermining resorption
or rearward resorption.
• When extreme force is applied during orthodontic
tooth movement, there is a net t in osteoclastic
activity as compared to bone formation, with the
result that the tooth becomes loosened in its socket.
• This method of resorption is called undermining
resorption because the attack is from the underside
of lamina dura.
Q.5. Enumerate various phases of tooth movements.

Ans.
• Burstone categorized the stages or phases of tooth
movement as follows:
• Three phases of tooth movement are
a. Initial phase
b. Lag phase
c. Postlag phase
a. Initial phase:
• Very rapid tooth movement occurs over a
short distance and then stops.
• This movement represents displacement of
tooth in periodontal ligament space and
probably bending of alveolar bone to certain
extent.
• Both light and heavy forces displace tooth to
the same extent. In this phase, tooth
movement is between 0.4 and 0.9 mm in a
week's time.
b. Lag phase:
• This phase represents the period of
hyalinization, characterized by formation of
hyalinized tissue in periodontal ligament.
• During this phase, little or no tooth
movement occurs.
• Duration of lag phase depends upon the
amount of force used to move the tooth,
usually extends up to 14 days.
• When light forces are applied - areas of
hyalinization are small and frontal
resorption occurs - lesser will be the
duration of lag phase.
• Heavy forces - areas of hyalinization are
large - rearward resorption occurs - longer
will be the duration of lag phase to eliminate
hyalinized tissue.
c. Postlag phase:
• Tooth movement progresses rapidly as the
hyalinized zone is removed and bone
resorption occurs directly facing periodontal
ligament.
• Periodontal ligament is widened.
Q.6. What is bodily tooth movement?

Ans.
[Same as SE Q.3]
Short notes:
Q.1. Ideal orthodontic force.

Ans.
• Ideal or optimum orthodontic force is the one which
moves teeth most rapidly in the desired direction
with least possible damage to tissue and with
minimum patient discomfort.
• Optimum orthodontic force = capillary pulse
pressure, i.e. 20-26 g/cm2 of root surface area.
• From clinical point of view, it produces rapid tooth
movement with minimum patient discomfort and
minimum lag phase and no marked mobility of teeth
being moved.
• From histological point of view, vitality of tooth and
supporting periodontal ligament is maintained and it
produces direct frontal resorption.
Q.2. Name theories of tooth movement.

Ans.
• Certain theories have been put forward to explain
mechanism of movement of a tooth by an
orthodontic force.
• Accepted theories are as follows:
i. Pressure tension theory- Schwarz (1932)
ii. Fluid dynamic theory/blood flow theory - Bein
iii. Bone bending piezoelectric theory - Farrar
(1876)
Q.3. Types of orthodontic force.

Ans.
• Based on the duration and decay rate, orthodontic
force is classified by Proffit as follows:
a. Continuous force
b. Interrupted force
c. Intermittent force
a. Continuous force:
• In this type, between the two successive visits
of the patient, force is maintained at some
appreciable fraction of the original force.
• The force level does not decline to zero.
• For the continuous force to be effective, it has
to be a light continuous force.
b. Interrupted force:
• In this type of force, the force level reduces to
zero between the two successive visits of the
patient.
• Both light and heavy interrupted forces are
clinically acceptable, e.g. fixed appliance.
c. Intermittent force:
In this type of force, there is a sudden drop of
force to zero level when the orthodontic
I
appliance is removed by the patient.
Intermittent force acts as an impulse or a shock
for short periods with a series of interruptions.
Example: functional appliances
Q.4. Piezoelectric theory.

Ans.
• Bone bending and piezoelectric theories of tooth
mrYvPmPnt - J:';:irr;:ir (1 R7h)
Q.4. Piezoelectric theory.
Ans.
• Bone bending and piezoelectric theories of tooth
movement - Farrar (1876)
• Farrar was the first to suggest that bone bending may
be a possible mechanism for bringing about tooth
movement.
• Peizoelecticity is a phenomenon observed in many
crystalline materials in which a deformation of the
crystal structure produces a flow of electric current
as a result of displacement of electrons from one part
of the crystal lattice to the other. A small electric

current is generated when bone is mechanically
deformed.
• Both bone and collagen have piezoelectric property.
Q.5. Undermining resorption.

Ans.
[Same as SE Q.4]
Q.6. Explain frontal resorption.

Ans.
[Ref SE Q.1]
Q.7. Interrupted force.

Ans.
• Interrupted force is a type of orthodontic force.
• In this type of force, the force level reduces to zero
between the two successive visits of the patient.
• Both light and heavy interrupted forces are clinically
acceptable, e.g. fixed appliance.
Q.8. Physiologic tooth movement.

Ans.
• Physiologic tooth movement designates primarily the
slight tipping of the functioning tooth in its socket,
and secondarily, the changes in tooth position that
occur in young persons during and after tooth
eruption.
• It is of the following types:
i. Movement during mastication
ii. Eruption of tooth
iii. Tooth migration
i. Movement during mastication
During chewing, the teeth tip slightly around the
neutral axis as fulcrum and are also displaced
because of bending of the alveolar process.
Movement during mastication is transient.
ii. Eruption of tooth
Different teeth move in different directions
during eruption.
iii. Migration of teeth
Migration of teeth is a slow tooth movement,
usually in mesial and occlusal directions.
These movements take place to compensate for
interproximal attrition and occlusal wear.
Q.9. Centre of resistance.

Ans.
• Centre of resistance is defined as the point in the
object at which the resistance to movement is at the
maximum.
• The centre of resistance of tooth is variable, it
depends on:
i. Root morphology
ii. Number of roots
iii. Level of alveolar bone support
iv. Root length
• Application of force to the centre of resistance of the
tooth produces true bodily movement.
Q.10. Root resorption.

Ans.
• Root resorption is more evident when heavy
orthodontic forces are applied.
• Excessive force and prolonged duration of treatment
increase the chances of resorption.
• Types of resorption:
Generalized resorption
Localized resorption
• Most of the teeth exhibit some loss of root after
orthodontic treatment. There is generalized
shortening of root seen in majority of orthodontic
patients.
• Orthodontic treatment causes severe localized
resorption. Maxillary incisors are more prone to
resorption.
• One of the most important causes of root resorption
in anteriors and molars is pressing of the roots
against the cortical plate.
• Root resorption index:
Grade I: irregular root contour
Grade II: root resorption < 2 mm at the apex
Grade III: root resorption 2 mm to one-third of root
length
Grade IV: root resorption > one-third of root length
Q.11. Blood flow theory to explain tooth movement.

Ans.
• The fluid dynamic theory is also called the blood flow
theory as proposed by Bein.
• According to this theory, tooth movement occurs
because of alterations in fluid dynamics in
• When orthodontic force is applied, it results in the
compression of periodontal ligament.
• Blood vessels of periodontal ligament are trapped
between principal fibres, resulting in their 'stenosis'.
The vessel above stenosis then balloons, resulting in
formation of 'aneurysm'.
• Bien suggested that there is alteration in the chemical
environment at the site of vascular stenosis due to
decreased 02 level in compressed area as compared
to tension side.
• The formation of these aneurysms and vascular
stenosis causes blood gases to escape into the
interstitial fluid, thereby creating a favourable local
environment for resorption.
Q.12. Intrusion.
Ans.
• Intrusion is defined as the axial movement of the
tooth along the long axis towards the apex of the
root.
• This tooth movement requires minimum force and
centre of rotation passes through the centre of
resistance.
• 10-20 g of force is required and the periodontal
ligament at the apex is compressed over a small area
and no areas of tension exist.
Q.13. Bodily movement.

Ans.
• Bodily movement is a pure translation movement.
• This is the most desirable type of tooth movement.
• In bodily movement, crown and root move to the
same distance in the same direction, either lingually
or labially.
• Uniform stress pattern is seen in the periodontal
ligament.
Q.14. De.fine force.

Ans.
• Force is a load or external influence applied to a body
that changes or tends to change the position of that
body.
• It is measured in grams or ounces.
• Types of force are as follows:
i. Compression
ii. Tension
iii. Shear force
Q.15. Name various types of tooth movements.

Ans.
[Ref SE Q.3]
Q.16. Force and couple.

Ans.
• Force is a load or external influence applied to a body
that changes or tends to change the position of that
body.
• Being a vector, force has a definite magnitude, a
specific direction and a point of application.
• Couple is a pair of concentrated forces having equal
magnitude and opposite direction with parallel but
noncollinear line of action.
• A couple when acting upon a body brings about pure
rotation.
Q.17. Write three advantages of optimum

orthodontic force.
Ans.
The advantages of optimum orthodontic force are as
follows:
• Efficient tooth movement is possible.
• Resorption is mainly of the frontal type.
• Elimination of lag phase and hyalinized zone.
• Less amount of pain and no damage to the supporting
structures.
• Chances for root resorption are minimal.
Q.18. Optimum orthodontic force.

Ans.
[Same as SN Q.1]
Topic 15 Anchorage
Long essays:
1. Define anchorage. Explain in detail different types
of anchorage with examples.
2. Define reinforced anchorage. Discuss method of
reinforcing anchorage.
3. Define and discuss the various anchorage
situations in removable and fixed appliances.

4. Define anchorage. Classify and explain
orthodontic anchorage with examples. [Same as
LE Q.1]
5. Define anchorage. Discuss classification of
anchorage. Explain intermaxillary anchorage.
[Same as LE Q.1]
6. Define orthodontic anchorage. Classify them.
Discuss the uses of extraoral anchorage in
orthodontics. [Same as LE Q.1]
7. Classify anchorage. Explain when, why and how
would you like to reinforce it. [Same as LE Q.2]
Short essays:
1. Define anchorage. Write Nanda's classification of
anchorage.
2. Extraoral anchorage.
3. Reinforced anchorage.
4. Intermaxillary anchorage.
5. Reciprocal anchorage.
Short notes:
1. Define anchorage.
2. Extraoral anchorage. [Ref SE Q.2]
3. Reciprocal anchorage. [Ref SE Q.5]
4. Intermaxillary anchorage.
5. Stationary anchorage. [Ref LE Q.1]
6. Simple anchorage. [Ref LE Q.1]
7. Define anchorage. Classify it with respect to
number of teeth used. [Ref LE Q.1]
8. Define reciprocal anchorage. Give examples of
reciprocal anchorage.
9. Define anchorage. Enumerate methods of
10. Cortical anchorage. [Ref LE Q.1]
11. Factors affecting anchorage.
12. Anchorage loss.
13. Anchorage in orthodontics. [Same as SN Q.1]
14. Define anchorage in orthodontics. Give White and
Gardiner's classification. [Same as SN Q.1]
15. Extraoral sources of anchorage. [Same as SN Q.2]
16. Baker's anchorage. [Same as SN Q.4]
17. What is reinforced anchorage? Give two
examples. [Same as SN Q.9]
Solved answers
Long essays:
Q.1. Define anchorage. Explain in detail different

types of anchorage with examples.
Ans.
{SN Q.7}
• Graber defined anchorage as 'the nature and degree
of resistance to displacement offered by an anatomic
unit when used for the purpose of effecting tooth
movement'.
• Proffit defined anchorage as resistance to unwanted
tooth movement.
Classification of anchorage:
A. Moyer has classified anchorage in the following
ways:
I Acc:ot\lno lo m1nnor ot torGe -..11C1110t1
.......... 111ry b 1n,.-111y

,-..o, ,
~.,ot trom IN,..,. f/lfl)
ta)ln11l11CW11 (bibhaonl (cl Mon<ul•

l
S
(I) lnnmrullfy
I
1,)...,mmlllfy l I
L :~:.., J• Rtaproal
·~
I
,Cr_
Ctr.al
FICIII ;,,
I S.OQII (OIJ P,lffilly anchcw>Qt

c-aoo '""""-0 cnt ... n,
Various types of anchorage are discussed in detail

below:
I. According to manner off orce application
a. Simple anchorage
b. Stationary anchorage
c. Reciprocal anchorage
{SN Q.6}
a. Simple anchorage
• It is the 'Dental anchorage in which manner and
application of force is such that it tends to change
the axial inclination of tooth or teeth that form the
anchorage unit'.
• The simple anchorage is nothing but resistance of
the anchorage unit to tipping.
• The combined root surface area of the teeth
forming the anchorage unit must be doubled that
of the teeth to be moved.
• Simple anchorage has a low resistance value.
{SN Q.5}
b. Stationary anchorage
• Stationary anchorage is defined as 'the dental
anchorage in which the manner and application of
force tend to displace the anchorage unit bodily'.
• Simply, the resistance to bodily movement is called
the stationary anchorage.
• An anchor tooth or source which does not move
against the forces of teeth to be pulled is the
stationary anchorage.
Examples:
i. Retraction of maxillary incisors using
molars as anchor teeth.
ii. In real sense, only extraoral source of
anchorage derived from headgears would
be the best example of stationary
anchorage.
c. Reciprocal anchorage
• The reciprocal anchorage is said to exist when
two teeth or two sets of teeth move to an equal
extent in an opposite direction.
• In reciprocal anchorage, the force applied for
tooth movement is dissipated to both active and
reactive components and the desired tooth
movement occurs by the movement of both
units.
• Teeth may need to be pulled against each other to
close the spaces.
Examples:
i. Closure of midline diastema
ii. Use of crossbite elastics to correct single-
tooth crossbite and class II malocclusion
with intermaxillary elastics
iii. Dental arch expansion
II. According to jaws involved
a. Intramaxillary (anchorage from the same jaw)
b. Intermaxillary (anchorage from both jaws)
a. Intramaxillary anchorage
• When all the anchorage units as well as the
teeth to be moved are situated within the
same jaw, the anchorage is described as
intramaxillary anchorage.
• Here, the appliances are placed in only one
jaw, either maxilla or mandible.
• It may be simple, stationary or reciprocal
type of resistance.
Example: elastic chains used to retract the
anterior segment using posterior teeth as
anchorage units
b. Intermaxillary anchorage
• It is also known as 'Baker's anchorage'.
• When the anchorage units situated in one
jaw are used to bring about tooth movement
in the opposing jaw, the anchorage is called
intermaxillary anchorage.
Examples:
• Class II elastics worn from mandibular molars
to maxillary anteriors are used to retract
maxillary anteriors.
• Class III elastics worn from maxillary molars to
mandibular anteriors are used to retract
mandibular anteriors.
III. According to the site of anchorage
a. Intraoral
b. Extraoral
c. Muscular
a. Intraoral anchorage
Intraoral anchorage is classified as follows:
i. Intramaxillary
ii. Intermaxillary
• Intraoral anchorage is an anchorage in which
all the anchorage units are situated inside
the oral cavity.
• Various sources of intraoral anchorage are as
follows:
i. Teeth
ii. Palate
iii. Lingual alveolar bone of the mandible
• When all the anchorage units and the teeth to
be moved are situated within the same jaw,
it is described as intramaxillary anchorage.
• When the anchorage units situated in one
jaw are used to bring about tooth movement
in the opposing jaw, the anchorage is called
intermaxillary anchorage.
Example: correction of class II and III
malocclusions using intermaxillary elastics
b.Extraoralanchorage
• Extraoral anchorage is an anchorage situation
wherein the anchorage units are situated outside
the oral cavity.
• Various types of extra anchorage are as follows:
i. Cervical
ii. Cranial
iii. Occipital
iv. Facial
• It is also used as a form of reinforced
anchorage.
• Extraoral anchorage is usually used to
correct skeletal problems.
• Various extraoral sources of anchorage are
headgear, face mask, chin cup, etc.
• Various sites of extraoral anchorage with
examples:
Occipital region: chin cap and high pull
headgear
Parietal: combination of headgear
Forehead: reverse pull headgear
Back of neck: cervical headgear
Chin: reverse pull headgear and chin cap
c. Muscular anchorage
• l\lf,,--,,1-- +---- . . --- h- ,,,..._,.J +-- 1,.,. _
i u i
c. Muscular anchorage
• Muscular forces can be used for anchorage
purpose.
• Muscular forces when redirected to a
favourable action on the teeth serve as a
source of anchorage.
Example: vestibular shield and lip bumper
A lip bumper transmits the force of
hyperactive lower lip to molars, aiding in its
uprighting.
{SN Q.7}
IV. According to number of anchorage units

a. Single (or) primary anchorage (anchorage
involving one tooth)
b. Compound anchorage (anchorage involving
multiple teeth)
c. Reinforced anchorage
a. Single or primary anchorage
• In primary anchorage, the resistance
provided by a single tooth with greater
alveolar support is used to move, the tooth
with less alveolar support.
• Example: Moving a tooth with smaller root
surface area against a tooth with large root
surface area, and is called an anchor.
b. Compound anchorage
• In this, the resistance provided by more than
one tooth with greater support is used to
move teeth with lesser support.
c. Reinforced anchorage
• It is also known as multiple anchorage.
• The anchorage where more than one
resistance unit is utilized is called reinforced
anchorage.
• When more units are added, resistance units
become more effective because reactionary
force is distributed over a large area.
• By distribution of force over a large area and
keeping the force light, trauma and pain
during treatment are minimized.
Examples:
i. Use of transpalatal arch, translingual arch
and Nance space holding buttons,
reinforces the anchorage unit.
ii. Usage of headgears.
iii. In cases with upper anterior bite plane,
use of labial bow to prevent flaring of
upper incisors is another example of
reinforced anchorage.
iv. Sved-type bite plates.
V. Other types of anchorage
{SN Q.10}
a. Cortical bone or cortical anchorage
• Cortical bone offers more resistant to resorption
than medullary bone.
• The response of cortical bone when compared to
medullary bone is different. If the roots are
torqued lingually or buccally, the resistance to
movement is increased, this principle is being
used by Ricketts and is called cortical anchorage.
Example: Space closure in old extraction site is
difficult as the roots encounter cortical bone
along the residual ridge.
b. Implants as anchorage
• Recently, implants are being used as anchorage
units. They have been designed exclusively for
orthodontic purpose.
• Various orthodontic implants are onplant,
orthosystem implant, Aarhus implant and mini-
implants.
• Onplant is a disc-like structure which can be
placed in hard palate on the posterior aspect
under local anaesthesia. Orthosystem implant is
a screw-type endosteal implant of about 4-6 mm
in length. Aarhus implant is very small in size
and early loading is possible, hence are used in
multiple sites between roots. Mini implants are
very small, 1.2 x 6 mm in dimension.
• Uses of implants:
i. Implants serve as a source of absolute
anchorage
Example: retromolar implant anchorage
for closing of edentulous space at first
molar extraction sites.
ii. They are used for anchorage and as
abutments for restorations.
iii. Implant is also used in distraction
osteo genesis.
Q.2. Define reinforced anchorage. Discuss method of

Ans.
• Reinforced anchorage is also known as multiple
anchorage.
• The anchorage where more than one resistance unit
is utilized is called reinforced anchorage.
• Reinforced anchorage refers to the augmentation of
anchorage by various means like extraoral
appliances, upper anterior inclined plane or a
transpalatal arch.
• Extraoral forces, i.e. forces generated from extraoral
areas, such as cranium, back of the neck and face,
can be used to reinforce anchorage.
• When more units are added, resistance units become
more effective because reactionary force is
distributed over a large area.
• By distribution off orce over a large area and keeping
the force light, trauma and pain during treatment
are minimized.
• Multiple anchorage is the augmentation of anchorage
by various methods like the following:
Fixed appliances, rigid labial bow, Sved bite planes,
intermaxillary anchorage and use of extraoral
anchorage
Examples:
Ci) Use of transpalatal arch, translingual arch and
Nance space holding buttons, reinforces the
anchorage unit.
a. Transpalatal arch: This is a wire that spans the
palate in transverse direction, connecting the
permanent upper first molars on either side
with an omega loop in the midline. It is used in
fixed mechano-therapy to augment anchorage.
It is effective as an anchorage maintenance
device and active orthodontic appliance.
b. Translingual arch: It is used in mandible, and
functions as anchorage device. It is usually
made up of 0.036" stainless steel wire
extending along lingual contour of mandibular
dentition from first molar on one side to the
opposite side of jaw.
c. Nance palatal arch:
i. It is used in upper arch as an anchorage
device during levelling and alignment, in
molar distalization cases and as a space
maintainer.
ii. Tissue and tooth-borne anchorage such as
palatal removable appliances with clasps of
molar bands.
iii. Upper anterior inclined plane:
A removable appliance incorporating an
upper anterior inclined plane results in
forward glide of mandible during the
closure of jaw. This results in the
stretching of retractor muscles of
mandible, which subsequently contracts
and forces the mandible against the upper
inclined plane.
Thus, a distal force is applied on the
maxillary teeth, thereby reinforcing
maxillary anchorage.
(ii) Usage of headgears to augment the resistance
unit.
(iii) In cases with upper anterior bite plane, use of
rigid labial bow to prevent flaring of upper
incisors is another example of reinforced
anchorage.
(iv) Similarly, instead of a labial bow, the acrylic
plate is constructed in such a way that it covers
the labial incisal aspect of maxillary incisors
which also prevents the labial flaring of
maxillary incisors. This type of reinforced
anchorage is called Sved-type bite plates.
(v) The anchorage may be reinforced in the case of
fixed appliances by designing the appliance so
that only bodily movement of the anchorage
teeth can occur.
Example: Passing a bow wire through the
horizontal tube on bands attached to adjacent
teeth.
Q.3. Define and discuss the various anchorage

situations in removable and fixed appliances.
Ans.
• Graber defined anchorage as 'the nature and degree
of resistance to displacement offered by an anatomic
unit when used for the purpose of effecting tooth
movement'.
• Proffit defined anchorage as resistance to unwanted
tooth movement.
A. Anchorage sources for removable appliance
Removable appliances derive their anchorage from
oral tissues and teeth in the following manner:
i. Tissue born anchorage:
• The acrylic base plate, which is the major
component of removable appliances, derives
anchorage from tissue contact against palate
and lingual surface of mandible.
• The acrylic, which extends into the interdental
spaces and embrasures, also secures the plate
in situ.
The base plate transmits the force all over the
dentition as well as to the underlying hard and
soft tissues.
• Modifications to base plate, such as bite planes,
also reinforce anchorage by transmitting
muscular forces to the jaws.
• The removable appliance also derives
anchorage from clasps, pinheads which
securely fit on the teeth. These provide
retention and help in the distribution of force.
B. Anchorage sources for fixed appliances
• The major sources of anchorage in the fixed
appliances are the teeth themselves.
• Fixed appliances entail heavy burden on anchor
teeth. Anchor units need to be supported either
with incorporation of more teeth or support from
cranium using headgears or modification of
biomechanics, so-called anchorage savers.
Q.4. Define anchorage. Classify and explain

orthodontic anchorage with examples.
Ans.
[Same as LE Q.1]
Q.5. Define anchorage. Discuss classification of

anchorage. Explain intermaxillary anchorage.
Ans.
[Same as LE Q.1]
0.6. Define orthodontic anchorage. Classifv them.

Topic 16 Age factors in orthodontics
Commonlyasked questions
Short essays:
1. Age factors in orthodontics.
2. Difference between adult and adolescent patients.
[Same as SE Q.1]

Short notes:
1. List Age factors in orthodontics.
2. Ideal age for various orthodontic treatments.
3. Adult orthodontics.
Solved answers
Short essays:
Q.1. Age factors in orthodontics.

Ans.
Differences in orthodontic treatment for young and
adults patients are as follows:
Factors Young patients Adult patients

1. Growth to Orthodontist has Due to lack of growth,
work with growth to work orthodontist
with, i.e. using merely relies on
growth tooth movement
potential of the or surgery
patient, most
orthodontic
and
orthopaedic
treatments can
be efficiently
carried out
2. Diagnosis Routine diagnostic Routine diagnostic
aids can be aids can be used
used and some dormant
pathologies like
impactions,
periodontal
problems, decay
and loss of teeth
can hamper the
success of
orthodontic
treatment
3. Appliance These patients can In these patients the
selection benefit from options are
orthopaedic restricted to
and orthodontic tooth
myofunctional movement and
appliances that surgery
help to
modulate
growth in case
of growth
abnormalities
4. Periodontal Less common More common
problems
5. Patient Not well Well motivated and
motivation motivated and cooperate well
and do not
cooperation cooperate well
6. Tissue Tissue vitality and Due to decreased
vitality responsiveness cellularity and
to force is vascularity, the
much greater tissue vitality and
in child responsive to
force is not so
much in adults
7. Treatment Achieved well The orthodontist has
objectives to strike the best
possible balance
between various
treatment
objectives like
function, stability
and aesthetics
8. Treatment Less in young More in adult
appreciation patients patients
Q.2. Difference between adult and adolescent

patients.
Ans.
[Same as SE Q.1]
Short notes:
Q.1. List age factors in orthodonti

cs?
Ans. .
The list of various age factors considered 1n
orthodontics are as follows:
i. Utilization of growth potential to work with
ii. Various diagnostic methods used
iii. Selection of appliance
iv. Periodontal problems
v. Patient motivation and cooperation
vi. Tissue vitality
vii. Treatment objectives
viii. Treatment appreciation
Q.2. Ideal age for various orthodontic treatments.

Ans.
i. The age of the patient influences orthodontic
therapeutic interventions and prognosis.
ii. The effectiveness of functional appliances, like twin
block, bionator, Frankel appliance given for class II
skeletal correction and orthopaedic appliances, like
headgears, to correct maxillary prognathism, are
effective during growing stage of the patient.
iii. Maxillary expansion procedures are carried out
before the fusion of palatal sutures during early
adolescence.
iv. Orthognathic surgeries are best undertaken in adult
patients after growth cessation.
Q.3. Adult orthodontics.

Ans.
i. Orthodontic treatment of adults is known as adult
orthodontics.
ii. Orthodontic treatment for adults is broadly classified
into two types:
a. Adjunctive orthodontic treatment
b. Comprehensive orthodontic treatment
iii. Adjunctive orthodontic treatment procedures are
carried out to facilitate other dental procedures to
control disease and restore function, e.g. uprighting
of molars, forced eruption, crossbite correction and
diastema closure.
iv. Comprehensive orthodontic treatment is an essential
treatment procedure carried out in children for
correction of malocclusion. Response to orthodontic
force is slightly slower in adults as compared to
children.
Topic 17 Preventive orthodontics
Long essays:
1. Define preventive orthodontics. Discuss the
various treatment plans given under the
preventive orthodontics.

2. Define preventive orthodontics and describe in
brief space maintainers and their classification
with examples.
3. What are the various preventive orthodontic
procedures? Explain in detail the various space
maintainers. [Same as LE Q.2]
4. Describe in brief space maintainers and their
classification with examples. [Same as LE Q.2]
5. What are space maintainers? Describe the various
types used in orthodontics and their indications.
[Same as LE Q.2]
Short essays:
1. Procedures under preventive orthodontia. [Ref LE
Q.1]
2. Define space maintainer. Mention its indications
and contraindications.
3. Features of an ideal space maintainer.
4. Preventive orthodontics.
5. Describe the rationale or the principle of
preventive orthodontic practice. [Same as SE Q.4]
Short notes:
1. Define preventive orthodontics. [Ref LE Q.1]
2. Define space maintainer. [Ref LE Q.1]
3. Fixed space maintainer.
4. Oral hygiene measures during orthodontic
treatment.
5. Distal shoe space maintainer.
6. What are the requirements of space maintainers?
[Same as SE Q.3]
7. Nance appliance.
8. Enumerate preventive orthodontic procedures.
[Same as SN Q.1]
9. Procedures under preventive orthodontics. [Same
as SN Q.1]
10. Classification of space maintainers. [Same as SN
Q.2]
11. Advantages of fixed space maintainer. Give an
example. [Same as SN Q.3]
12. Willet's appliance. [Same as SN Q.5]
Solved answers
Long essays:
Q.1. Define preventive orthodontics. Discuss the

various treatment plans given under the preventive
orthodontics.
Ans.
(SE Q.1 and SN Q.1)
• {(Graber has defined preventive orthodontics as the
action taken to preserve the integrity of what
appears to be a normal occlusion at a specific time.
• Proffit and Ackerman have defined it as prevention of
potential interference with occlusal development.
• Procedures undertaken in preventive orthodontics
are as follows:
A. Preventive procedures without use of
appliances
I. Predental procedures and parental
education
II. Maintenance of oral hygiene
III. Caries control and restoration of
decayed teeth
IV. Care of deciduous dentition
V. Management of tooth ankylosis/locked
permanent first molar.
VI. Extraction of supernumerary
teeth/retained deciduous tooth
VII. Maintenance of quadrant-wise tooth
shedding timetable and space
maintenance
VIII. Management of abnormal frenal
attachments and check up for deleterious
oral habits
IX. Prevention of damage to
occlusion/occlusal equilibration)}
[SE Q.1]
{B. Preventive procedures with use of appliances
I. Mouth protectors
II. Space maintenance
A. Preventive procedures without use of appliances
are described in detail below:
I. Predental procedures/parental education
(a) All these preventive procedures ideally
should begin before the birth of the child and
are instituted before the eruption of teeth.
(b) The expecting mothers should be educated on
the following matters:
• Nutrition
• Proper nursing and care of the child
• Use of physiologic nipples
• Detrimental effect of prolonged use of
pacifiers on dentition
• Correct method of brushing child's teeth
Overall, the parents should be educated on need
for maintaining good oral hygiene of the child.
II. Oral hygiene
Parents and children should be taught
appropriate oral hygiene measures as
applicable to that age group as given below:
• Infants (younger than 1 year): Brushing
should start with the eruption of first
primary teeth. Parents should do the gentle
massage of gums and cleaning of the teeth.
• Toddlers (children aged 1-3 years):
Toothbrush should be introduced along with
some nonfluoridated pastes. Parents should
do the brushing for children.
• Preschoolers (children aged 3-6 years):
Children should start brushing under
parental supervision and fluoride toothpaste
can be introduced.
• School aged (children aged 6-12 years): Child
should be taught proper brushing technique
and regular brushing habits.
III. Caries control and restoration of decayed
teeth
• Unrestored caries/undercontoured restoration
of proximal surface of deciduous teeth lead to
loss of arch length, so to prevent reduction of
arch length, proper restoration of affected
teeth should be undertaken immediately.
• All possible caries prevention methods are to
be followed like proper tooth brushing and
fluoride prophylaxis at regular intervals.
• To prevent premature loss of deciduous teeth,
simple preventive measures like application of
topical fluoride and pit and fissure sealants
should be undertaken.
permanent first molar
• Ankylosed deciduous teeth prevent eruption of
permanent teeth or deflect them to erupt in
abnormal positions; hence, they should be
diagnosed and removed surgically at an
appropriate time.
• Sometimes, permanent first molars are deeply
locked by a prominent distal bulge on second
deciduous molar which prevents their
eruption. It should be assessed and the slicing
of distal surface ofi. + 1~ should be
undertaken to guide the eruption of

• Supernumerary teeth should be identified and
extracted before they cause displacement of
other teeth and interfere with normal eruption
pattern and normal occlusion.
shedding timetable and space maintenance
(a) Maintenance of tooth shedding timetable
is important as premature loss of
deciduous teeth may cause drifting of the
adjacent teeth into the space, which can
result in abnormal axial inclination of
teeth, spacing between teeth and shift in
the midline.
(b) There should not be more than 3
months' gap between shedding of
deciduous teeth and eruption of
permanent teeth as compared with one
quadrant to other quadrants.
(c) Space maintenance is a procedure to
prevent loss of arch development due to
premature loss of deciduous teeth.
(d) Space maintainer is an appliance or a
device that prevents loss of arch length
and guides the permanent teeth into
correct position in dental arch.
oral habits
(a) The presence of abnormally thick
maxillary labial frenum produces midline
diastema. A blanch test and notching of
interdental bone in a periapical
radiograph confirms the thick frenal
attachment, which should be diagnosed
and treated at an early age.
(b) Presence of anklyloglossia or tongue tie
prevents normal functional development
and results in abnormal speech and
swallowing patterns. This should be
treated surgically to prevent full-fledged
malocclusions.
(c) Oral habits like finger and thumb
sucking, tongue thrusting, lip biting and
nail biting should be identified and
stopped to enhance normal functional
and deglutitional activity.
(d) Early correction of habits is easier and
helps in elimination of the unfavourable
sequelae of habits which lead to
malocclusion.
IX. Prevention of damage to occlusion/occlusal
equilibration
IX. Prevention of damage to occlusion/occlusal
equilibration
(a) Damage to occlusion as well as
retardation of mandibular growth and
possible deformities are caused by
orthopaedic appliances used for
correction of scoliosis. Example:
Milwaukee brace should be prevented by
using functional appliances and
positioners made of soft materials.
(b) All functional prematurities leading to
deviation of mandibular path of closure

and bruxism should be detected, and
selective grinding should be carried out to
attain occlusal equilibration.
(c) Pseudo-class III and crossbites caused
due to functional shifts should be checked
and eliminated.
(d) Occlusal equilibration is performed as
preventive, interceptive and corrective
orthodontic procedure.}
Q.2. Define preventive orthodontics and describe in

brief space maintainer's and their classification with
examples.
Ans.
Graber has defined preventive orthodontics as the
action taken to preserve the integrity of what appears to
be a normal occlusion at a specific time.
Proffit and Ackerman have defined it as prevention of
potential interference with occlusal development. The
best time to initiate preventive orthodontics is ideally
during prenatal counselling.
Procedures undertaken in preventive orthodontics
are as follows:
A. Preventive procedures without use of
appliances:
I. Predental procedures and parental
education
II. Maintenance of oral hygiene
III. Caries control and restoration of
decayed teeth
permanent first molar
shedding time table and space
maintenance
oral habits
IX. Prevention of damage to
occlusion/occlusal equilibration
B. Preventive procedures with use of
appliances:
I. Mouth protectors
II. Space maintenance
Space maintainer: A device used to maintain the
space created by the loss of a deciduous tooth is
known as space maintainer.
The ideal requirements of a space maintainer
are as follows:
• Should maintain the desired mesiodistal
width/space created by premature loss of
tooth
• Must restore function and should be strong
enough to withstand functional forces
• Should not interfere with eruption of other
permanent teeth
• Should not exert excessive stress on
adjoining teeth and should prevent
supraeruption of opposing teeth
• Should be simple in fabrication
• Should be easily cleansable and permit
maintenance of good oral hygiene
(SN Q.2)
Classification of space maintainers
I. According to Hitchcock:
i. Removable or fixed or semifixed
ii. With bands or without bands
iii. Functional or nonfunctional
iv. Active or passive
v. Certain combinations of the above
II. According to Raymond C. Thurow:
i. Removable
ii. Complete arch
(a) Lingual arch
(b) Extra-oral anchorage
iii. Individual tooth
III. According to Hinrichsen:
t +
Fixed space Removable space
maintainers maintainer
Example: Acrylic
i partial dentures
t +
Class I Class II
Example: Cantilever
type {distal shoe,
Two types
band and loop)
t
Nonfunctional
i. Bar type
•
Functional
i. Pontic type
ii. Loop type ii. Lingual arch type
Some commonly used removable space maintainers

i. Acrylic partial dentures
ii. Full or complete dentures
iii. Removable distal shoe space maintainers
Removable space maintainers are mainly
indicated:
• When there are multiple losses of deciduous teeth
which may require functional replacement and
restoration of aesthetics
• In case of partially erupted permanent teeth,
where abutment teeth cannot support a fixed
appliance
Examples:
• Acrylic partial dentures - in cases of multiple
extractions.
• Full or complete dentures - in case of extraction
of all primary teeth in a preschooler due to
rampant caries.
• Removable distal shoe space maintainer - in case
of loss of deciduous second molar, shortly before
eruption of first permanent molars, an
immediate acrylic distal shoe extension has been
successfully used to guide the permanent first
molar into the position.
Some commonly used fixed space maintainers
Fixed space maintainers are those which are fixed or
fitted on to the teeth and require minimum or no
tooth preparation.
Example: band and loop space maintainer (Fig 17.1)
-1Loop
Band
FIG. 17 .1 Band and loop space

maintainer.
(i) Band and loop space maintainer

• It is a fixed, semi-rigid, nonfunctional type of
passive appliance.
• Indicated for space maintenance in the
posterior segments when a single tooth is
lost, e.g. premature loss of deciduous
canines, first molars or second molars
unilaterally.
• Advantage: ease of fabrication.
• Disadvantage: supraeruption of opposing
tooth
. . and slipping of the loop towards
gmgiva.
• Modifications:
a. Mayne's modification where loop extends
only on buccal side.
b. Band and loop with vertical projection,
where occlusal rest prevents tipping and
sliding of the loop gingivally.
c. Crown and loop: Band is replaced by a
stainless steel crown.
(ii) Crown and loop space maintainer
• Crown and loop space maintainers are
similar to band and loop space maintainers
in every respect except that a stainless steel
crown is used for abutment tooth in the
place of band.
• It is useful where the tooth used as abutment
is highly carious or pulpotomized or
markedly hypoplastic.
Loop Crown
FIG. 17.2 Crown and loop appliance.
(iii) Lingual arch space maintainer

• The lower lingual holding arch is a
nonfunctional, passive fixed appliance.
·~:::_--Stainless steel
\ lingual arch wire
E
\ °'>
\
I
Prematurely
lost primary
teeth
~t) (d "'I
l-lj Li-) Band
FIG. 17.3 Lingual arch space maintainer.
• It is the most effective space maintainer in

cases of multiple losses of primary molars
bilaterally in mandibular arch.
• It maintains arch perimeter by preventing
both mesial drifting of the molars and
linvual collanse of anterior tPPth.
J
• It maintains arch perimeter by preventing

both mesial drifting of the molars and
lingual collapse of anterior teeth.
• Example: used in cases of premature loss of
deciduous first or second molars
bilaterally
(iv) Palatal arch appliances:

FIG. 17 .1 Band and loop space
maintainer.
Palatal arch space maintainers
l
Nance palatal holding arch Transpalatal arch
FIG. 17.4 Nance holding arch.
(i'
Ll-J
FIG. 17.5 Transpalatal arch.
• Nance holding arch is a maxillary palatal arch space

maintainer mainly used in cases of bilateral loss of
deciduous molars in maxilla. It is the appliance of
choice.
• Transpalatal arch is best indicated when one side of
the arch is intact and several primary teeth on other
side are missing prematurely.
(v) Distal shoe space maintainer (intra-alveolar
appliance)
• Distal shoe appliance is an intra-alveolar appliance
introduced by Willets (1932) and later modified by
Roche (1942).
• It is primarily used in cases of premature loss of
deciduous second molar prior to eruption of
permanent first molars.
• The distal shoe appliance provides a greater control
on path of eruption of unerupted permanent first
molar tooth and at the same time prevents its
undesirable mesial migration.
FIG. 17.6 Distal shoe space maintainer
(vi) Aesthetic anterior space maintainer

• Introduced and described by Steffen, Miller and
Johnson in 1971.
• Mainly used for space maintenance in premature
loss of deciduous incisors. It consists of plastic
teeth fixed onto a lingual arch, which in turn is
attached to molar bands.
(vii) Band and bar types or crown and bar space
maintainer
These are fixed space maintainers where abutment
teeth on either side of extraction space are either
banded or given stainless steel crowns and
connected to each other by a bar.
FIG. 17. 7 Band and bar space maintainer.
FIG. 17.8 Crown and bar space

maintainer.
Example: used in the cases of premature loss of

deciduous first and second molars
Q.3. What are the various preventive orthodontic

procedures? Explain in detail the various space
maintainers.
Ans.
[Same as LE Q.2]
Q.4. Describe in brief space maintainers and their

classification with examples.
Ans.
[Same as LE Q.2]
Q.5. What are space maintainers? Describe the

various types used in orthodontics and their
indications.
Ans.
[Same as LE Q.2]
Short essays:
Q.1. Procedures under preventive orthodontia.

Ans.
[Ref LE Q.1]
Q.2. Define space maintainer. Mention its indications

and contraindications.
Ans.
A device used to maintain the space created by the loss
of a deciduous tooth is known as space maintainer.
Indications of space maintainers:
Space maintainers are indicated in the following
conditions:
• Early loss of primary anterior teeth.
• When a second primary molar is lost before the
eruption of permanent first molars and before
the second premolars are ready to take its place.
• Early loss of the primary first molar.
• In cases of congenitally missing second premolars
where a prosthesis is planned later.
• Loss of permanent first molar after eruption of
second permanent molar.
• Active space maintainers or space regainers are
used when there is minor amount of loss of
space that has to be gained.
Contraindications to space maintainers:
• When there is only soft tissue covering or very
minimal amount of bone overlying the crown of
erupting permanent tooth.
• When the space available is in excess of the
mesiodistal dimension of the erupting
succedaneous tooth.
• When the minor arch length discrepancy exists,
which can be corrected with the amount of space
available.
• Congenitally missing permanent successor.
• Space maintainer may not be necessary when a
small period of gap exists between shedding of
deciduous tooth and eruption of succedaneous
tooth.
Q.3. Features of an ideal space maintainer.

Ans.
{SN Q.6}
Space maintainer is a device used to maintain the
space created by the loss of a deciduous tooth.
The ideal requirements of a space maintainer are as
follows:
• Should maintain the desired mesiodistal width/space
created by premature loss of tooth
• Must restore function and should be strong enough to
withstand functional forces
• Should not get deformed, distorted or break
• Should not interfere with eruntion of other
• Should not get deformed, distorted or break
• Should not interfere with eruption of other
permanent teeth
• Should not exert excessive stress on adjoining teeth
and should prevent supraeruption of opposing teeth
• Should not impede the vertical eruption of adjacent
tooth
• Should maintain individual functional movements of
the teeth
• Should not interfere with normal development of
occlusion
• Should be able to provide rnesiodistal space opening

if required
• Should be simple in fabrication
• Should be easily cleansable and permit good oral
hygiene maintenance
Q.4. Preventive orthodontics.

Ans.
• Graber has defined preventive orthodontics as the
action taken to preserve the integrity of what
appears to be a normal occlusion at a specific time.
• Proffit and Ackerman have defined it as prevention of
potential interference with occlusal development.
• Preventive orthodontics is a dynamic and constant
vigilance to prevent malocclusion by both dentist
and patient/parent.
The rationale of preventive orthodontics is as
follows:
Requirements
i. Establishment of a good rapport between patient
and dental surgeon.
• Patient should be educated about periodical
checkups in identifying the problems at early
stage and advantages of its prevention by
appropriate measures.
ii. Need for diagnostic records.
• For a 2-year-old child: Clinical examination,
intraoral radiographs and panoramic
radio graphs.
• For a 5-year-old child: Longitudinal records are
required.
• If there are any signs of developing
malocclusion, periapical radiographs should
be taken once a year.
iii. Study casts.
• Between 6 and 12 years of age, study casts
make up invaluable records.
• In required cases, study casts should be
prepared every year to compare and evaluate
potential problems.
Identification of future orthodontic problems
• The critical step in preventive orthodontics is the
recognition of future problem.
• The possible future problems can be detected by
two ways: clinical and radiographic indicators.
i. Clinical indicators
• A thorough visual examination will reveal
potential problems.
• Differentiation of potential problems from self-
correcting malocclusions is essential.
Example: identification of proximal caries,
planning for space maintenance
ii. Radiographic indicators
• Most important radiographic indicators are
resorption and eruption patterns of primary
and permanent dentitions respectively.
Benefits of preventive orthodontics are as
follows:
• Psychological benefits due to prevention of
malocclusion.
• Preventive measures eliminate aetiologic factors
and make it possible to restore normal growth
and possibility of achieving better results.
• Early treatment of deleterious habits eliminates
problems of malocclusion.
• Makes the treatment economical.
Q.5. Describe the rationale or the principle of

preventive orthodontic practice.
Ans.
[Sarne as SE Q.4]
Short notes:
Q.t. Define preventive orthodontics.

Ans.
[Ref LE Q.1]
Q.2. Define space maintainer.

Ans.
[Ref LE Q.1]
Q.3. Fixed space maintainer.

Ans.
Fixed space maintainers are those which are fixed onto
the teeth either with bands or crowns.
Advantages of.fixed space maintainers are as follows:
i. Can be used in uncooperative patients.
ii. Minimum or no tooth preparation is required to
fix bands and crowns.
iii. Jaw growth is not affected.
iv. They permit eruption of succedaneous permanent
teeth and passive eruption of abutment teeth
without any interference.
v. If panties are placed, rnasticatory function is
restored.
Q.4. Oral hygiene measures during orthodontic

treatment.
Ans.
Proper oral hygiene measures throughout the
orthodontic treatment are essential.
Various devices and methods to maintain good oral
hygiene during orthodontic treatment are as follows:
i. Special orthodontic brushes wherein the middle row
is shortened are used for home care.
ii. Electronic tooth brushes - for patients lacking good
motor control.
iii. Interdental stimulation with special uni-tufted
brushes helps to prevent soft tissue proliferation.
iv. Digital gum massage for about 5 min a day controls
gingival proliferation.
v. Waterpik is very effective in removing the debris.
Q.5. Distal shoe space maintainer.

Ans.
Distal shoe space maintainer is also known as eruption
guidance appliance, Willet's appliance or Roche's
appliance.
• Distal shoe appliance is an intra-alveolar appliance
introduced by Willets (1932) and later modified by
Roche (1942).
• It is primarily used in cases of premature loss of
deciduous second molar prior to eruption of
permanent first molars.
• It is of the following types:
i. Fixed: (a) functional, and (b) nonfunctional.
ii. Removable
• The distal shoe appliance provides a greater control
on path of eruption of unerupted permanent first
molar tooth and, at the same time, prevents its
undesirable rnesial migration.
FIG. 17.9 Distal shoe space maintainer
Q.6. What are the requirements of space

maintainers?
Ans.
[Sarne as SE Q.3]
Q.7. Nance appliance.

Ans.
It is a type of fixed palatal arch space maintainer.
(i) Nance appliance is an appliance of choice in cases of
bilateral loss of deciduous molars in maxillary arch.
(ii) It incorporates an acrylic button in the anterior
region that contacts palatal tissue in the anterior
palate without contacting the anterior maxillary
teeth.
(iii) Advantages:
a. Economical
b. Allows transverse growth in intercanine and
permanent interrnolar areas
(iv) Disadvantages:
a. Requires good clinical skills.
b. Inflammation
.
of soft tissues in anterior palatal
region.
FIG. 17.1 o Nance appliance.
Q.8. Enumerate preventive orthodontic procedures.

Ans.
[Sarne as SN Q.1]
Q.9. Procedures under preventive orthodontics.

Ans.
[Sarne as SN Q.1]
Q.10. Classification of space maintainers.

Ans.
[Sarne as SN Q.2]
Q.11. Advantages of a fixed space maintainer. Give

an example.
Ans.
[Sarne as SN Q.3]
Q.12. Willet's appliance.

Ans.
[Sarne as SN Q.5]
Topic 18 lnterceptive orthodontics
Long essays:
1. Define interceptive orthodontics. Enumerate the
various interceptive orthodontic procedures and
describe serial extraction procedures in detail.

2. Define interceptive orthodontics, and discuss in
detail the various procedures involved.
3. Define interceptive orthodontics. Discuss serial
extraction procedure. [Same as LE Q.1]
4. Describe the indications, contraindications and
technique of serial extraction. [Same as LE Q.1]
5. Define serial extraction. Discuss in detail the
indications and procedures of serial extraction.
[Same as LE Q.1]
6. Define serial extraction. Discuss indications and
contraindications, and advantages and
disadvantages of serial extraction. [Same as LE
Q.1]
7. Define interceptive orthodontics and describe
various methods of interceptive orthodontics.
[Same as LE Q.2]
Short essays:
1. Muscle exercises. [Ref LE Q.2]
2. Interceptive orthodontics. [Ref LE Q.2]
3. Serial extractions. [Ref LE Q.1]
4. Classify space regainers and write briefly on any
one.
5. Developing anterior crossbite correction.
6. Indications and contraindications for serial
extraction procedures. [Same as SE Q.3]
7. Indications for serial extraction. [Same as SE Q.3]
Short notes:
1. Define serial extraction. Add a note on it.
2. Muscle exercises. [Ref LE Q.2]
3. Interceptive orthodontics.
4. Advantages of serial extraction. [Ref LE Q.1]
5. Disadvantages of serial extraction. [Ref LE Q.1]
6. Define serial extraction. Give its
contraindications. [Ref LE Q.1]
7. Enumerate various serial extraction procedures.
[Ref LE Q.2]
8. Space regain er. [Ref LE Q.2]
9. Developing anterior crossbite correction. [Same as
SE Q.5]
10. Define serial extraction. [Same as SN Q.1]
11. Write few indications of serial extractions. [Same
as SN Q.1]
12. Define serial extraction and discuss any one
method of serial extraction. [Same as SN Q.7]
13. Classification of anterior crossbites. [Same as SN
Q.9]
Solved answers
Long essays:
Q.1. Define interceptive orthodontics. Enumerate the

various interceptive orthodontic procedures and
describe serial extraction procedures in detail.
Ans.
• Interceptive orthodontics has been defined as that
phase of the science and art of orthodontics
employed to recognize and eliminate potential
irregularities and malpositions of the developing
dentofacial complex.
• Interceptive orthodontics basically refers to measures
undertaken to prevent a potential malocclusion from
progressing into a more severe one.
The procedures undertaken in interceptive orthodontics
include the following:
• Serial extractions
• Correction of developing crossbite: anterior and
posterior
• Control of abnormal habits
• Space regaining
• Muscle exercises
• Interception of skeletal malrelation
• Removal of soft tissue or bony barrier to enable
eruption of teeth
• Extraction of supernumerary and ankylosed teeth
[SE Q.3]
{Serial extraction
• Serial extraction is defined by Tweed as the
planned and sequential removal of the primary
and permanent teeth to intercept and reduce
dental crowding problems.}
• This procedure is usually initiated in the early
mixed dentition period. It includes the planned
extraction of certain deciduous teeth and later
specific permanent teeth in an orderly sequence
and predetermined pattern to guide the erupting
permanent teeth into a more favourable position.
History:
Kjellgren (1929) - used the term serial extraction.
Nance (1940) - termed it as planned and
progressive extraction and popularized the
technique in the USA.
Hotz (1970) - termed it as active supervision of
teeth by extraction.
Rationale:
Serial extraction is based on mainly two principles:
1. Arch length -Tooth material
discrepancy is corrected by
reducing the tooth material.
2. Physiologic tooth movement is
being utilized in serial extraction
for self-correction.
3. Result of serial extraction is
influenced by normal growth of
dental, skeletal and soft tissues.
[SE Q.3]
{Indications:
i. Class I malocclusion with an arch length-
tooth size deficiency of 10 mm or more
per quadrant showing harmony between
skeletal and muscular systems.
ii. As compared with the tooth material, the
arch length deficiency is the most
important indication for serial extraction.
iii. In patients where growth is not enough
to overcome the discrepancy between
tooth material and basal bone.
iv. Patients with straight profile and
pleasing appearance.
v. The arch length deficiency either
unilateral or bilateral due to
nonpathological causes like premature
loss of canines with midline shift,
malpositioned or impacted lateral
incisors erupting out of the arch,
bimaxillary protrusion, ectopic eruption
of teeth and localized gingival recession
in the lower anterior region.
vi. The arch length deficiency due to
pathologic causes like extensive proximal
caries and subsequent mesial migration
of buccal segment, ankylosis of tooth,
premature loss of deciduous teeth,
deleterious oral habits and improper
proximal restorations.}
(SE Q.3 and SN Q.6)
{(Contraindications:
i. Mild class I malocclusions with minimum
space deficiency and skeletal class II or III
malocclusion.
ii. Congenital absence of teeth -
anodontia/oligodontia.
iii. Open bite and deep bite.
iv. Spaced dentition and midline diastema.
vi. Unerrupted malformed teeth, e.g.
dilaceration.
vii. Extensive caries or heavily filled first
permanent molars.)}
Diagnosis:
• Study model analysis - Carey's analysis for lower
arch
Arch perimeter analysis for upper arch
• OPG - for evaluation of eruption status of
dentition
• Cephalometrics - assessment of skeletal tissues to
study underlying skeletal relationship
• Clinical examination + cephalograms - for soft
tissue assessment
Procedure:
i. Dew el 's method:

Dewel proposed a three-step serial extraction
procedure as follows:
The sequence of proposed extractions: CD4
Step 1: Extraction of 'C' - between 8 and 9 years to
create space for alignment of incisors.
Step 2: Extraction of 'D' - one year later, i.e. at 10
years of age to accelerate eruption of first
premolars.
Step 3: Extraction of '4' (first premolar) - to permit
the eruption of permanent canines in their place.
Modified Dewel's technique:
Wherein first premolars are enucleated at the time
of extraction of the first deciduous molar,
especially in mandibular arch where canines
erupt before first premolars.
ii. Tweed's method:
The sequence of proposed extractions: DC4
Step 1: Extraction of 'D' (deciduous first molar) - at 8
years of age.
Step 2: Deciduous canines are maintained till
premolars are in advanced eruptive stage.
Then both 'C' along with first premolars '4' are
extracted simultaneously.
iii. Nance's method:
The sequence of proposed extractions: D4C.
This method is basically modified Tweed's method.
Step 1: Extraction of 'D' (deciduous first molars) - at 8
years of age.
Step 2: Extraction of '4' (first premolars) and 'C'
(deciduous canines) simultaneously.
D,u:~t-~orinl ovt-rnrt-inn t-horn"f'n,•
Postserial extraction therapy:
Most cases of serial extraction need fixed
orthodontic appliance therapy for correction of
axial inclination and detailing of occlusion.
{SN Q.4}
Advantages of serial extraction:
i. Treatment is more physiologic.
ii. As the treatment is carried out, an early age
psychological trauma can be avoided.
iii. Reduces duration of multibanded fixed
treatment as well as retention period.
iv. Reduced risk of caries due to better oral

hygiene.
v. More stable results - as tooth material and arch
length are in harmony.
{SN Q.S}
Disadvantages:
i. Prolong treatment time and follow-up.
ii. Regular patient visits - cooperation of patient
needed.
iii. Tendency to develop tongue thrust - due to
created extraction spaces.
iv. Serial extraction requires - good clinical
judgement.
v. Extraction of buccal teeth results in - deepening
of bite.
vi. This is not a definitive treatment, the axial
inclination of teeth at the end of serial
extraction procedure requires - short-term
fixed appliance therapy.
vii. Poorly executed serial extraction programme
can be worse than none at all.
Q.2. Define interceptive orthodontics, and discuss in

detail the various procedures involved.
Ans.
[SE Q.2]
• {Interceptive orthodontics has been defined as that
phase of the science and art of orthodontics
employed to recognize and eliminate potential
irregularities and malpositions of the developing
dentofacial complex.
• Interceptive orthodontics basically refers to measures
• The procedures undertaken in interceptive
orthodontics include the following:
i. Serial extractions
ii. Correction of developing crossbite: anterior and
posterior
iii. Control of abnormal habits
iv. Space regaining
v. Muscle exercises
vi. Interception of skeletal malrelation
vii. Removal of soft tissue or bony barrier to
enable eruption of teeth
viii. Extraction of supernumerary and ankylosed
teeth}
{SN Q.7}
i. Serial extractions:
i. Serial extractions is an interceptive
orthodontic procedure that includes the
planned extraction of certain deciduous teeth
and later specific permanent teeth in an
orderly sequence and predetermined pattern
to guide the erupting permanent teeth into a
more favourable position.
ii. Three popular methods in serial extraction
procedure are
a. Dewel's method
b. Tweed's method
c. Nance's method
iii. Dewel's method of serial extraction is the
most popular method, where the sequence of
proposed extractions is CD4.
Extraction of deciduous canines creates the
space for alignment of the incisors, whereas
eruption of first premolars is accelerated by
extraction of deciduous first molars. Finally,
permanent first premolars are extracted to
permit permanent canines to erupt into their
place and achieve harmonious occlusion.
ii. Correction of developing crossbite
• The developing crossbite should be corrected
before it becomes established.
• The tongue blade therapy can be used to
correct developing anterior crossbite in the
cooperative children with adequate space
for tooth in crossbite to be moved.
iii. Control of abnormal habits
• Habit can be defined as the tendency towards
an act that has become a repeated
performance, relatively fixed, consistent and
easy to perform by an individual, e.g. thumb
sucking, tongue thrusting and mouth
breathing.
• Due to their repetitive nature and longer
duration, the deleterious orofacial habits
influence the form of orofacial structures.
• The various modalities of treatment to
control these abnormal oral habits are as
follows:
a. Elimination of cause
b. Reminder therapy/interception of habit
c. Corrective therapy
• Interception and treatment of abnormal
habits is age and severity-dependent.
• In children younger than 3 years, no active
intervention is instituted whereas children
aged between 4 and 8 years age need only
reassurance, positive reinforcement and
friendly reminders to divert child's attention
to other things like play and toys.
• Screening patients for underlying
psychological disturbances or any
anatomical obstructions and referring to
concerned professionals for appropriate
treatment.
• Teaching child the correct method of
swallowing, removal of obstruction, tongue
exercises, lip exercises, etc.
• Use of habit breaking appliances, both fixed
and removable, is basically reminding
appliances that assist to quit the habit.
• Some of the commonly used removable
appliances include upper Hawley's plate
with tongue cribs, roller balls for tongue
exercise, etc.
• Correction of malocclusion.
{SN Q.8}
iv. Space regaining:
• Space regaining is one of the interceptive
orthodontic procedures.
• This procedure is preferably undertaken at an
early age prior to eruption of second molar.
• Two types of space regainers are:
A. Removable space regainers:
• Removable appliance with finger spring
• Removable lingual arch
• Expansion screws
• Split saddle regainer
B. Fixed space regainers:
• Gerber space regainer
• Lip bumpers
• Lingual arch
• Commonly used space regainers are Gerber space
regainer, jackscrews and cantilever spring.
• In the case of Gerber space regainer, the forces
generated by compressed coil springs bring
about a distalization of first molar.
• In the case of cantilever springs, distalization of
molars can be achieved by using removable
appliance incorporating simple finger springs.
v. Muscle exercises:
[SE Q.1]
• {The presence of normal orofacial muscle
function is essential for development of normal
occlusion.}
(SE Q.1 and SN Q.2)
• {(The aberrant muscle functions can be improved
by certain muscle exercises as follows:
a. Exercises for masseter muscle
strengthening: Patient is asked to clench
the teeth and count to 10 and then relax
and repeat this over some duration of
time.
b. Exercise for the lips and cheeks (circum
oral muscles): The patient is asked to hold
a piece of paper between lips which
maintains lip seal by stretching the upper
lip, holding and swishing the water
behind the lips and Button pull exercise,
etc.
c. Exercises for the tongue: One elastic and
two elastic swallow, tongue hold exercise
etc.
Limitations of muscle exercises are that they
are not a substitute for corrective
orthodontic treatment, and if not done
correctly, they can be counterproductive
also.)}
vi. Interception of skeletal malrelation:
Skeletal malrelations can be treated taking
advantage of growth potential of an individual
and using myofuntional appliances and
orthopaedic appliances like headgears and
chin cups.
vii. Removal of soft tissue or bony barrier:
Soft tissue or any honey barrier should be
removed to enable proper eruption of teeth.
viii. Extraction of supernumerary and
ankylosed teeth:
Supernumerary teeth or any teeth which are
ankylosed should be extracted so that the path
of eruption of permanent teeth is not
obstructed by them.
Q.3. Define interceptive orthodontics. Discuss serial

extraction procedure.
Ans.
[Same as LE Q.1]
Q.4. Describe the indications, contraindications and

technique of serial extraction.
Ans.
[Same as LE Q.1]
Q.S. Define serial extraction. Discuss in detail the

indications and procedure of serial extraction.
Ans.
[Same as LE Q.1]
Q.6. Define serial extraction. Discuss indications and

contraindications, and advantages and
disadvantages of serial extraction.
Ans.
[Same as LE Q.1]
Q.7. Define interceptive orthodontics and describe

Anc;:
Q.7. Define interceptive orthodontics and describe
Ans.
[Sarne as LE Q.2]
Short essays:
Q.1. Muscle exercises.

Ans.
[Ref LE Q.2]

Q.2. Interceptive orthodontics.
Ans.
[Ref LE Q.2]
Q.3. Serial extractions.

Ans.
[Ref LE Q.1]
Q.4. Classify space regainers and write briefly on any

one.
Ans.
(i) Space regaining is one of the interceptive orthodontic
procedures.
(ii) Space regaining procedure is preferably undertaken
at an early age prior to eruption of second molar. In
such patients space lost by rnesial movement of the
molars can be regained by distal movement of the
first molar.
(iii) Commonly used space regainers are
Gerber space regainer
Jackscrews
Cantilever spring
(a) Gerber space regainer ( Fig 18.1)
(i) An orthodontic band or a crown is
selected for tooth to be distalized.
(ii) This space regainer consists of 'U'-
shaped hollow tubing soldered or welded
to rnesial aspect of first molar, which is to
be moved distally.
(iii) 'U'-shaped rods with open coil springs
of adequate length are fitted into the
above tubing so that they contact rnesial
aspect of first molar to be moved distally.
The forces generated by compressed coil
springs bring about a distal movement of
first molar.
(b) Space regainer using jackscrews ( Fig 18.2)
This appliance consists of split acrylic plate
with jackscrew in relation to edentulous
space, and is retained using Adam's clasp.
(c) Space regainer using cantilever spring ( Fig 18.3
)
Dista1ization of molar can be achieved by
using removable appliance incorporating
simple finger springs.
1st premolar
Gerber space
regainer
tst molar
FIG. 18.1 Gerber space regainer.
--Jack screws
Split acrylic plate

FIG. 18.2 Space regainer using jackscrew.
Adamsclasp---
Finger
springs
FIG. 18.3 Space regainer using cantilever

spring
Q.5. Developing anterior crossbite correction.

Ans.
{SN Q.9}
(i) The correction of developing anterior crossbite is an
interceptive orthodontic procedure.
(ii) Classification of anterior crossbites.
Functional
Dentoalveolar Skeletal (pseudo-
class III)
Due to one or more Due to skeletal Due to
maxillary teeth discrepancies occlusal
positioned in prematurit es
lingual relation to
mandibular
anterior teeth
Treated by tongue Best treated by growth Treated by
blades catalans modification eliminatior
appliance double procedures using of occlusal
cantilever springs myofunctional or prematurit es
orthopaedic
appliances
(iii) Anterior crossbite is a condition characterized by

reverse overjet. 'The best time to treat crossbites is
the first time they are seen', because they are self-
perpetuating and if not treated early, they develop
into skeletal malocclusions, which require
complicated orthodontic as well as surgical
procedures later for their correction.
Q.6. Indications and contraindications for serial

extraction procedures.
Ans.
[Same as SE Q.3]
Q.7. Indications for serial extraction.

Ans.
[Sarne as SE Q.3]
Short notes:
Q.1. Define serial extraction. Add a note on it.

Ans.
Serial extraction is defined by Tweed as the planned and
sequential removal of the primary and permanent teeth
to intercept and reduce dental crowding problems.
Indications:
i. Class I malocclusion with an arch length-tooth
size discrepancy (>10 mm).
ii. Patients with straight profile and pleasing
appearance.
iii. The arch length deficiency either unilateral or
bilateral due to nonpathological causes.
Example: premature loss of canines with rnidline
shift, bimaxillary protrusion and ectopic
eruption of teeth
iv. The arch length deficiency due to pathologic
causes.
Example: extensive proximal caries, ankylosis of
tooth and deleterious oral habits
Q.2. Muscle exercises.

Ans.
[Ref LE Q.2]
Q.3. Interceptive orthodontics.

Ans.
i. Interceptive orthodontics has been defined as that
phase of the science and art of orthodontics employed
to recognize and eliminate potential irregularities
and rnalpositions of the developing dentofacial
complex.
ii. Interceptive orthodontics basically refers to measures
iii. A few procedures undertaken in interceptive
orthodontics include: serial extractions, correction of
developing crossbites, control of abnormal habits,
muscle exercises, etc.
iv. Many of the interceptive orthodontic procedures are
nothing but extension of preventive orthodontic
procedures, only the difference is timing of
treatment.
Q.4. Advantages of serial extraction.

Ans.
[Ref LE Q.1]
Q.5. Disadvantages of serial extraction.

Ans.
[Ref LE Q.1]
Q.6. Define serial extraction. Give its

contraindications.
Ans.
[Ref LE Q.l]
•
Q.7. Enumerate various serial extraction
procedures.
Ans.
[Ref LE Q.2]
Q.8. Space regainer.

Ans.
[Ref LE Q.2]
Q.9. Developing anterior crossbite correction.

Ans.
[Sarne as SE Q.S]
Q.10. Define serial extraction.

Ans.
[Sarne as SN Q.1]
Q.11. Write few indications of serial extractions.

Ans.
[Sarne as SN Q.1]
Q.12. Define serial extraction and discuss any one

method of serial extraction.
Ans.
[Sarne as SN Q.7]
Q.13. Classification of anterior crossbites.

Ans.
[Sarne as SN Q.9]
Topic 19 Methods of space gaining
Long essays:
1. Enumerate the various methods of gaining space
and discuss extractions in orthodontics.
2. Describe various methods to gain space in

orthodontics. Give their indications and
contraindications. [Same as LE Q.1]
3. What is arch length discrepancy? How will you
assess the total discrepancy in a given adult
patient? What methods can be used to correct
arch length discrepancy? [Same as LE Q.1]
Short essays:
1. What are the methods of gaining space in
orthodontics?
2. Distal driving of molars.
3. Proximal stripping.
4. Methods of space gaining in dental arch. [Same as
SE Q.1]
5. Slenderization. [Same as SE Q.3]
Short notes:
1. Molar distilization - indications. [Ref SE Q.2]
2. Proximal stripping - mention few advantages. [Ref
SE Q.3]
3. What are the methods of gaining space in
orthodontics? [Ref LE Q.1]
4. Uprighting of molars.
5. Reproximation of teeth [Same as SN Q.2]
6. Slenderization. [Same as SN Q.2]
7. Enlist methods of gaining space. [Same as SN Q.3]
Solved answers
Long essays:
Q.1. Enumerate the various methods of gaining space

and discuss extractions in orthodontics.
Ans.
{SN Q.3}
Planning space is an important aspect of the
treatment planning in orthodontics. Some of the
methods of gaining space include:
i. Proximal stripping
ii. Expansion
iii. Extraction
iv. Distalization
v. Uprighting of molars
vi. Derotation of posterior teeth
vii. Proclination of anteriors
I. Proximal stripping
(Reproximation, slenderization, disking and
proximal slicing)
• It is a method by which the proximal surfaces of
the teeth are sliced in order to ! M-D width of the
teeth.
Indications:
• When space required is minimum, i.e. 0-2.5
mm.
• If the Bolton's analysis shows mild tooth
material excess in either of the arches.
• It can be undertaken as an aid to retention in
the lower anterior region.
Contraindications:
• Young patients with large pulp chamber t risk
of pulp exposure.
• Patients susceptible to caries/those with high
caries index.
Aids/investigations:
a. Carey's/arch perimeter analysis (tooth
material excess of 0-2.5 mm over arch
length in diagnosis)
b. Bolton's analysis (reveals excess tooth
material in either of the arches)
c. Diagnostic set-up (helps to localize the
problem, and discloses amount of enamel
reduction)
d. IOPAs (it gives an idea of enamel
thickness and extent of pulp horns,
thereby helps in estimating amount of
enamel that can be removed)
Procedure of proximal stripping:
Armamentarium:
• Use of metallic abrasive strips
• Safe-sided carborundum discs
• Safe-sided diamond discs
• Very long and thin tapered fissure burs
Procedure:
Proximal stripping is of two types: (i) localized
and (ii) generalized.
• Localized reduction is usually carried out in
mandibular or maxillary anterior regions.
• In the moderate space discrepancy cases, a
generalized interproximal reduction is
carried out.
• Contact points are converted into contact
areas taking care to establish proper contact
between the teeth.
Amount of proximal stripping:
• Not more than 50°/o of enamel thickness should
be reduced by proximal stripping and equally
distributed over all teeth.
Advantages:
• Extractions are avoided in the borderline cases
where space requirement is minimal.
• In the patients with Bolton's discrepancy, a
normal interarch relationship (favourable
over bite and overjet relation) can be
established by eliminating tooth material
excess in either of the arches.
• More stable results can be established by
broadening the contact area, which prevents
slipping of contact.
Disadvantages/drawbacks:
• Causes roughened proximal surface that
attracts plaque and calculus, resulting in
gingivitis.
• t Caries susceptibility (proximal caries).
• Hypersensitivity of teeth may develop.
• Alteration of teeth morphology (altered
aesthetics due to improper
procedure/inexperienced hands).
• Food impaction (because of loss of normal
contact between adjacent teeth).
Comprehensive fluoride programme should
follow this proximal stripping procedure.
II. Expansion as a method of gaining space
• It is a noninvasive method.
Types of expansions:
Orthodonric/dentoal veol ar -
r-+ produce dental expan ion
with no skeletal.
Results from intrinsic

Three types of --
. . forces exerted by the tongue.
pa ive-expan ions
Skeletal/orthopaedic -
...___... re ults from splitting of
mid-palatal urure.
Indications of arch expansion:

• Crossbite (unilateral/bilateral)
• Constricted arches
Types of expansion appliances:
• They are broadly of two types: (i) maxillary and (ii)
mandibular
Expansion appliances
t
Maxillary
* Mandibular
Example: Lower
Schwarz plate
Slow Rapid
Removable
* Fixed Banded RME
* Bonded RME
Examples: Examples: Examples: Example:
i. Coffin spring i. W-arch i. Haas i. Cast metal
ii. Active plate ii. Quad helix ii. Isaacson /acrylic
with screws iii. Fixed appli- iii. Derichs- splints
or Z-springs ance with weiler
expansion
screws
III. Extractions as a method of gaining space

• In clinical orthodontics, extractions form a main
part among all space gaining procedures.
• Extractions are indicated for correction of
crowding, anteroposterior dental arch relations,
vertical problems, skeletal jaw deformities and
presence of supernumerary teeth.
• Therapeutic extractions are extractions that are
undertaken as a part of orthodontic treatment.
• Choice of teeth for extraction depends on various
factors like condition of teeth, position of teeth and
position of crowding. Premolars (most frequently
extracted teeth) utilized for correction of anterior +
posterior segments.
• Molars or lower incisors are also preferred.
IV. Distalization
• Moving the molars in a distal direction so as to gain
space is known as distalization.
• It has become a popular technique of recent times.
• Ideal timing for distalization - during mixed
__Zl1_
dentition period prior to eruption of 717
Two methods
t
Maxillary Mandibular
molar distalization molar distalization
.~-.:...-----.
Extra oral
+ Example: Lip bumper
lntraoral (removable and fixed)

Examples: Headgears Examples:
Disadvantages of i. Sagittal appliance - split
extraora/: acrylic plate joined by
a. Patient cooperation is jackscrew. It can be used to
essential for timely wear distalize one tooth at a time.
ii lntr!lnr<ll m!lnno>tc, - l"nnc,ic,t
Two methods
t
Maxillary Mandibular
molar distalization molar distalization
.~-"------.
Extraoral
i Example: Lip bumper
lntraoral (removable and fixed)

Examples: Headgears Examples:
Disadvantages of i. Sagittal appliance - split
extraora/: acrylic plate joined by
a. Patient cooperation is jackscrew. It can be used to

essential for timely wear distalize one tooth at a time.
of appliance. ii. lntraoral magnets - consist
b. Appliance not worn cont- of repelling magnet placed
inuously. Intermittent in on molar and a tooth anterior
action and prolonged to it.
treatment time. iii. Use of open coil springs -
open coil NiTi spring
compressed between molar
and anterior segments.
iv. Pendulum appliance -
Incorporates a modified
Nance's button - anchorage
and an SS wire with a helix
which is inserted into a sleeve
on palatal aspect of molar to
be distalized.
V. Uprighting of molars
• Uprighting springs or coil springs are used.
• By uprighting of mesially or distally tipped molar,
certain amount of space can be recovered.
VI. Derotation of posterior teeth
• A little amount of space can be gained by correcting
rotated teeth.
• This is best achieved by fixed appliances
incorporating springs or elastics using a force
couple.
VII. Proclination anterior teeth
• Slight proclination of anterior teeth results in
gaining of arch length.
Indications:
a. Retroclined anteriors
b. Cases where protracting anteriors will not
affect soft tissue profile
c. In patients with obtuse nasolabial angle
Q.2. Describe various methods to gain space in

orthodontics. Give their indications and
contraindications.
Ans.
[Same as LE Q.1]
Q.3. What is arch length discrepancy? How will you

assess the total discrepancy in a given adult patient?
What methods can be used to correct arch length
discrepancy?
Ans.
[Same as LE Q.1]
Short essays:
Q.1. What are the methods of gaining space in

orthodontics.
Ans.
Various space gaming methods are implemented in
orthodontic treatment. Some of the methods of gaining
space include:
ii. Expansion
iii. Extraction
iv. Distalization
(Reproximation, slenderization, disking and
proximal slicing)
• It is a method by which the proximal surfaces of
the teeth are sliced in order to ! M-D width of the
teeth.
• Indicated when space required is minimum, i.e.
0-2.5 mm.
• Contraindicated in young patients with large pulp
chambers and patients with high caries index.
• Not more than 50°/o of enamel thickness should
be reduced by proximal stripping and equally
distributed overall teeth.
ii. Expansion as a method of gaining space
• It is a noninvasive method.
• Three types of expansions:
a. Orthodontic/dentoalveolar
b. Passive expansion
c. Skeletal/orthopaedic
• Arch expansion is indicated in cases with crossbite
(unilateral/bilateral) and constricted arches.
• Types of expansion appliances:
a. Maxillary, e.g. coffin spring, W-arch, quad
helix and Isaacson.
b. Mandibular, e.g. lower Schwarz plate.
iii. Extractions as a method of gaining space
• In clinical orthodontics, extractions form a main
part among all space gaining procedures.
presence of supernumerary teeth.
factors like condition of teeth, position of teeth.
Example: premolars (most frequently extracted
teeth) utilized for correction of anterior+ posterior
segments
iv. Distalization
space is known as distalization.
• Ideal timing for distalization - during mixed
dentition period prior to eruption of

• Uprighting springs or coil springs are used.
*
• A little amount of space can be gained by correcting
rotated teeth.
• This is best achieved by fixed appliances
incorporating springs or elastics using a force
couple.
vii. Proclination anterior teeth
• Slight proclination of anterior teeth results in
gaining of arch length.
• Indicated in the cases of retroclined anteriors or in
cases where protracting anteriors will not affect
soft tissue profile.
Q.2. Distal driving of molars.

Ans.
{SNQ.1}
space is known as distal driving or distalization of
molars.
• Ideal timing for distalization - during mixed dentition
2LL
period prior to eruption of 7T7
Indications:
• Class II cases due to maxillary prognathism
• Mild-to-moderate protrusion/crowding in maxillary
arch with normal mandible
• Mild arch discrepancy in mandibular arch
• In cases of anchorage, loss during orthodontic
treatment
Contraindications:
• Dental class I or class III molar relation
• Bimax protrusion
• Both skeletal and dental open bite cases
• Cases with concave soft tissue profile
Methods of distalization:
Two methods
i
+
Maxillary molar Mandibular molar
distalization distalization
! Example: Lip bumper
Extraoral lntraoral
Example: Headgears
+ i
+
Removable Fixed
Example: Finger Example: Open coil springs,
springs, Expansion Pendulum appliance,
plate Jones jig
Disadvantages of extraoral method:

• Patient cooperation is essential for timely wear of
appliance.
• Appliance not worn continuously, intermittent in
action and prolonged treatment time.
Intraoral method (removable and fixed appliances):
• Sagittal appliance: A split acrylic plate joined by
jackscrew can be used to distalize one tooth at a
time.
• Intraoral magnets: Consist of repelling magnet
placed on molar and a tooth anterior to it.
• Use of open coil springs: Open coil NiTi spring
compressed between molar and anterior
segment.
• Pendulum appliance: Incorporates a modified
Nance's button - anchorage and an SS wire with
a helix which is inserted into a sleeve on palatal
aspect of molar to be distalized.
Q.3. Proximal stripping.

Ans.

{SN Q.2}
• Proximal stripping is also known as reproximation,
slenderization, disking and proximal slicing.
• It is a method by which the proximal surfaces of the
teeth are sliced in order to ! M-D width of the teeth.
Indications:
• When space required is minimum, i.e. 0-2.5 mm.
• If the Bolton's analysis shows mild tooth material
excess in either of the arches.
• It can be undertaken as an aid to retention in the
lower anterior region.
Contraindications:
• Young patients with large pulp chamber t risk of
pulp exposure.
• Patients susceptible to caries/those with high caries
index.
Aids/investigations:
a. Carey's/arch perimeter analysis (tooth material
excess of 0-2.5 mm over arch length in
diagnosis).
b. Bolton's analysis (reveals excess tooth material
in either of arches)
c. Diagnostic set-up (helps to localize the problem
and discloses amount of enamel reduction)
d. IOPAs (gives an idea of enamel thickness and
extent of pulp horns, thereby helps in
estimating amount of enamel that can be
removed)
Procedure of proximal stripping:
Armamentarium
• Use of metallic abrasive strips
• Safe-sided carborundum discs
• Safe-sided diamond discs
• Very long and thin tapered fissure burs
Procedure:
Proximal stripping is of two types: (i) localized and
(ii) generalized.
• Localized reduction is usually carried out in
mandibular or maxillary anterior regions.
• In the moderate space discrepancy cases, a
generalized interproximal reduction is carried
out.
• Contact points are converted into contact areas
taking care to establish proper contact between
the teeth.
Amount of proximal stripping:
• Not more than 50°/o of enamel thickness should be
reduced by proximal stripping and equally
distributed overall teeth.
{SN Q.2}
Advantages:
• Extractions are avoided in the borderline cases
where space requirement is minimal.
• In the patients with Bolton's discrepancy, a normal
interarch relationship (favourable overbite and
overjet relation) can be established by eliminating
tooth material excess in either of the arches.
• More stable results can be established by
broadening the contact area, which prevents
slipping of contact.
Disadvantages/drawbacks:
• Causes roughened proximal surface that attracts
plaque and calculus resulting in gingivitis
• t Caries susceptibility (proximal caries)
• Hypersensitivity of teeth may develop
• Alteration of teeth morphology (altered aesthetics
due to improper procedure/inexperienced hands)
• Food impaction (because of loss of normal contact
between adjacent teeth)
Comprehensive fluoride programme should follow
this proximal stripping procedure.
Q.4. Methods of space gaining in dental arch.

Ans.
[Same as SE Q.1]
Q.5. Slenderization.
Ans.
[Same as SE Q.3]
Short notes:
Q.1. Molar distilization - indications.

Ans.
[Ref SE Q.2]
Q.2. Proximal stripping - mention few advantages

Ans.
[Ref SE Q.3]
Q.3. What are the methods of gaining space in

orthodontics?
Ans.
[Ref LE Q.1]
Q.4. Uprighting of molars.

Ans.
• Uprighting of molars is a method gaining space in
orthodontics without reducing any tooth material.
• Uprighting of molars is required when they are
tipped either mesially or distally occupying more
space in the arch.
• Uprighting springs or coil springs are commonly used
for uprighting the molars.
Q.5. Reproximation of teeth.

Ans.
[Same as SN Q.2]
Q.6. Slenderization.
Ans.
[Same as SN Q.2]
Q. 7. Enlist methods of gaining space.

Ans.
[Same as SN Q.3
Topic 20 Arch expansion
Long essays:
1. Enumerate various methods to gain space in
orthodontics and write in detail about rapid
maxillary expansion.

2. Classify expansion in orthodontics. Discuss your
line of treatment for a case of 12 years with
bilateral buccal crossbite. [Same as LE Q.1]
3. Enumerate various methods to gain space in
orthodontics. Discuss rapid palatine expansion.
[Same as LE Q.1]
4. Explain rapid maxillary expansion in detail. [Same
as LE Q.1]
Short essays:
1. Arch expansion. [Ref LE Q.1]
2. Expansion screws.
3. Indications of rapid maxillary expansion. [Ref LE
Q.1]
4. Compare rapid and slow palatal expansions.
5. Rapid palatine expansion. [Same as SE Q.3]
6. Dental versus skeletal expansion. [Same as SE Q.4]
Short notes:
1. Slow expansion appliance.
2. Rapid maxillary expansion.
3. Coffins spring.
4. Expansion screws. [Ref SE Q.2]
5. Role of expansion as a method of gaining space.
6. Give indications for rapid palatine expansion. [Ref
LE Q.1]
7. Derichsweiler appliance.
8. Hyrax screw.
9. Quad helix appliance.
10. RME. [Same as SN Q.2]
11. Expansion devices. [Same as SN Q.4]
Solved answers
Long essays:
Q.1. Enumerate various methods to gain space in

orthodontics and write in detail about rapid
Ans.
Various methods to gain space in orthodontics include:
ii. Expansion
iii. Extraction
iv. Distalization
Expansion as a method of gaining space
Expansion is a noninvasive method of gaining space.
[SE Q.1]
{Types of expansions:
Orthodontic/denroalveolar -
~ Produce dental expansion
with no skeletal change.
Three type of --1----... Result from intrinsic force

. .
pas ive expansions exerted by the tongue.
Skeletal/orthopaedic re ults
......__. from splitting of mid-
palatal suture.
Indications of arch expansion:

• Crossbite (unilateral/bilateral)
• Constricted arches
Types of expansion appliances:
• They are broadly of two types: (i) maxillary and (ii)
mandibular.
Expansionappliances
..
Maxillary
* Mandibular
Example: Lower
Schwarz plate
Stow Rapid
Removable
* Fixed Banded RME
* Bonded RME
Examples: Examples: Examples: Example:
i. Coffin spring i. W-arch i. Haas i. Cast metal
ii. Active plate ii. Quad helix ii. Isaacson /acrylic
with screws iii. Fixed appli- iii. Derichs- splints
or Z-springs ance with weiler
expansion
screws
Rapid maxillary expansion (RME)

Emerson C Angell (1860) is the pioneer of rapid
maxillary expansions. Nowadays it is an important
form of orthopaedic therapy.
[SE Q.3]
Indications of RME:
(SE Q.3 and SN Q.6)
{(Indications of rapid maxillary expansion can be
considered under the following two headings:
Orthodontic indications Medical indications
i. Unilateral or bilateral posterior i. Poor nasal airway

skeletal crossbite
ii. Narrow maxilla in certain ii. Recurrent ear. nasal or
class II cases sinus infections
iii. Class Ill malocclusion iii. Allergic rhinitis and asthma
iv. Collapsed maxillary arch due iv. Before correction of septa!
to cleft palate deformities
v. Treatment along with reverse
pull headgear to loosen the
sutures
vi. To gain space in anterior
crossbile
vii. High angle cases (bonded
type of RME)
[SE Q.3]
{Principle of RME
• Force applied to widen the maxilla causes opening
of the mid-palatal suture and induces new bone
formation. Space created in the midline is initially
filled with tissue fluids and blood; later after 3-4
months, new bone fills in the space.
Classification of rapid expansion appliances:
A. Removable
B. Fixed
a. Bonded or banded type
b. Tooth borne
Or
Tooth- and tissue-borne type}
A. Removable appliances
• They are not effective for rapid maxillary
expansion as they are not rigid enough to
produce skeletal expansion.
• A removable appliance consists of split acrylic
plate with a mid.line screw.
• Appreciable skeletal effects are produced with
these appliances when treatment is performed
during deciduous or early mixed dentition
period.
B. Fixed rapid maxillary expansion appliances
They can be bonded or banded or tooth borne,
tooth and tissue borne.
a. Banded RME appliances:
• Usually here the first premolars or deciduous
molars and first permanent molars are
banded. They are joined labially and
palatally
. by soldering with heavier gauge
wire.
• The basic RME appliance is the screw, which
is placed in the mid.line.
• Different types of banded RMEs: The
difference in appliance design of various
banded RME appliances is based on various
types of screws and mode of attachments.
They are as follows:
i. HAAS type:
• In this type of banded RME, a heavy
stainless steel wire (0.045 inch/1.15
mm) is welded and soldered along
the palatal aspects of the band.
• The free ends are turned back to be
embedded in acrylic.
• The screw used in this type of RME
is similar to Derichsweiler type.
ii. Isaacson type:
• It is a tooth-borne appliance without
any palatal acrylic covering.
• The drawback of expansion screw is
the build-up of pressure, which is
hazardous to tissue.
• A special spring-loaded screw, called
a MINNE expander, is used in this
design soldered directly to the
bands to overcome the pressure
built up and to make the force
application smooth and constant.
iii. Hyrax or Biedermann type:
• Biedermann-type RME uses Hyrax
(hygienic rapid expander) screw.
• Hyrax screws have heavy gauge
wire extensions, which are
adapted to the palatal contour,
welded and soldered to the palatal
aspect of the bands on premolars
and molars.
iv. Derichsweiler type:
• In this type of appliance, the screw
is connected to the bands by
means of wire tags that are welded
and soldered to the palatal aspect
of band on one side and embedded
in acrylic on the palatal aspects of
all nonbanded teeth except the
incisors. Acrylic adapts to the
palate and is in two halves to
permit activation of screw.
b. Bonded RME appliances:
In bonded RME, instead of bands, metallic cap
splints or acrylic covering is used.
i. Cast metal cap splints:
Cast cap splints to which screws are soldered
are prepared for all the teeth and the
entire assembly is cemented or bonded.
ii. Acrylic splints:
• Thick gauge stainless steel wire is
closely adapted buccally and
palatally around the posterior
teeth from premolars to molars
and a screw is soldered to the wire.
• Acrylic is covered over the occlusal,
buccal and palatal-occlusal third of
all the posterior teeth, and the
assembly is cemented/bonded.
Advantages of bonded RME:
• Bonded appliances are useful in
high angle cases.
• The occlusal acrylic covering acts as
a splint and prevents increase in
mandibular angle.
Appliance management in children younger
than 15 years:
• Activated twice in a day.
• 90° activation each time with total
180° activation every day.
• 0.5 mm/day.
• Review: after 1 week.
Pain is felt in patients who are in
late adolescences and adults due to
build up of force.
Cl ; tT h t rH C' r» rv 1'Y'I f' /"\ l" t 1'Y'I <H T h O f' 0 l t
build up of force.
Slight discomfort may be felt
during expansion. Persistent pain
is noticed in patients wherein
suture is fused. In such cases,
activation should be stopped.
• Surgically assisted rapid palatal expansion
(SARPE)
In adults, palatal osteotomies lateral to mid-palatal
suture is done to assist rapid expansion.
Clinical implications of expansion
• Mid-palatal suture does not open evenly but

opens in a 'V' fashion, with the broad end of V
in anterior region and the apex in the
posterior region.
• Occlusal and frontal cephalometric radiographs
will reveal suture opening.
• Force recorded during rapid expansion is in the
range of 10-20 pounds.
• Usual treatment period is 2 weeks and the
relapse is higher after RME; hence
overcorrection is advised.
Tissue changes observed with RME
Tissue changes can be observed in bone, sutures
and dental structures.
Bone changes:
• Maxilla moves laterally due to expansion and
also rotates with the fulcrum at frontonasal
suture.
• Downward and backward rotation of mandible
with increase in mandibular angle.
• Increase in nasal airway, reduction in airway
resistance.
Sutural changes:
• Space created by sutural opening is filled with
tissue fluid and haemorrhage and later the
area is invaded by osteoblasts.
• New bone is deposited at the edges of palatal
process and the space is gradually filled with
the bone.
Dental changes:
• Initially, teeth move labially by translation and
later there is an increased buccal inclination of
the posterior teeth with slight extrusion.
• Appearance of median diastema, which later
closes due to pull of trans-septal fibres.
Tissue reaction after expansion:
• At the end of active expansion, 80°/o skeletal
and 20°/o dental expansion occurs.
• After 4 months, 50°/o skeletal and 50°/o dental
changes are observed.
• Relapse is highest during the first 6 weeks after
expansion, and there is more skeletal relapse
while dental correction is retained.
Retention schedule after RME:
• The objective of retention is to hold the
expansion, while the forces generated have
decayed.
• The same fixed RME appliance is used as
retainer for first 3 months with the hole of the
screw filled with self-cure acrylic.
• From fourth month onwards removable
retainers are given and are worn for full time
for about 9 months after expansion, and later
half-time wear is advised.
Q.2. Classify expansion in orthodontics. Discuss your

line of treatment for a case of 12 years with bilateral
buccal crossbite.
Ans.
[Same as LE Q.1]
Q.3. Enumerate various methods to gain space in

orthodontics. Discuss rapid palatine expansion.
Ans.
[Same as LE Q.1]
Q.4. Explain rapid maxillary expansion in detail.

Ans.
[Same as LE Q.1]
Short essays:
Q.t. Arch expansion.

Ans.
[Ref LE Q.1]
Q.2. Expansion screws.

Ans.
{SN Q.4}
• A typical expansion screw consists of an oblong body
divided into two halves, with each half consisting of
threaded inner side that receives one end of a
double-ended screw.
• The screw has a central basing with four holes, which
receive a key, which is used to turn the screw.
• The turning of screw to 90° brings about linear
movement of 0.18.
• Various types of expansion screws used in removable
and fixed appliances are jackscrews, coffin springs,
quad helix, Isaacson, Hyrax and Derichsweiler, for
example.
• Activation schedule: To achieve desired results,
different activation schedules have been advocated
by different authors; the most popular ones are:
a. Schedule by Timms
b. Schedule by Zimring and Isaacson
• According to Timms:
In patients aged up to 15 years: 90° rotation in the
morning and evening.
In patients aged over 15 years: 45° activation for four
times a day.
• According to Zimring and Isaacson:
In growing individuals: Two turns each day for 4-5
days, and later one turn per day till the desired
expansion is achieved
In non-growing adults: Two turns each day for first 2
days and later one turn per day for next 5- 7 days
and one turn every alternate day till the desired
expansion is achieved
Q.3. Indications of rapid maxillary expansion.

Ans.
[Ref LE Q.1]
Q.4. Compare rapid and slow palatal expansions.

Ans.
The comparable features of rapid and slow palatal
expansions are as follows:
Slow .
Features Rapid expansion expansion
i. Nature of Mostly skeletal and even Mainly dental
expansion dental
ii. Age Before fusion of mid- Any age
palatal suture (young
growing individuals)
iii. Rate of Rapid Slow
expansion
.
lV. Skeletal crossbite cases in Cases of minor
Indication class II and class III space
discrepancy
v. Force Greater forces around 10- Milder forces
level used 20 pounds between 2-
4 pounds
vi. Type of Traumatic Physiological
tissue
reaction
vii. Type of Mostly fixed appliance Either fixed or
appliance removable
used
...
Vlll. More frequent Less frequent
Frequency 0.5-1 mm/day 1 mm/month
of
activation
ix. Duration Short duration of about 2-3 Long duration
of weeks of around
treatment 2-3 months
x. Retention 9 months 3 months
Q.5. Rapid palatine expansion.

Ans.
[Same as SE Q.3]
Q.6. Dental versus skeletal expansion.

Ans.
[Same as SE Q.4]
Short notes:
Q.t. Slow expansion appliance.

Ans.
i. Slow expansion is traditionally known as
dentoalveolar expansion, although some minute
skeletal changes can also be seen.
ii. Here, expansion is done slowly at the rate of 0.5-1
mm/week. The forces generated by slow expansion
are much less of around 2-4 pounds.
iii. Compared with rapid expansion, slow expansion
produces more stable results and less relapse.
Q.2. Rapid maxillary expansion.

Ans.
i. The RME is also called 'rapid palatal expansion' and is
a skeletal type of expansion.
ii. Emerson C. Angell (1860) is the pioneer of RME.
Nowadays, it is an important form of orthopaedic
therapy.
iii. It is indicated in the cases of unilateral or bilateral
posterior skeletal crossbites, narrow maxilla in
certain class II and class III cases of malocclusion and
collapsed maxillary arch due to cleft palate.
iv. It is also indicated in certain medical conditions like
poor nasal airway, allergic rhinitis and asthma and
recurrent ear, nasal or sinus infections.
v. Both removable and fixed types of appliances are
used for rapid maxillary expansion, e.g. Isaacson
type, Hyrax type, Derichsweiler type and Hass type.
Q.3. Coffins spring.

Ans.
i. Coffins spring is a slow expansion appliance
introduced by Walter Coffin.
ii. Design:
• The spring is made up of a 1.25-mm heavy stainless
steel wire. It consists of U- or omega-shaped loop
positioned in the mid-palatal region. The distal
ends of the U-loop are limited to the distal of the
first permanent molar.
• It is a continuous type of spring where both ends
are fixed to the base plate.
• Appliance is activated by expanding the appliance
manually by pulling the sides apart, first in the
anterior region and then in the posterior region.
• An expansion of 2-3 mm is made during activation.
iii. Indications:
• An expansion of 2-3 mm is made during activation.
iii. Indications:
• Expansion of constricted maxillary arch and
correction of crossbite.
• Conditions requiring differential expansions.
iv. Advantages:
• Economical
• Differential expansion of arch is possible
• Less bulky
v. Disadvantage
• It is unstable if it is not made precisely.

Q.4. Expansion screws.
Ans.
[Ref SE Q.2]
Q.5. Role of expansion as a method of gaining space.

Ans.
i. Expansion has a unique place among various methods
to gain the space in orthodontics like proximal
stripping, extractions, distalization and uprighting of
molars and proclination of anteriors.
ii. Types of expansions:
Three types of expansions are as follows:
a. Orthodontic/dentoalveolar expansion: produces
dental expansion with no skeletal change
b. Passive expansion: results from intrinsic forces
exerted by the tongue
c. Skeletal/orthopaedic expansion: results from
splitting of mid-palatal suture
iii. Arch expansion is indicated in crossbite
(unilateral/bilateral) cases and constricted arches.
iv. There are broadly of two types of expansion
appliances, i.e. (i) maxillary and (ii) mandibular.
Q.6. Give indications for rapid palatine expansion.

Ans.
[Ref LE Q.1]
Q.7. Derichsweiler appliance.

Ans.
i. Derichsweiler type of appliance is a type of banded
RME appliance.
ii. In this type of appliance, the screw is connected to the
bands by means of wire tags that are welded and
soldered to the palatal aspect of bands on first
premolars and first molars on one side and
embedded in acrylic on the palatal aspects of all
nonbanded teeth except the incisors.
iii. Acrylic adapts to the palate and is in two halves to
permit activation of screw.
Q.8. Hyrax screw.

Ans.
i. Hyrax screw is a type of screw used in fixed rapid
maxillary banded RME expansion appliances.
ii. Hyrax or Biedermann type of RME uses Hyrax
(hygienic rapid expander) screw.
iii. Hyrax screws have heavy gauge wire extensions,
which are adapted to the palatal contour, welded and
soldered to the palatal aspect of the bands on
premolars and molars.
Q.9. Quad helix appliance.

Ans.
i. Quad helix is one of the appliances used to expand a
narrow maxilla.
ii. The quad helix incorporates four helices that increase
the wire length, therefore the flexibility and range of
action of this appliance is more.
iii. The appliance is constructed using 0.038-inch wire
and is soldered to bands on the first molars.
iv. The quad helix can be used to expand a narrow arch
as well as to bring about rotation of molars and
brings about a slow dentoalveolar expansion.
v. It can be pre-activated by stretching the two molar
bands apart prior to cementation or by using three
prong pliers after cementation.
vi. When used in children during deciduous and early
mixed dentition periods, a skeletal mid-palatal
splitting can be achieved.
Q.10. RME.
Ans.
[Same as SN Q.2]
Q.11. Expansion devices.

Ans.
[Same as SN Q.4]
Topic 21 Extractions
Long essays:
1. Describe in detail extractions in orthodontics.
2. What are the reasons for extractions in
orthodontics? Discuss the choice of teeth for

extractions. [Same as LE Q.1]
3. How will you plan extractions in orthodontic
treatment? [Same as LE Q.1]
4. Classify extractions in orthodontics. Write about
therapeutic extractions in detail. [Same as LE Q.1]
Short essays:
1. Describe the factors that justify extraction of teeth
for treating malocclusion. [Ref LE Q.1]
2. Wilkinson's extractions. [Ref LE Q.1]
3. Serial extractions.
Short notes:
1. Extraction in orthodontics.
2. Therapeutic extraction in orthodontics.
3. Wilkinson's extraction. [Ref LE Q.1]
4. Planning extractions.
5. Impacted tooth and its orthodontic correction.
6. Impacted canines. [Same as SN Q.5]
Solved answers
Long essays:
Q.1. Describe in detail extractions in orthodontics.

Ans.
• In clinical orthodontics extractions form a main part
among all space gaining procedures.
• Calvin S. Case was pioneer of extraction philosophy in
orthodontics, which was later supported by Charles
Tweed.
[SE Q.1]
{Reasons for extraction
presence of supernumerary teeth as described in
detail below.
i. Correction of crowding
• Crowding usually results from arch length
and tooth material discrepancy, hence prior
to extraction a careful analysis of tooth size-
arch length discrepancy should be
performed.
• In many cases the tooth material-arch length
disproportion cannot be treated by t the
arch length. Hence, ! of tooth material is the
only alternative.
• In case of severe tooth material, arch length
discrepancy extraction of one or more teeth
is undertaken to correct the malocclusion.
ii. Correction of sagittal interarch relationship
• The cases of abnormal sagittal
malrelationships like class II or class III
malocclusion may require extraction of
teeth to achieve normal sagittal interarch
relation.
• In Angle's class I cases: It is preferable to
carry out extractions in both arches.
• In Angle's class II: In most class II cases, it is
possible to reduce the abnormal maxillary
proclination by extracting only first
premolars in the upper arch.
• In Angle's class III: It is beneficial to avoid
extraction in upper arch. They are
preferably treated by extraction only in the
lower arch or by extraction in both arches.
iii. Abnormal size and farm of teeth
Deformed teeth which interfere with normal
occlusion necessitate their extraction in order
to achieve satisfactory occlusion, e.g.
macrodontia, severe hypoplastic teeth,
dilacerations and abnormal crown
morphology.
iv. Skeletal jaw malrelations
Respective surgical procedures along with
extractions may be required in correction of
severe skeletal malrelationship of the jaws
that may not be satisfactorily treated using
orthodontic appliances alone.
v. Preservation of symmetry:
Extractions may be undertaken to correct any
asymmetry in dental arches.}
The choice of teeth for extraction or indications for
extraction
position of crowding.
Teeth Indications for extraction

I. Maxillary i. Grossly carious and unrestorable
incisors incisors
(rarely ii. Unfavourably impacted or totally
extracted) blocked buccally/lingually
iii. In cases where one lateral is
congenitally missing, the other may
be extracted to maintain arch
symmetry
iv. Malformations of incisor
crowns/teeth with dilacerated root
v. Trauma/irreparable damage to
incisors by fracture
II. i. Totally locked buccaly/lingually.
Mandibular ii. Severe trauma, gingival recession or
incisors bone loss.
iii. Severe arch length deficiency with
fanning of lower anteriors.
iv. For correction of lower incisor
crowding in mild class II cases.
III. Canines i. Ectopically erupted or unfavourably
(seldom impacted.
extracted) ii. Totally blocked bucally or lingually.
iii. Deciduous canine extracted as part
of serial extraction.
iv. Premature shedding of a deciduous
canine usually indicates the
extraction of its fellow on the opposite
side of the arch to restore symmetry.
v. In class II cases if the lower deciduous
canines are shed early, the upper
deciduous canines should also be
removed to avoid worsening of the
post normalcy (class II tendency).
vi. In class III cases if the upper
deciduous canines are shed early, it
may necessitate the extraction of
lower deciduous canines to avoid
worsening of prenormalcy (class III
tendency).
IV. First i. To relieve moderate-to-severe
premolars crowding U/L arch and proclination,
(teeth of in class II, division I or class I bidental
choice for protrusion.
extraction) Reasons for the extraction offirst
premolars are as follows:
• Their location in the arch is such that
the space gained by their extraction
can be utilized for correction in both
anterior and posterior regions.
• The contact that results between
canine and second premolar is
satisfactory.
V. Second i. To relieve mild discrepancy of
premolars crowding and proclination.
ii. Unfavourably impacted.
iii. In open bite cases.
iv. If grossly decayed or have a
questionable prognosis.
VI. First i. To correct mild
molars crowding/proclination.
ii. Grossly decayed with poor prognosis.
iii. In open bite cases to encourage
deepening of bite.
VII. Second i. To prevent third molar impaction.
molars ii. To enable distalization of first molar.
VIII. Third No extraction for orthodontic purposes.
molars
Various extraction techniques are as follows:

A. Wilkinson's extraction
B. Balancing extraction
C. Compensating extraction
D. Serial extraction
E. Extractions in camouflage treatment
F. Drift odontics
(SN Q.3 and SE Q.2)
{(A. Wilkinson's extraction technique
~
• Wilkinson advocated extraction of all 6f6

between the age of 81/2 and 91/2 years
• Basis for this extraction is the fact that the first
permanent molars in children are highly
susceptible to caries.
• Advantages:
i. Impaction of third molars can be avoided
by making the space available for their
eruption.
ii. In general, crowding of arch is
minimized,
. thereby lowering the risk of
caries.
iii. Makes it possible to maintain oral
hygiene effectively.
• Drawbacks:
i. The extraction of first molars offers
limited space for alleviation of crowding.
ii. The second biscuspids and second molars
rotate and may tip into the extraction
space.
iii. Deprivation of adequate anchorage for
any orthodontic tooth movement.
iv. Improper contacts lead to accumulation
of plaque and calculus, resulting in
periodontal problems.)}
B. Balancing extraction
• Removal of teeth symmetrically on either side
of the arch is known as balanced extraction.
• Removal of tooth on one side of the arch results
in asymmetry; to prevent this, extractions
have to be balanced to allow equal movement
of remaining teeth towards extraction site on
both sides of the arch.
• Extraction of teeth in opposing jaws or arches
is known as compensating extraction.
• This type of extraction preserves interarch
• Extraction of teeth in opposing jaws or arches
is known as compensating extraction.
• This type of extraction preserves interarch
relationship and maintains lateral symmetry.
D. Serial extraction
• Robert Bunon introduced the concept of serial
extraction. The term 'serial extraction' was
coined by Kj ellgren.
• Extraction of certain deciduous and permanent
teeth in a sequence to alleviate crowding is
known as serial extraction.

• Usual sequence of extraction is first primary
canines fallowed by primary first molars, then
permanent first premolars (C, D, 4).
E. Drift odontics or extractions of permanent
teeth without appliance therapy
• Extraction of the lower first premolars
* is often associated with

spontaneous de crowding of lower anteriors. It
is referred to as drift odontics and is less
frequent in the upper arch.
• These may be instances when the extraction of
a permanent tooth is not followed by
orthodontic treatment for varied reasons such
as nonavailability of specialist or point
unsuitable for fixed appliance therapy. These
types of extractions are preferable.
Q.2. What are the reasons for extractions in

orthodontics? Discuss the choice of teeth for
extractions.
Ans.
[Same as LE Q.1]
Q.3. How will you plan extractions in orthodontic

treatment?
Ans.
[Same as LE Q.1]
Q.4. Classify extractions in orthodontics. Write about

therapeutic extractions in detail.
Ans.
[Same as LE Q.1]
Short essays:
Q.1. Describe the factors that justify extraction of

teeth for treating malocclusion.
Ans.
[Ref LE Q.1]
Q.2. Wilkinson's extractions.

Ans.
[Ref LE Q.1]
Q.3. Serial extractions.

Ans.
• Robert Bunon introduced concept of serial extraction.
The term 'serial extraction' was coined by Kjellgren.
• Extraction of certain deciduous and permanent teeth
in a sequence to alleviate crowding is known as
serial extraction.
• Three popular methods of serial extraction are as
follows:
I. Dewel's method
II. Tweed's method
III. Nance's method
I. Dewel's method: Dewel proposed a three-step
serial extraction procedure as follows:
The sequence of the proposed extractions is C, D,
4.
Step 1: Extraction of 'C' - between 8 and 9 years
to create space for alignment of incisors.
Step 2: Extraction of 'D' - one year later, i.e. at 10
years of age to accelerate eruption of first
premolars.
Step 3: Extraction of '4' (first premolar) - to
permit the eruption of permanent canines in
their place.
Modified Dewel's technique: Where first
premolars are enucleated at the time of
extraction of first deciduous molar, especially
in mandibular arch where canines erupt
before first premolars.
II. Tweed's method: The sequence of the
proposed extraction: D, C, 4.
Step 1: Extraction of 'D' (deciduous first molar) -
at 8 years of age.
Step 2: Deciduous canines are maintained till
premolars are in advanced eruptive stage.
Then both 'C' (deciduous canines) and first
premolars '4' are extracted simultaneously.
III. Nance's method: The sequence of the
proposed extraction: D, 4, C.
This method is basically modified Tweed's
method.
Step 1: Extraction of 'D' (deciduous first molars) -
at 8 years of age.
Step 2: Extraction of '4' (first premolars) and 'C'
(deciduous canines) simultaneously.
Postserial extraction therapy: Most cases of
serial extraction need fixed orthodontic
appliance therapy for correction of axial
inclination and detailing of occlusion.
Short notes:
Q.1. Extraction in orthodontics.

Ans.
• In clinical orthodontics, extractions form a main part
• Extractions are indicated for correction of crowding,
anteroposterior dental arch relations, vertical
problems, skeletal jaw deformities and presence of
supernumerary teeth.
• Therapeutic extractions are extractions that are
undertaken as a part of orthodontic treatment.
position of crowding.
• Premolars (most frequently extracted teeth) utilized
for correction of anterior + posterior segments.
• Molars or lower incisors are also preferred.
Q.2. Therapeutic extraction in orthodontics.

Ans.
• When teeth are extracted for orthodontic correction,
it is called therapeutic extraction.
• In orthodontics, extractions are indicated for
correction of crowding, anteroposterior dental arch
relations, vertical problems, skeletal jaw deformities
and presence of supernumerary teeth as per the
need of the situation.
Q.3. Wilkinson's extraction.

Ans.
[Ref LE Q.1]
Q.4. Planning extractions.

Ans.
• In clinical orthodontics, extractions form a main part
• Calvin S Case was the pioneer of extraction
philosophy in orthodontics, which was later
supported by Charles Tweed.
• In planning extractions 'think organized', i.e.
malocclusion should be analysed first in the
anteroposterior plane, then the vertical plane and
finally in the transverse plane.
• Extractions are indicated for correction of crowding,
anteroposterior dental arch relations, vertical
problems, skeletal jaw deformities and presence of
supernumerary teeth as the situation exists.
• Extraction should not be done if it affects soft tissue
balance.
Q.5. Impacted tooth and its orthodontic correction.

Ans.
• Teeth are impacted due to variety of reasons like arch
length discrepancy, abnormal developmental
position and deflection in the path of eruption.
• The possible methods of treatment for an impacted
tooth are as follows:
a. Leave as it is
b. Extraction
c. Surgical exposure only
d. Surgical exposure and orthodontic alignment
• If the impacted tooth/canine is asymptomatic and
well aligned, it can be left as it is with periodic
follow-up.
• If the teeth are unfavourably positioned or shows
signs of pathology or causes resorption of adjacent
teeth, then it should be extracted.
• If the impacted tooth is favourably positioned with
unobstructed path of eruption and is well within the
eruptive period, then only surgical exposure is
enough.
• If impacted tooth is malpositioned, having insufficient
space available in arch on eruption or associated
with orthodontic problems, then it should be
exposed surgically and mechanical approaches, e.g.
Nitinol wires, auxiliary arrangement of springs like
PG springs and magnets. Should be utilized to align
the tooth in the arch.
Q.6. Impacted canines.

Ans.
[Same as SN Q.5]
Topic 22 Orthodontic appliances -
general principles
Long essays:
1. What are the advantages and disadvantages of
removable and fixed appliances?

2. What are the basic requirements of orthodontic
appliances?
3. What are the indications and contraindications of
removable and fixed orthodontic appliances?
[Same as LE Q.1]
4. Define orthodontic appliances. Classify them. State
the advantages of fixed and removable appliances.
[Same as LE Q.1]
5. Compare the merits and demerits of removable
and fixed orthodontic appliances. [Same as LE Q.1]
Short essays:
1. Compare fixed and removable appliances.
Short notes:
1. Mention three ideal requisites of orthodontic
appliance.
Solved answers
Long essays:
Q.1. What are the advantages and disadvantages of

removable and fixed appliances?
Ans.
Orthodontic appliances are the devices by means of
which mild pressure may be applied to a tooth or a
group of teeth and their supporting structures so as to
bring about necessary changes within the bone which
will allow the tooth movement.
Orthodontic appliances are broadly classified into two
groups:
B. Myofunctional appliances
Mechanical appliances
They exert mild pressure on a tooth or a group of
teeth and their supporting structures in a
predetermined direction with the help of active
components like springs, elastics, screws etc. which
are part of the appliance itself.
Myofunctional appliances
They are loose fitting or passive appliances that
harness the natural forces of orofacial
musculature which are transmitted to the teeth
and alveolar bone through the medium of the
appliance. They transmit, eliminate or guide the
natural perioral muscle forces onto the dentition.
They do not contain active components and are
used for growth modification procedures.
Removable appliances
Advantages Disadvantages
i. Ability to i. Patient cooperation is needed.
maintain oral
hygiene.
ii. Usually used for ii. Inability to perform complex
simple tooth tooth movements.
movements that
can be brought
about by tipping.
iii. Less chair side iii. The treatment duration is
time of prolonged in case of severe
orthodontist to malocclusion, as whenever
fabricate them, multiple tooth movements are
so they can to be carried out, it should be
handle more done one at a time.
number of
patients.
iv. Simple iv. Complex tooth movements like
movements like multiple rotations are difficult
tipping and to treat using removable
overbite appliances.
reduction can be
undertaken.
v. Lesser forces are v. It is very difficult to close
used. So the residual space by forward
strain on anchor movement of posterior teeth in
teeth is lesser cases of extraction.
than fixed.
vi. Can be used by vi. There is a great chance of
general dental patient misplacing or damaging
practitioners who the removable appliances.
have received
basic training.
vii. Relatively vii. They cannot be used in severe
economical cases of class II and III
compared with malocclusions with
fixed appliances. unfavourable growth pattern.
viii. Damaged
appliances that
apply
undesirable
forces can be
removed by the
patient.
Fixed appliances
i. Fixed appliances offer better i. Oral hygiene
control and to a large extent maintenance is more
lessen the need for patient difficult.
cooperation.
ii. It is easy to bring about ii. They take up more
various types of tooth chair side time, as
movements, e.g. tipping, they are time-
bodily movement, rotation, consuming to fix and
intrusion and extrusion. adjust.
iii. As multiple tooth ill. Aesthetically
movements are possible unpleasing unless
simultaneously, the modern tooth-
treatment duration is coloured
considerably reduced. appliances/lingual
orthodontics are
used.
iv. More precise tooth iv. Requires special
movements and correction training of the
of occlusion is possible operator and is
using fixed appliances. invariably handled
by specialized
orthodontists.
v. Fixed appliances are used to v. Damaged appliances
treat most malocclusions, that apply
including very complicated misdirected forces
ones. cannot be removed
by the patient.
vi. These appliances offer vi. More expensive.
better control over
anchorage.
Q.2. What are the basic requirements of orthodontic

appliances?
Ans.
Ideal requirements of orthodontic appliances are
categorized under the following headings:
a. Biological requirements
b. Mechanical requirements
c. Aesthetic requirements
d. Hygienic requirements
• The appliance should bring about the desired tooth
movements.
• The appliance should not interfere with normal
growth and function.
• The appliance should not produce pathologic
changes such as root resorption, periodontal
damage or non vitality of the teeth.
• The appliance should not bring about sudden and
unwanted tooth movements.
• The material used in fabrication should be
biocornpatible and should not produce toxic
effects.
• The appliance should be
i. Simple to fabricate.
ii. Strong enough to withstand rnasticatory
forces.
iii. Able to deliver controlled force of
desired intensity, duration and direction.
iv. Universally applicable, i.e. must be able
to handle various malocclusions.
• The appliance should not be bulky and should be
comfortable for the patient using it.
c. Hygienic requirement: Appliance should be self-
cleansing or easy to clean or should not interfere with
oral hygiene maintenance.
d. Aesthetic requirements: Appliance should be
aesthetically acceptable and should be inconspicuous
as possible.
Q.3. What are the indications and contraindications

of removable and fixed orthodontic appliances?
Ans.
[Sarne as LE Q.1]
Q.4. Define orthodontic appliances. Classify them.

State the advantages of fixed and removable
appliances.
Ans.
[Sarne as LE Q.1]
Q.5. Compare the merits and demerits of removable

and fixed orthodontic appliances.
Ans.
[Sarne as LE Q.1]
Short essays:
Q.1. Compare fixed and removable appliances.

Ans.
Fixed appliances Removable appliances

i. Fixed appliances i, Patient cooperation is needed
offer better to a large extent.
control, and to a
large extent lessen
the need for
patient
cooperation.
ii. Oral hygiene ii. Oral hygiene maintenance is
maintenance is easy.
more difficult.
iii. As multiple tooth iii. The treatment duration is
movements are prolonged in case of severe
possible malocclusion as whenever
simultaneously, multiple tooth movements are
the treatment to be carried out it should be
duration is done one at a time.
considerably
reduced.
iv. They take up iv. Less chair side time of
more chair side orthodontist to fabricate them,
time as they are so they can handle more
time-consuming to number of patients.
fix and adjust
them.
v. More expensive. v. Relatively economical
compared to fixed appliances.
vi. Requires special vi. Requires no special training,
training of the can be used by general dental
operator and are practitioners who have
invariably received basic training.
handled by
specialized
orthodontists.
Short notes:
Q.1. Mention three ideal requisites of orthodontic

appliance.
Ans.
Ideal requirements of an orthodontic appliance are as
follows:
• The appliance should bring about only desired tooth
movements.
• It should not interfere with normal growth and
function.
• It should be simple to fabricate but strong enough to
withstand masticatory forces.
• It should not be bulky and should be comfortable for
the patient in using it.
• It should be self-cleansing or easy to clean.
• It should be aesthetically acceptable.
Topic 23 Removable orthodontic
appliances
Long essays:
1. Discuss the advantages, disadvantages and
indications for using removable orthodontic

appliance.
2. Define and classify orthodontic appliances. Discuss
how the various types of tooth movements are
achieved using removable appliances.
3. Enumerate ideal properties of an orthodontic
appliance and describe various types of canine
retractors.
4. Classify orthodontic appliances and name the
basic components of a removable appliance.
5. What are the various active components of
removable orthodontic appliance? Write about
springs.
6. Discuss the base plate used in orthodontics.
7. Define orthodontic appliances. Explain various
mechanical factors to be considered in designing a
8. Discuss the treatment of different types of
malocclusion with removable appliances. [Same
as LE Q.2]
9. Classify orthodontic appliances and explain the
retentive components of removable orthodontic
appliances and Adams clasp in detail. [Same as LE
Q.4]
Short essays:
1. Give classification of canine retractors. [Ref LE
Q.3]
2. Orthodontic appliance-labial bows.
3. Hawley's appliance.
4. Describe components/parts of removable
appliances and write about ideal requirements of
springs. [Ref LE Q.4]
5. Enumerate various types of clasps used in an
orthodontics appliances and the ideal
requirements of the clasp.
6. Advantages of removable orthodontic appliances.
7. Adams clasp and its advantages.
8. Springs used for distalizing the canines. [Same as
SE Q.1]
9. Hawley's retainer. [Same as SE Q.3]
Short notes:
1. Z-spring. [Ref LE Q.5]
2. Crozat clasp.
3. Adams clasp.
4. Labial bow. [Ref SE Q.2]
5. Classify canine retractors.
6. Roberts retractor.
7. Orthodontic springs - mention one classification.
8. Define removable orthodontic appliance and name
its components.
9. Mention three ideal requirements of orthodontic
appliance. [Ref LE Q.3]
10. Name few self-supporting springs. [Ref LE Q.5]
11. Finger spring. [Ref LE Q.5]
12. Coffin spring. [Ref LE Q.5]
13. High labial bows.
14. Arrowhead clasp.
15. Double cantilever spring.
16. Types of labial bow and their uses.
17. Mention few active plates.
18. Buccal canine retractors.
19. Adams clasp- modification.
20. Disadvantages of removable orthodontic
appliances.
21. Orthodontic clasp-ideal requirements.
22. Cantilever spring.
Solved answers
Long essays:
Q.1. Discuss the advantages, disadvantages and

indications for using removable orthodontic
appliance.
Ans.
The advantages and disadvantages of removable orthodontic appliances are as
follows:
i. Ability to maintain oral i. The need for patient
hygiene. cooperation.
ii. Usually used for simple ii. Inability to perform
tooth movements that complex tooth
can be brought about by movements.
tipping.
iii. Less chair side time of iii. In case of severe
orthodontist to fabricate malocclusions, the
them, so they can treatment duration is
handle more number of prolonged, as whenever
patients. multiple tooth
movements are to be
carried out it should be
done one at a time.
iv. Various movements iv. It is difficult to treat
like tipping, overbite multiple rotations using
reduction can be removable appliances.
undertaken.
v. Lesser forces are used. v. In cases requiring
So the strain on anchor extraction, it is very
teeth is lesser than difficult to close residual
fixed. space by forward
movement of posterior
teeth.
vi. General dental vi. The chances of patient
practitioners who have misplacing or damaging
received adequate the removable
training can use them. appliances is more.
vii. Less inventory is vii. Patients should have
required for fabrication. enough skill to remove
and replace the
appliance without
distorting them.
viii. Relatively more viii. Severe cases of class II
economical than fixed and III malocclusions
appliances. with unfavourable
growth pattern cannot be
treated using removable
appliances.
ix. As they take less chair ix. They require more
side time and are more regular monitoring.
economical, they can be
used in community-
based programmes,
wherein large number
of patients are treated.
x. They are less
conspicuous and
aesthetically more
pleasing when
compared with fixed
appliance.
xi. The patient can remove
damaged appliances
that apply undesirable
forces by himself.
The various types of malocclusions that can be treated

by removable mechanical appliances are as follows:
i. Mild and moderate proclination
ii. Anterior and posterior crossbite
iii. Median diastema
iv. Generalized anterior spacing
v. Buccally placed canines and premolars
vi. Palatally placed canines
vii. Deep overbite
viii. Anterior open bite
Q.2. Define and classify orthodontic appliances.

Discuss how the various types of tooth movements
are achieved using removable appliances.
Ans.
Orthodontic appliances are defined as devices by means
of which mild pressure may be applied to a tooth or a
group of teeth and their supporting structures so as to
bring about necessary changes within the bone which
will allow the tooth movement.
Orthodontic appliances are broadly classified into two
groups:
~ Fixed
.---+ Removable
B. Myofunctional appliances
Mechanical appliances:
They exert mild pressure on a tooth or a group of
teeth and their supporting structures in a
components which are part of the appliance itself.
Treatment of different types of malocclusions by
removable mechanical appliances is as follows:
i. Mild proclination:
• Hawley's appliance
• Hawley appliance with long labial bow if
there is space distal to canine
ii. Moderate proclination:
• Roberts retractor
iii. Median diastema:
• Upper Hawley appliance with two finger
springs to move both the central incisors
mesially towards each other
• Upper plate with split-type labial bow
• Simple Hawley appliance if the median
diastema is due to proclination
iv. Generalized anterior spacing:
• High labial bow with apron spring.
• Hawley appliance with the base plate
trimmed on the palatal aspect.
v. Anterior crossbite:
• Hawley appliance with posterior bite plane
and Z-spring to correct the tooth in crossbite.
• Upper anterior expansion (Schwarz
appliance) with posterior bite plane.
• Inclined plane if the bite is deep.
"tTi Pn<;:tPri nr r-r-rvc c hitp·
~ ~
vi. Posterior crossbite:
• Schwarz-type lateral expansion with
posterior bite plane for occlusal clearance.
• Hawley appliance with posterior bite plane
and T-springs or Z-springs to correct the
tooth in crossbite.
vii. Buccally placed canine:
• Buccal canine retractor when palatal and
distal movement is required.
• Helical loop canine retractor when the sulcus
depth is shallow.
viii. Buccally placed premolar:

• Spring for palatal movement of premolars.
ix. Palatally placed canine:
• Hawley appliance with Z-spring and
posterior bite plane when only buccal
movement is required.
• Palatal canine retractor with posterior bite
plane when both distal and buccal
movements of canine are required.
x. Deep overbite:
• Upper Hawley's appliance with flat anterior
bite plane.
xi. Anterior open bite:
• In cases of open bite caused due to habits,
upper Hawley's appliance with tongue
spikes is advised and posterior bite planes to
intrude molar.
Q.3. Enumerate ideal properties of an orthodontic

appliance and describe various types of canine
retractors.
Ans.
{SN Q.9}
Ideal requirements of orthodontic appliances are
categorized as follows:
• The appliance should bring about only desired
tooth movements without any sudden and
unwanted tooth movements.
• The appliance should not interfere with normal
growth and function.
• The appliance should not produce pathologic
changes such as root resorption, periodontal
damage or non vitality of the teeth.
• The material used in fabrication should be
biocompatible and should not produce toxic
effects.
• The appliance should be simple to fabricate and
strong enough to withstand masticatory forces.
• It should be able to deliver controlled force of
desired intensity, duration and direction.
• The appliance should not be bulky and should be
comfortable to the patient.
c. Hygienic requirement
• Appliance should be self-cleansing or easy to clean
or should not interfere with oral hygiene
maintenance.
d. Aesthetic requirements
• Appliance should be aesthetically acceptable.
• With more number of adults seeking orthodontic
treatment, the appliance should be acceptable
aesthetically.
• Should be less visible.
e. Cost factor
• Appliance should be economical for the patient.
• It should not be expensive.
[SE Q.1]
{Canine retractors
• Canine retractors are springs that are used for
distal movement of canines.
• The canine retractors can be classified by a number
of ways as follows:
i. Based on location:
(a) Buccal - buccally placed
(b) Palatal - palatally placed
ii. Based on presence of helix or loop:
(a) Canine retractor with helix
(b) Canine retractor with loop
iii. Based on the mode of action:
(a) Push type
(b) Pull type
• Types of canine retractors based on placement
position are as follows:
i. Buccally placed:
a. Buccal canine retractor
b. Helical loop canine retractor
c. U-loop canine retractor
ii. Palatally placed:
a. Palatal canine retractor}
Indications:
• It is indicated in cases of buccally placed
canines and canines placed high in the
vestibule.
• They are used where a buccally placed
canine has to be moved both palatally and
distally.
Spring design:
• It is made up of 0.7-mm or 21-gauge
stainless steel (SS) wire.
• It consists of a coil of 3 mm diameter, an
active arm and a retentive arm.
• Coil is placed as high as possible in
between the present and future positions
of canine, i.e. distal to long axis of canine.
• The end of the spring is bent at right angle
to the canine to be moved and then it is
shaped to the tooth.
• Tag should cross over the mesial side of
second premolar.
Modifications:
• There are two modifications of buccal
canine retractor:
a. Supported or sleeved
b. Self-supported or stabilized
• The supported canine retractors are made
of thinner gauge wire (0.5 mm). Thus, they
are more flexible and therefore
mechanically efficient. As they lack
stability, they are enclosed in SS tubing.
• The self-supported canine retractors are
made of thicker gauge wire (0.7 mm) so
that the spring can support itself.
Activation of buccal canine retractor:
• It is one of the few springs where the coil is
closed for activation.
• The self-supported canine retractors are
activated by closing the helix 1 mm at a
time, while the supported canine
retractors can be activated up to 2 mm at a
time.
• Activation is done by using 'hollow chop'
pliers like Mathews or Andresen's.
b. Reverse loop canine retractor or helical loop
canine retractor
Indications:
It is indicated in patients with shallow
sulcus, and especially in the mandibular
arch.
Spring design:
• It is made up of 0.7-mm/21-guage SS wire.
• It consists of a helix or coil of 3 mm
diameter, an active arm and a retentive
arm.
• The mesial arm or retentive arm is adapted
between the premolars.
• The distal arm is active and is bent at right
angles to engage the canine below the
height of contour.
• The coil is placed 3-4 mm below the
gingival margin. The height of the coil can
be adjusted based on the vestibular height.
Drawbacks:
It is stiff in the horizontal plane and
unstable vertically.
Activation:
There are two methods of activation.
It is activated either by opening the helix by
1 mm or by cutting 1 mm of the free end
and readapting it around the canine.
c. U-Loopcanine retractor
Indications:
• Mechanically, it is least effective and is
indicated when minimal distal retraction
of 1-2 mm of canine is required.
Spring design:
• It consists of a U-loop, an active arm and a
retentive arm which is distal. The base of
the U-loop should be 2-3 mm below the
cervical margin. The mesial arm of the U-
loop is bent at right angles and adapted
around the canine below its mesial contact
point.
Disadvantage:
This is the least efficient of all the canine
retractors.
Advantages:
• Ease in fabrication, simple in design and
less bulky.
Activation:
• It is activated by closing the loops by 1-2
mm or cutting the free end of the active
arm by 2 mm and readapting it.
a. Palatal canine retractors:
• This is similar to finger springs and is made
up of 0.6-mm SS wire.
Indication:
It is indicated in retraction or distalization of
palatally placed canines.
Spring design:
• It consists of an active arm, a guide arm or
retentive tag and a coil of 3-mm diameter.
• The active arm is placed mesial to canine.
The helix/coilis is placed along the long
axis of the canine and as far away as
possible to have retractor a good range of
action. Retentive tag gets embedded in the
acrylic plate.
Activation:
It is done by either of the following:
• Opening the coil/helix by 2-3 mm at a
time.
• Pulling the free arm of the spring slightly
away from the point of emergence from
coil.
• Tension can be given to the spring by
squeezing the coil with the tip of the
pliers.
Q.4. Classify orthodontic appliances and name the

basic components of a removable appliance.
Ans.
Classification of Orthodontic Appliances
Broadly two groups

I
? Mvnf11ndinn~I ~nnli~nr11c::
Broadly two groups
I
i +
1. Mechanical appliances 2. Myofunctional appliances
i. Removable __ _..
ii. Fixed
Mechanical appliances:
Exert mild pressure on a tooth or a group of teeth
and their supporting structures in a

components which are part of the appliance itself.
The active components may include springs,
elastics, screws, etc.
Myofunctional appliances:
They are loose fitting or passive appliances that
harness the natural forces of the orofacial
musculature which are transmitted to the teeth
and alveolar bone through the medium of the
appliance. They transmit, eliminate or guide the
natural perioral muscle forces onto the dentition.
They do not contain active components and are
mainly used for growth modification procedures.
[SE Q.4]
{Components of removable orthodontic appliance
There are three basic components in a removable
orthodontic appliance:
a. Retentive components
b. Active components
c. Base plate
a. Fixation or retention components
i. Clasps
ii. Bows
b. Active components
i. Springs
ii. Labial bows
iii. Screws
iv. Elastics
c. Anchorage
i. Clasps
ii. Contact of base plate with
nonmoving part
iii. Headgears
iv. Intermaxillary elastics
d. Base plate:
Forms the framework}
Retentive components:
• The retentive components help in keeping the
appliance in place and resist displacement of the
appliance.
• The success of a removable appliance is to a large
extent dependent upon good retention of the
appliance.
• The wire components that aid in retention of a
removable appliance are called clasps.
• Mode of action of clasps: They act by engaging the
undercuts of the teeth.
The various clasps can be classified under two
broad headings:
A. Free-ended clasps in which one end of the clasp
is embedded in acrylic
Examples:
• C-clasp
• Triangular clasp
• Ball end clasp
• Duyzing's clasp
• Crozat clasp
• Arrow pin clasp
• Wrought Roach clasp
• Visick's clasp
• Lingual extension clasps
B. Continuous clasp in which both ends of the
clasp are embedded in acrylic
Examples:
• Jacksons clasp
• Arrowhead clasp
• Eyelet clasp
• Adams clasp
• Delta clasp
• Southend clasp
Types of clasps based on the undercuts used
I. Clasps using mesial/distal undercuts:
• Adams clasp
• Ball end clasps
• Arrowhead/Schwarz clasp
• Crozat clasp
II. Using buccal/lingual undercuts:
• Jacksons clasp
• Southend clasp
• Duyzing's clasp
III. Using both the proximal and buccal
lingual undercuts:
• 'C' clasp
Requirements of an ideal clasp
Offer adequate retention
Off er adequate retention even in the presence

of shallow undercuts
Permit usage in both fully-erupted and

partial erupted teeth
Be easy to fabricate
By itself apply any active force that would

bring about undesirable tooth movements
of an old age tooth
It should not -- Impinge on soft tissues
lnterf ere with normal occlusion
CLASPS
1. i. It is also known as three-quarter

Circumferential clasp or 'C' clasp.
clasp (Fig 23.1)
FIG. 23.1 C-clasp.
ii. They are simple clasps that are

designed to engage the bucco-
cervical undercut.
iii. Advantage: Simplicity of design
and fabrication.
iv. Disadvantage: It cannot be used in
partially erupted teeth, wherein the
cervical undercut is not available
for clasp fabrication.
2. Jacksons i. It is also called full clasp or 'U'-clasp.
clasp (Fig
23.2)
FIG. 23.2 Jackson's

clasp.
ii. It engages all undercuts, i.e. buccal,

cervical, mesial and distal.
iii. Wire is adapted along the bucco-
cervical margin and both the
proximal undercuts, and then
carried over the occlusal
embrasures to end as retentive
arms on both sides of the molar.
iv. Advantage: It is simple to construct,
and offers adequate retention.
v. Disadvantage: It offers inadequate
retention in partially erupted teeth.
3. Southend This clasp is used when retention in
clasp (Fig anterior region is required.
23.3)
FIG. 23.3 Southend

clasp.
4. Triangular i. It is used between two adjacent

clasp (Fig posterior teeth.
23.4) ii. It indicated when additional
retention is needed.
FIG. 23.4 Triangular

clasp.
5. Ball end i. Preformed wires with ball at one

clasp (Fig end are available.
23.5) Or
Ball can be made at the end of the
wire with silver solder.
ii. Indicated when additional
retention is required.
FIG. 23.5 Ball end clasp.
6. Schwarz Predecessor of Adams clasp. A

clasp (Fig number of arrowheads engage
23.6) interproximal undercuts between
molars and premolars.
Drawbacks:
i. Special pliers are required.
ii. Difficult and time-consuming to
fabricate.
iii. Large amount of space in buccal
vestibule.
iv. Injures interdental soft tissue.
FIG. 23.6 Schwarz

clasp.
7. Crozat clasp i. It resembles full clasp with additional piece of

(FiQ" 23.7) wire soldered which engages mesial and distal
7. Crozat clasp i. It resembles full clasp with additional piece of
(Fig 23.7) wire soldered which engages mesial and distal
undercuts.
FIG. 23.7 Crozat clasp.

8.Adams clasp It is also known as Liverpool clasp,
universal clasp or modified
arrowhead clasp.
Adams clasp ( Fig 23.8)

• It was described by Professor Philip Adams.
• It is also known as Liverpool clasp, universal clasp
or modified arrowhead clasp.
• Constructed using O. 7-mm round SS wire.
• Parts of Adams clasp are as follows:
a. Two arrowheads - engage mesial and
distal undercuts.
b. Bridge - connects to arrowheads and is at
45 ° to long axis of tooth.
c. Two retentive arms.
Advantages:
• It is rigid and offers excellent retention.
• Can be fabricated on both deciduous and
permanent teeth.
• Can be used on partially or fully erupted teeth.
• Can be used on molars, premolars and incisors.
• No specialized instrument is needed to fabricate
the clasp.
• It is small and occupies minimum space.
• The clasp can be modified in a number of ways.
Modifications to Adams clasp are as follows:
• Adams with single arrowhead.
• Adams with J-hook.
• Adams with incorporated helix.
• Adams with additional buccal tube.
• Adams with soldered buccal tube.
• Adams with distal extension.
• Adams on incisors and premolars.
i. Adams with single arrowhead:
• Usually indicated in partially erupted tooth.
• In last erupted molar, single arrowhead is
made to engage the mesioproximal undercut
of tooth.
• Bridge is modified to encircle the tooth distally
and ends on palatal aspect as a retentive arm.
ii. Adams with ]-hook ( Fig 23.9 ):
J-hook can be soldered onto bridge of the Adams
clasp which is useful in engaging elastics.
iii. Adams with incorporated helix ( Fig 23.10 ):
A helix can be incorporated in the bridge of the
Adams clasp to help in engaging elastics.
iv. Adams with additional arrowhead ( Fig 23.11 ):
This additional arrowhead engages the proximal
undercut of adjacent tooth and is soldered
onto the bridge of the Adams. This type of
clasp offers additional retention.
v. Adams with soldered buccal tube ( Fig 23.12 ):
Buccal tube is soldered to the bridge of the
Adams clasp. It permits the use of extraoral
anchorage using face bow head area assembly.
vi. Adams with distal extension ( Fig 23.13 ):
Distal arrowhead of Adams clasp has a small
extension incorporated distally which helps in
engaging elastics.
vii. Adams on incisors and premolars ( Fig 23.14 ):
Adams clasp can be fabricated in the incisors
and PMs when retention in those areas is
required. They may span over single tooth or
two teeth.
FIG. 23.8 Adams with single arrow head.
FIG. 23.9 Adams with J-hook.
FIG. 23.1 o Adams with incorporated

helix.
FIG. 23.11 Adams with additional arrow

head.
FIG. 23.12 Adams with soldered buccal

tube.
FIG. 23.13 Adams with distal extension.
FIG 23.14 Adams on incisors and

premolars.
Q.5. What are the various active components of

removable orthodontic appliance? Write about
springs.
Ans.
The active components of removable orthodontic
appliances are as follows:
i. Bows
ii. Screws
iii. Elastics
iv. Springs
i. Bows
• Bows are active components of removable
orthodontic appliances which are mostly used for
incisor retraction.
• There are various types of bows used routinely in
orthodontics. They are as follows:
Short labial bow, long labial bow, split labial bow,
reverse labial bow, Roberts retractor, Mills
retractor, etc.
ii. Screws
• Screws are active components that can be
incorporated in a removable appliance.
• The removable appliances that make use of screws
can bring about three types of tooth movements:
a. Arch expansion
b. Movement of a group of teeth in a buccal
or labial direction
c. Movement of one or more teeth in a distal
or mesial direction
iii. elastics
• Elastics as active components are rarely used along
with removable appliances.
• Removable appliances using elastics for anterior
retraction generally make use of a labial bow with
hooks placed distal to the canines.
iv. Springs
• Springs are active components of removable
appliances.
• There are various methods of classification of
springs.
I. Classification of springs based on their ability to
withstand forces of distortion:
a. Self-supported springs
i. Buccal canine retractor
ii. U-loop canine retractor
iii. Helical loop canine retractor
iv. Coffin springs
b. Guided springs
b. Guided springs
i. Cantilever springs
ii. Finger springs
iii. Palatal canine retractor
iv. T-springs
c. Auxiliary springs
i. Apron springs
II. Based on their point of attachment, springs are
a. Free-ended springs
ii. Finger springs

iii. Canine retractors
iv. T-springs
b. Springs attached at both ends
i. Labial bows
ii. Coffin springs
c. Accessory springs attached to arches
i. Apron springs
III. Based on the presence of loops or helix, springs
are classified as follows:
a. Helical springs
b. Looped springs
The detail description of some commonly used
springs is as follows:
{SN Q.10}
Self-supported springs
• The springs which can resist on their own the
distortion forces are known as self-supported
springs.
They are made of 0.7-mm or 0.9-mm hard SS wire.
They usually have a stability ratio of 1.
• The various springs that fall under the category of
self-supported springs are
i. Canine retractors
ii. Coffin springs
i. Canine retractors
• It is indicated in cases of buccally placed
canines and canines placed high in the
vestibule.
• It is made up of 0.7-mm or 21-gauge SS wire.
• It consists of a coil of 3-mm diameter, an
active arm and a retentive arm.
• It is one of the few springs where the coil is
closed for activation.
• Activation is done by using 'hollow chop'
pliers like Mathews or Andresen's.
b. Helical loop canine retractor or reverse loop
canine retractor
• It is indicated in patients with shallow sulcus,
and especially in the mandibular arch.
• It consists of a helix or coil of 3-mm diameter,
an active arm and a retentive arm.
• The coil is placed 3-4 mm below the gingival
margin. The height of the coil can be
adjusted based on the vestibular height.
• It is stiff in the horizontal plane and unstable
vertically.
• It is activated either by opening the helix by 1
mm or by cutting 1 mm of the free end and
readapting it around the canine.
• It is made up of0.7-mm/21-guage SS wire.
• It consists of a U-loop, an active arm and a
retentive arm which is distal. The base of the
U-loop. should be 2-3 mm below the cervical
margin.
• Mechanically, it is least effective and is
indicated when minimal distal retraction of
1-2 mm of canine is required.
• Ease in fabrication, simple design and less
bulky.
• It is activated by closing the loops by 1-2 mm
or cutting the free end of the active arm by 2
mm and readapting it.
{SN Q.12}
ii. Coffin springs
• It is a removable type of arch expansion spring
introduced by Walter Coffin.
• It is used to bring about slow dentoalveolar arch
expansion in patients with constricted upper
archer unilateral crossbite.
• It is made of 1.2-mm hard round SS wire. It
consists of a U- or omega-shaped wire placed in
the mid-palatal region.
• It can be activated 1-2 mm at a time manually by
holding both the ends at the region of the clasps
and pulling the sides gently apart.
Guided springs
Guided springs are those that cannot resist distortion
on their own. They are usually made of 0.5-mm
wires.
a. Single cantilever spring
• The spring is constructed with 0.5-mm hard
SS wire.
• A single cantilever spring consists of three
parts:
• Retention tag is embedded in the acrylic
resin of the base plate.
• Coil is the active part of the spring.
• Active arm is in contact with the tooth to be
moved.
• The spring is activated by opening the coil.
• First visit: Activated by 1-2 mm.
• Subsequent visits: Activated by 2-3 mm.
b. Double cantilever spring or Z-spring
{SN Q.1}
The Z-spring is made of 0.5-mm/23-gauge hard
round SS wire.
• The spring consists of two coils of very small
internal diameter. The spring should be
perpendicular to the palatal surface of the
tooth.
• Indications:
i. When both labial and lateral movements of
the incisors are required.
ii. Minor rotation correction.
iii. When two or more teeth have to be moved
labially.
• The Z-spring is activated by opening both the
helices by about 2-3 mm at a time. In the case
of minor rotation correction, one of the helices
is opened.
{SN Q.11}
ii. Finger springs
• The finger spring is also called single
cantilever spring as one end is fixed in
acrylic and the other end is free.
• It is made of 0.5-mm or 0.6-mm hard round
SS wire.
• It is used for mesiodistal movement of teeth
only when they are located correctly within
the line of the arch.
• The finger spring consists of an active arm,
coil or helix and a retention tag.
• The finger spring is activated by moving the
active arm towards the teeth intended to be
moved. This is done as close to the coil as
possible. Activation of up to 3 mm is
considered ideal when 0.5-mm wire is used
for its fabrication. Whenever 0.6-mm wire
has been used the activation should be half
of that.
• This is similar to finger springs and is made
up of 0.6-mm SS wire.
• It is indicated in retraction or distalization of
palatally placed canines.
• Spring design consists of an active arm, a
guide arm or retentive tag and a 3-mm
diameter coil.
• Activation is done by either opening the
coil/helix by 2-3 mm at a time or pulling
the free arm of the spring slightly away
from the point of emergence from coil.
iv. T-springs
• T-spring is used to bring about the buccal
movement of premolars and sometimes
canines.
• It is made of 0.5-mm hard round SS wire.
• The spring consists of a T-shaped arm whose
ends are embedded in acrylic. Loops can be
incorporated in both arms of the T so that as
the tooth moves buccally, the head of the T can
be made to remain in contact with the crown
by slightly opening the loops.
• The spring is activated by pulling the free end
of the T towards the intended direction of
tooth movement.
Auxiliary springs
• They are also known as Apron springs.
• Made up of 0.35-mm to 0.40-mm SS wire.
They are used in correction of extreme
proclination of incisors to move them lingually
and also to correct single-tooth proclination.
Q.6. Discuss the base plate used in orthodontics.

Ans.
• Base plate forms the framework of removable
orthodontic appliance and serves to hold all the
components of the appliance together.
• Usually base plates are made either from cold-cure or
heat-cure acrylic.
• Cold-cure acrylic is commonly used because it is
simple to process and chances of thermal distortion
are less. But the heat-cure acrylic is stronger.
• Clear acrylic resin is preferred because any pressure
spots can be visualized by the presence of blanching
with the appliance.
The uses of base plate in removable appliances are as
follows:
a. As a base of operation:
i. Helps to unite all the components of the
appliance into a single unit.
ii. Provides support for the wire/screw
components.
ii. Transmits forces from the active components
and distributes over a large area.
iii. Protects the palatal springs.
iv. Facilitates movement, e.g. posterior bite-blocks.
b. As anchorage:
i. Prevents unwanted movement of teeth.
ii. Contacts with teeth and palate and helps
in anchoring the appliance.
c. As an active component:
i. Split plate.
ii. Bite planes can be incorporated
into plate to treat certain
orthodontic problems.
iii. Upper anterior inclined plane.
Dimensions of a base plate:
• The base plate should be of minimum thickness
to help in patient acceptance.
• Base plates should not be made unduly thick.
Single thickness of wax shall be used and the
base plate is thickened over the wire tags only.
• Base plates of 1.5-2-mm thickness offer adequate
strength and, at the same time, are well tolerated
by patients.
• Maxillary and mandibular plates extend up to
distal of first permanent molar.
• The mandibular base plate is usually shallow to
avoid irritation to the lingual sulcus. For this
reason it should be made thicker to increase the
strength.
• The base plate should fit snugly around the necks
of teeth that are not being moved. This helps in
avoiding food accumulation under the base
plate.
• Bite planes can also be incorporated into the base
plates. These bite planes help in disengaging the
occlusion.
Anterior bite planes:
• Anterior bite planes are used to treat the deep
bite cases.
• They are also used for relieving occlusal
interference.
• They are fabricated by thickening the base plate
behind the maxillary anteriors.
• By selective eruption of the posterior teeth
relative to the anteriors, opening of bite occurs,
bite plates are trimmed and then labial bow is
activated for lingual movement of teeth.
Posterior bite planes/molar capping:
• Posterior bite planes are formed by extending the
base plate to cover the occlusal surface of the
teeth.
• The thickness of bite plane should be just enough
to clear the occlusion.
• Posterior bite.... planes are generally
... ...
used in the
.. .
• Posterior bite planes are generally used in the
treatment of crossbites as they help in removing
the interference of opposing teeth.
• It is used to get occlusal clearance to tooth
movement during correction of anterior
crossbite.
Q.7. Define orthodontic appliances. Explain various

mechanical factors to be considered in designing a
Ans.
• Orthodontic appliances are devices by means of

which mild pressure may be applied to a tooth or a
group of teeth and their supporting structures to
bring about necessary changes within the bone
which will allow the tooth movement.
• Orthodontic arch wires or springs can be considered
as beams supported either on one side or both sides.
• Wires or appliances supported on one side act as
cantilever beams, e.g. springs projecting from the
removable appliance. Appliances supported on both
sides include labial bows and arch wire.
• When a force is applied to a beam, its response can be
analysed as follows:
Force:
• It is an act or load applied to an object which
tends to change the position of object.
• Force delivered for a given deflection depends on
the wire length CL), radius (r) and elastic
modulus (E)
If the size or diameter of wire is doubled, it increases

the stiffness by 16 times.
Increasing the length by two times reduces the stiffness
by eight times.
Stress: It is defined as force per unit area in a body
which resists an external force.
Strain: It is defined as the internal distortion produced
by load or stress.
Elastic limit: It is defined as the greatest stress to which
a material can be subjected to so that it will return to
its original dimension when the forces are released.
Proportional limit: It is the point at which permanent
deformation is first observed.
Yield strength: It is the point at which 0.1 °/o of
deformation is observed.
Ultimate tensile strength: It is the maximum load a wire
can sustain. This determines the maximum force a
spring can deliver.
Springiness: It depends on the elastic or proportional
limit.
Range: It is defined as the distance the wire will bend
elastically before permanent deformation occurs.
Resilience of the wire: It is the area under stress-strain
curve up to proportional limit. It represents the
mechanical energy stored in the wire. It is a
combination of strength and springiness.
Formability: It is the amount of permanent
deformation a wire can withstand before it breaks.
Fatigue: The fracture of the wire due to repeated stress
is called fatigue.
Incorporating a coil: Introduction of a coil into a
cantilever increases the length of the spring and
thereby its flexibility.
Burstone enumerated three important features of
an orthodontic appliance:
i. Moment to force ratio
ii. Load deflection rate
iii. Maximal elastic moment
These three properties are called spring
characteristics and all three properties put
together are found within the elastic range of an
orthodontic wire.
Moment to force ratio: It determines the centre of
rotation of tooth. Varying the moment to force
ratio produces different types of tooth movements.
Load deflection rate: It gives the force produced per
unit activation. Active members of the appliance
should have low load deflection rate which implies
light continuous force.
Maximum elastic moment: It is the greatest force or
moment that can be applied to the appliance
without producing permanent deformation. This
will prevent distortion of the appliance during
activation or accidental overloading during a
chewing.
Q.8. Discuss the treatment of different types of

malocclusion with removable appliances.
Ans.
[Same as LE Q.2]
Q.9. Classify orthodontic appliances and explain the

retentive components of removable orthodontic
appliances and Adams clasp in detail.
Ans.
[Same as LE Q.4]
Short essays:
Q.1. Give classification of canine retractors.

Ans.
[Ref LE Q.3]
Q.2. Orthodontic appliance - labial bows.

Ans.
{SN Q.4}
• Labial bows are active components of removable
incisor retraction.
• There are various types of bows routinely used in
orthodontics, they are as follows:
i. Short labial bow
ii. Long labial bow
iii. Split labial bow
iv. Reverse labial bow
v. Roberts retractor
vi. Mills retractor
vii. High labial bow with apron springs
viii. Fitted labial bow
Short labial bow: used for minor overjet reduction and
anterior space closure.
Long labial bow:
Uses:
• Closure of minor anterior space and space distal
to canine
• Minor overjet reduction
• Guidance of canine during retraction of canine
using palatal retractor
• Retaining device at the end of the treatment
Split labial bow: used for anterior retraction and
closure of midline diastema
Reverse labial bow: used for minor overjet reduction
and anterior space closure
Roberts retractor: used to correct severe anterior
proclination
Mills retractor: correction of large overjet
High labial bow with apron springs: used for retraction
of one or more teeth
Fitted labial bow: bring out active tooth movement
Q.3. Hawley's appliance.

Ans.
• Hawley's appliance is the most frequently used
retainer designed by Charles Hawley in 1920.
• It is a passive appliance that can be removed by the
patient and reinserted at will.
• The classic Hawley's retainer consists of clasps on
3
molars, short labial bow to
3
having adjustment loops.
Several modifications of Hawley's appliance to suit
specific requirements are as follows:
I. The labial bow can be made to extend from one
first PM to opposite first PM. This design helps
in closing spaces distal to canine.
FIG. 23.14 Hawley's retainer.
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I (j1
(.1:-1
FIG. 23.15HR with labial bow soldered to
Adams clasp.
II. To solder the bow to the bridge of the Adams

clasp. This design avoids the risk of space
opening up between the canine and the
premolar due to the crossover wires. Fitted
labial bow can also be used to offer excellent
retention.
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
III. Anterior bite plans can be incorporated to retain or

correct deep bite cases.
Advantages of Hawley's appliance:
i. Ease of fabrication due to simple design.
ii. Minimal patient discomfort due to reduced
bulk.
iii. It is acceptable to most patients as it is
relatively inconspicuous.
Q.4. Describe components/parts of removable

appliances and write about ideal requirements of
springs.
Ans.
[Ref LE Q.4]
Q.5. Enumerate various types of clasps used in an

orthodontics appliances and the ideal requirements
of the clasp.
Ans.
Ans.
Various types of clasps used in an orthodontic appliance
are as follows:
• Circumferential clasp
• Jacksons clasp
• Adams clasps
• Southend clasp
• Ball end clasp
• Schwarz clasp
• Crozat clasp
Ideal requirements of orthodontic clasp are as follows:

• It should be passive and should not produce any
undesirable tooth movements.
• It should be easy to fabricate and adjust.
• It should not get distorted easily on regular usage.
• It should not interfere with occlusion and irritate
the soft tissues.
• It should be versatile.
• It should provide adequate resistance against
displacement and good retention.
• It should function as anchorage part.
Q.6. Advantages of removable orthodontic

appliances.
Ans.
The removable appliances are the devices that can be
inserted into and removed from the oral cavity by the
patient at his will.
Advantages of removable orthodontic appliances are as
follows:
i. Ability to maintain good oral hygiene.
ii. Usually used for simple tooth movements that
can be brought about by tipping.
iii. Less chair side time of orthodontist to fabricate
them so that they can handle more number of
patients.
iv. Various movements like tipping, overbite
reduction can be undertaken.
v. Lesser forces are used. So the strain on anchor
teeth is lesser than fixed appliances.
vi. General dental practitioners who have
received adequate training can use them.
vii. Less inventory is required for fabrication.
viii. Relatively more economical.
ix. As they take less chair side time and are more
economical, they can be used in cornrnunity-
based programmes where a large number of
patients are treated.
x. They are less conspicuous and aesthetically
more pleasing.
xi. The patient can himself remove damaged
appliances that apply undesirable forces.
xii. Used as retention appliances.
Q.7. Adams clasp and its advantages.

Ans.
• Adams clasp was described by professor Philip
Adams.
• It is also known as Liverpool clasp, universal clasp or
modified arrowhead clasp.
• Constructed using 0.7-rnrn round SS wire.
• Parts of Adams clasp are as follows:
a. Two arrowheads - engage rnesial and distal
undercuts.
b. Bridge - connects to arrowheads and is at 45° to
long axis of tooth.
c. Two retentive arms.
Advantages of Adams clasp are as follows:
• It is rigid and offers excellent retention.
• It can be fabricated on both deciduous and
permanent teeth.
• It can be used on partially or fully erupted teeth.
• It can be used on molars, premolars and incisors.
• No specialized instrument is needed to fabricate
the clasp.
• It is small and occupies minimum space.
• It can be modified in a number of ways.
Q.8. Springs used for distalizing the canines.

Ans.
[Sarne as SE Q.1]
Q.9. Hawley's retainer.

Ans.
[Sarne as SE Q.3]
SHORT NOTES:
Q.1. Z-spring.
Ans.
[Ref LE Q.5]
Q.2. Crozat clasp.

Ans.
i. It is a free-ended clasp made of 1-rnrn or 18-gauge
hard SS wire.
FIG. 23. 16 Crozat clasp.
ii. It resembles full clasp with additional piece of wire

soldered which engages rnesial and distal undercuts.
iii. Its advantages are that it offers better retention than
the full clasp and can be used for active appliances.
iv. Its disadvantages are chances of causing tissue
irritation and separation of the tooth.
Q.3. Adams clasp.

Ans.
• The Adams clasp was first described in 1948 by
Professor Phillip Adams.
• The. clasp is constructed using 0.7-rnrn hard round SS
wire.
• It consists of two arrowheads, a bridge and two
retentive arms.
• The two arrowheads engage the rnesial and the distal
proximal undercuts and are connected to each other
by a bridge, which is at 45° to the long axis of the
tooth.
• Its advantages are that it is simple, strong and can be
easily constructed on deciduous and permanent
teeth, and requires no specialized instrument to
fabricate.
Q.4. Labial bow.

Ans.
[Ref SE Q.2]
Q.5. Classify canine retractors.

Ans.
• Canine retractors are springs that are used for distal
movement of canines.
• Types of canine retractors based on placement position
are as follows:
i. Buccally placed:
ii. Palatally placed:
a. Palatal canine retractor
Q.6. Roberts retractor.

Ans.
• Roberts retractor was designed by G.H. Roberts.
• It is made up of 0.5-rnrn or 23-gauge hard SS wire.
• It is indicated for retraction of four incisors, as it is
highly flexible and is an excellent retraction bow.
• Roberts' retractor consists of two sleeved canine
retractors joined to form an apron spring.
• The arch should lie way up the crowns of the teeth
and extends only up to two-thirds of the width of the
lateral incisors, and coils are placed at the point of
emergence of the wire from the sleeves.
• Activation is done by adjusting the vertical limb
below the coil by bending it palatally.
• Disadvantages: Breakages and damage are common
and is difficult to repair.
Q.7. Orthodontic springs mention one

classification.
Ans.
• Springs are active components of removable
appliances.
• There are various methods of classification of springs.
I. Classification of springs based on their ability to
withstand forces of distortion:
a. Self-supported springs:
i. Buccal canine retractor
ii. U-loop canine retractor
iii. Helical loop canine retractor
iv. Coffin springs
b. Guided springs:
ii. Finger springs
iv. T-springs
c. Auxiliary springs:
i. Apron springs
Q.8. Define removable orthodontic appliance and

name its components.
Ans.
i. Orthodontic appliances are defined as the devices by
means of which mild pressure may be applied to a
tooth or a group of teeth and their supporting
structures so as to bring about necessary changes
within the bone which will allow tooth movement.
ii. The removable orthodontic appliances are the
devices that can be inserted into and removed from
the oral cavity by the patient at his will.
iii. There are three basic components in a removable
orthodontic appliance:
a. Retentive components, e.g. clasps, bows
b. Active components, e.g. springs, labial bows,
screws
c. Base plate - forms the framework
Q.9. Mention three ideal requirements of an

orthodontic appliance.
Ans.
[Ref LE Q.3]
Q.10. Name few self-supporting springs.

Ans.
[Ref LE Q.5]
Q.11. Finger spring.

Ans.
[Ref LE Q.5]
Q.12. Coffin spring.

Ans.
[Ref LE Q.S]
Q.13. High labial bows.

Ans.
• High labial bow with apron springs is used for
retraction of one or more teeth.
• The two components of high labial bow with apron
.
springs are
(i) Heavy base arch wire
(ii) Apron spring
• Heavy base arch wire used is a 0.9-rnrn or 19-gauge
hard SS wire.
• High labial arch should neither contact the mucosa
nor extend deep into the full depth of the sulcus.
• Apron springs constitute the active components used
with high labial bow.
• Apron springs are attached to the base arch by
winding a few turns in vertical arm and horizontal
arm.
Q.14. Arrowhead clasp.

Ans.
• Arrowhead clasp is also known as Schwarz clasp.
• It is made with 0.7-rnrn/21-gauge hard SS wire.
• A number
, .,.
of arrowheads, engage
,
interproxirnal
,
Q.14. Arrowhead clasp.
Ans.
• Arrowhead clasp is also known as Schwarz clasp.
• It is made with 0. 7-mm/21-gauge hard SS wire.
• A number of arrowheads engage interproximal
undercuts between molars and premolars.
• Advantages: More elastic, facilitates eruption of
buccal teeth, can be used in combination with
posterior bite blocks.
• Drawbacks: Fabrication is difficult and time-
consuming and requires a special pliers like
Tischler's pliers or optical pliers, and injures

interdental soft tissue.
Q.15. Double cantilever spring.

Ans.
• Double cantilever spring is also known as Z-spring.
• It is made of 0.5-mm/23-gauge hard round SS wire.
• The spring consists of two coils of very small internal
diameter. The spring should be perpendicular to the
palatal surface of the tooth.
• Indications:
i. When both labial and lateral movements of the
incisors are required.
iii. When two or more teeth have to be moved
labially.
• The Z-spring is activated by opening both the helices
by about 2-3 mm at a time. In case of minor rotation
correction, one of the helices is opened.
Q.16. Types of labial bow and their uses.

Ans.
• Labial bows are active components of removable
incisor retraction.
• The various types of bows routinely used in
orthodontics and their uses are as follows:
Short labial bow:
Used for minor overjet reduction and anterior
space closure
Long labial bow:
Closure of minor anterior space and space distal to
canine, minor overjet reduction
Split labial bow:
Used for anterior retraction and closure of midline
diastema
Reverse labial bow:
Used for minor overjet reduction and anterior
space closure
Roberts' retractor:
Used to correct severe anterior proclination
Mills retractor:
Correction of large overj et
High labial bow with apron springs:
Used for retraction of one or more teeth
Q.17. Mention few active plates.

Ans.
• Base plate forms the framework of removable
orthodontic appliance and serves to hold all the
components of the appliance together.
• Usually, base plates are made of either cold-cure or
heat-cure acrylic.
• It functions as an active component. A few appliances
which are considered as active plates are as follows:
i. Split plate.
ii. Bite planes can be incorporated into plate to
treat certain orthodontic problems
iii. Upper anterior inclined plate.
Q.18. Buccal canine retractors.

Ans.
• Buccal canine retractors are indicated in cases of
buccally placed canines and canines placed high in
the vestibule.
• They are used where a buccally placed canine has to
be moved both palatally and distally.
• It made up of 0.7-mm or 21-gauge SS wire.
• It consists of a coil of 3-mm diameter, an active arm
and a retentive arm.
• It is one of the few springs where the coil is closed for
activation.
Q.19. Adams clasp- modification.

Ans.
• The clasp is constructed using 0.7-mm hard round SS
wire.
Modifications of Adams clasp are as follows:
Adams clasp with:
• Single arrowhead
• Additional arrowhead
• Distal extension
• [-hook
• Helix
• Soldered buccal tube
• An incisor and premolar
Q.20. Disadvantages of removable orthodontic

appliances.
Ans.
The disadvantages of removable orthodontic appliances
are as follows:
i. The need of patient's cooperation is highly important.
ii. Inability to perform multiple and complex tooth
movements.
iii. The chances of patient misplacing or damaging the
removable appliances is more.
iv. Patients should have enough skill to remove and
replace the appliance without distorting it.
Q.21. Orthodontic clasp - ideal requirements.

Ans.
• Clasps are the wire components that aid in the
retention of a removable appliances, e.g. C-clasp,
Crozat clasp, Jacksons clasp and Adams clasp.
• Mode of action of clasps: They act by engaging the
undercuts of the teeth.
• Requirements of an ideal clasp:
........+ Offer adequate retention
IL should --+_.. Permit usage in both fully erupted and

partial erupted teeth
Q.22. Cantilever spring.

Ans.
Cantilever springs are of two types:
a. Single cantilever spring
• It is constructed with 0.5-mm hard SS wire.
• A single cantilever spring consists of three parts:
retention tag, coil and an active arm.
• The spring is activated by opening the coil.
b. Double cantilever spring or Z-spring:
• The Z-spring is made of 0.5-mm/23-gauge hard
round SS wire.
• The spring consists of two coils of very small
internal diameter.
• Indications:
i. When both labial and lateral movements
of the incisors are required.
iii. When two or more teeth have to be
moved labially.
• The Z-spring is activated by opening both the
helices by about 2-3 mm at a time.
Topic 24 Fixed orthodontic
appliances
Long essays:
1. Discuss the advantages and disadvantages of fixed
appliances over removable appliances.
2. Explain various components of fixed orthodontic
appliances.

Short essays:
1. Begg's appliance technique.
2. Fixed appliances - advantages.
3. Active parts of fixed appliances. [Ref LE Q.2]
4. Passive components of fixed appliances. [Ref LE
Q.2]
5. Name a few fixed appliance techniques. Write
about anyone technique.
6. Name three fixed appliance techniques.
Differentiate between Begg's technique and edge-
wise technique.
7. Pre-adjusted edge-wise appliances.
8. Indirect bonding.
9. Direct bonding.
10. Orthodontic bands.
11. Lingual orthodontics.
12. Write about any one fixed appliance technique.
[Same as SE Q.1]
13. Active components of fixed appliance. [Same as
SE Q.3]
14. Differentiate between Begg's technique and edge-
wise technique. [Same as SE Q.6]
Short notes:
1. Elastics.
2. Fixed appliance.
3. Components of fixed appliance. [Ref LE Q.2]
4. Fixed appliances versus removable appliances.
5. NiTi wires.
6. Edge-wise appliance technique.
7. Stages of Begg's appliance treatment.
8. Advantages of fixed appliances.
9. Disadvantages of fixed appliances.
10. Classify brackets in fixed orthodontic appliances.
11. Class II elastics.
12. Pre-adjusted edge-wise appliance.
13. Ideal properties of orthodontic wires.
14. What are the advantages of bonding over
banding?
15. Enumerate the objectives of stage I of Begg's
technique.
16. Molar tubes.
17. Metallic brackets.
18. Orthodontic bands. [Ref SE Q.10]
19. Ceramic brackets.
20. Types of elastics. [Same as SN Q.1]
21. Parts of fixed orthodontic appliances. [Same as
SN Q.3]
Solved answers
Long essays:
Q.1. Discuss the advantages and disadvantages of

fixed appliances over removable appliances.
Ans.
The advantages and disadvantages of fixed
appliances over removable appliances are as
follows:
i. Fixed appliances offer i. Oral hygiene
better control and to a maintenance becomes
large extent remove the more difficult.
need for patient
compliance or
cooperation.
ii. It is possible to bring ii. They take up more chair
about various types of side time as they are
tooth movements, e.g. time-consuming to fix
tipping, bodily and adjust.
movement, rotation,
intrusion and extrusion.
iii. The treatment duration iii. More conspicuous than
is considerably reduced, removable appliances.
as multiple tooth Aesthetically unpleasing
movements are possible unless modern tooth-
simultaneously. coloured appliance are
used.
iv. More precise tooth iv. Fixed orthodontic
movements and appliances require
detailing of occlusion is special training of the
possible using fixed operator and are
appliances. invariably handled by
specialized
orthodontists.
v. Fixed appliances can be v. Damaged appliances
used to treat most that apply misdirected
malocclusions, including forces cannot be
very complicated ones. removed by the patient.
vi. Fixed appliances offer vi. Patient has to visit
better control over orthodontist at regular
anchorage. intervals.
vii. More expensive.
Q.2. Explain various components of fixed

orthodontic appliances.
Ans.
[SE Q.3]
• {Fixed orthodontic appliances are those orthodontic
appliances that are rigidly attached to the teeth by
means of bands or rings of metal, which are closely
adapted and cemented to the teeth. Patients cannot
remove them by themselves.
• The components/parts of fixed appliances are broadly
i. Active components
ii. Passive components}
(SE Q.3 and SN Q.3)
{(1. Active components
i. Separators
ii. Arch wires
iii. Springs
iv. Elastics
v. Expansion screws
2. Passive components
i. Bands/band material
ii. Brackets
iii. Buccal tubes
iv. Lingual attachments
v. Lock pins
vi. Ligature wire
vii. Bypass clamps)}
[SE Q.3]
{1. Active components of fixed appliances are
described below.
i. Separators
• Separators are the active components of fixed
appliances used to bring about separation of
teeth and create space in-between two adjacent
teeth generally for the purpose of banding.
• They are used in cases of tight interdental contact
to break those contacts.
Principle of separators:
• It is a device to wedge the teeth in a place
between the adjacent teeth.
• It causes tooth movement and separation of
teeth for easy placement of bands.
Types of separators
One classification based on material used.
i. Metal separators:
a. 0.020" brass wire
b. Kesling separating spring
ii. Elastic separators:
a. Elastic thread
b. Maxian elastic separator
c. Elastomeric rings or doughnut
Based on duration of action, they may be
classified as fallows:
I. Slow separators:
i. Brass wire separator
ii. Kesling's spring separator
II. Rapid separators:
i. Ring separators or elastic rings or
doughnut
ii. Elastic separators or dumbbell
separators}
i. Brass wire separator:
• Soft brass wire of 0.5-0.6-mm diameter
is rotated through the embrasure
between teeth and cut short and tucked
between the teeth and left for 5- 7 days.
ii. Kesling's spring separator:
• Separating springs like Kesling's spring
exerts a scissors-like action when kept for
7 days.
iii. Ring separators or doughnut:
Ring separators are small elastic rings
passed through the contact using a special
plier/applicator. As the stretched elastic
ring encircling the interdental contact
area contracts, the teeth are separated.
iv. Elastic separators or dumbbell
separators:
• Elastic separator/a dumbbell piece of
elastic stretched and passed through
interdental contact area brings about
separation of teeth by trying to regain its
original length. It is effective after 2 or 3
days of placement.
[SE Q.3]
{ii. Arch wires
• Arch wires are one of the active components
that exert force to the teeth and are used for
achieving all types of tooth movements.}
• They bring about various tooth movements
through medium of brackets and buccal tubes.
Ideal requirements of arch wire are as follows:
The arch wire should have:
• Low stiffness and high spring back
• High amount of stored energy
• High resiliency and formability
• Good biocompatibility and environmental
stability
• Capability to be welded and soldered
[SE Q.3]
{Classification of arch wires:
a. Based on cross section:
• Round
• Square
• Rectangular
• Multistranded
b. Based on material used:
• Gold and gold alloys
• Stainless steel alloys
• Beta titanium alloys
b. Based on material used:
• Gold and gold alloys
• Stainless steel alloys
• Beta titanium alloys
• Co-Cr-Ni alloys
• Nickel-titanium alloys
• Optiflex wires
c. Based on the modifications incorporated in arch
wires:
• Plain arch wires
• Arch wire with loops
iii. Springs

• Springs are the active components used to bring
about various tooth movements.
Various types of springs:
i. Coil springs:
• These are two types of coil springs: open
coil spring and closed coil spring.
These are used to close or open the spaces between
the teeth.
a. Open coil springs: Springs which
are compressed between two teeth
to open the space between them
are called open coil springs.
b. Closed coil springs: The springs
which are stretched between the
teeth to close the space are called
closed coil springs.
ii. Uprighting springs: These are used for
root movement in mesial ordistal
direction.
iii. Rotation springs: Used to correct rotated
teeth.
iv. Torquing spring: Used to move the root
in a lingual/palatal direction.
iv. Elastics
• Elastics are made up of latex rubber material and
are available in various diameters. The force
applied by the elastics depends upon the diameter.
• Elastics are used for a number of purposes, such as
to move the teeth, to fix arch wire to the teeth and
for separation of teeth.
• They are available in the form of bands, threads,
modules and rotational wedges.
• Rotation wedges are used to correct a rotated tooth.
• Elastics are available in different colours such as
yellow, pink, green, blue, white and red.
• Uses: To close the spaces, correct crossbite, open
bite and interarch relationship.
v. Expansion screws
• Expansion screws are used in cases of maxillary
arch constriction to achieve expansion.}
[SE Q.4]
{2. Passive components/parts of fixed
appliances are described below.
• Bands
• Brackets
• Buccal tubes
• Lingual attachments
• Lock pins
• Ligature wires
i. Bands
• Bands are thin strips of stainless steel
which are adapted to the contours of the
tooth to which other orthodontic
attachments are welded or soldered, for
example:
Buccal tubes: It holds the arch wires and
the inner bow of the face bow attachment.
Lingual sheaths: Receive and attach lingual
arch wires.
Molar hooks, lingual buttons and cleats:
These are used for engaging elastic bands
and modules.
• Bands are mainly used for the posterior
teeth. Nowadays with the advent of direct
bonding of brackets, bands are rarely used
for anterior teeth.
Various classifications of bands are as
follows:
a. Based on tooth used:
Teeth Size (inches)

Molar band 0.005 x 0.20 or 0.005 x 0.18
Premolars band 0.004 x 0.150
Incisor band 0.003 x 0.125
b. Based on fabrication
i. Preformed - They are available
ready-made in assorted sizes.
ii. Custom-made - Specially made as
per the patient requirement. These
are contoured by the orthodontists
using special pliers.
ii. Orthodontic brackets
• Orthodontic brackets can be compared
with door handles, they transmit force
from the active components to the teeth.
Classification of orthodontic brackets:
They can be classified in number of ways as
follows:
I. Based on the technique
i. Edge-wise type of brackets
ii. Pre-adjusted edge-wise brackets
iii. Begg's brackets
iv. Lingual orthodontic brackets
IL Based on the type of material used
i. Metallic brackets
ii. Plastic brackets
iii. Ceramic brackets
III. Based on the method offixing
i. Bondable
ii. Weldable}
Edge-wise type of brackets
• These brackets are used in the edge-wise
and the straight wire techniques. They
have a horizontal or rectangular slot
facing labially.
• These brackets accept wires of rectangular
cross section with large dimension.
• They provide greater control over tooth
movement and do not permit tipping of
teeth.
Ribbon arch brackets
• These brackets are used in the Begg's fixed
appliance and posses a vertical slot facing
occlusal or gingival direction.
• These types of brackets are used with
round wires to bring about tipping of teeth
in labiolingual or mesiodistal direction.
Metallic brackets
• These are commonly used brackets.
• Advantages:
They are not expensive.
They can be sterilized and recycled.
They resist deformation and fracture.
They exhibit the least friction at the wire-
bracket interface.
• Disadvantages:
They are not aesthetic and patient tends to have a
metallic smile.
They can corrode and cause staining of teeth.
Plastic brackets
• They are made up of polycarbonate or a
modified form of polycarbonate.
• Advantage:
They improve aesthetic value of appliance
and are available in tooth-coloured or
transparent form.
• Disadvantage:
They tend to discolour and have poor
dimensional stability, and slots tend to
distort.
Friction between plastic brackets and metal
arch wire is very high.
Ceramic brackets
• They are introduced in the 1980s and are
made up of aluminium oxide or zirconium
oxide.
• Advantages:
They are durable and resist staining.
They are dimensionally stable and do not
distort in oral cavity.
• Disadvantages:
They are brittle and bulky in size.
They exhibit greater friction at wire-bracket
interface compared with metallic brackets.
[SE Q.4]
{iii. Lingual attachments
• Attachments which can be fixed on the lingual
aspect are called Lingual attachments.
• They are useful for engaging elastics.
• Various lingual attachments include lingual
buttons/lingual cleats/lingual eyelets/ball end
hooks.
iv. Accessories
i. Lock pins
ii. Ligature wire
iii. modules
i. Lock pins:
• Lock pins are made from brass and are used
to secure or engage the arch wire into the
vertical slot of the Begg's brackets.
• Various types of lock pins are stage I, stage II,
stage III and T pins.
ii. Ligature wire: They are made from soft
fully annealed stainless steel wires and
are used to tie the arch wire to the
brackets.
iii. Modules: Modules are used to fix the
arch wire to the bracket slot. They are
elastomeric rings used in pre-adjusted
edge-wise technique.}
Short essays:
Q.1. Begg's appliance technique.

Ans.
Begg's technique or modified ribbon arch
technique:
• Raymond Begg, in the 1950s, introduced Begg's light
wire differential force technique. He introduced
the concept of differential force technique where
the bodily movements of anchor molars were
pitted against the tipping movement of anterior
teeth. Hence, light forces are used in this
technique.
• The type of tooth movement achieved in this
technique is tipping. Anchorage preparation is not
very critical.
• There are three different stages in Begg's treatment:
Stage 1.
This stage is concerned with:
Alignment
Correction of spacing
Correction of crowding
Correction of rotation
Overjet and overbite correction
Achieving an edge-to-edge anterior bite
Stage 2.
l\K::i-int::i-in-inrr rnrrort-inn nf ::irn-ioi:rort tro::itrnont in
Stage 2.
Maintaining correction of achieved treatment in
stage one and space closure.
Stage 3.
Involves achieving normal axial inclination of
teeth by uprighting and torquing.
Q.2. Fixed appliances - advantages.

Ans.
• Fixed orthodontic appliances are those orthodontic

i. Fixed appliances offer better control and to a
large extent remove the need for patient
compliance or cooperation.
ii. It is possible to bring about various types of
tooth movements, e.g. tipping, bodily
movement, rotation, intrusion and extrusion.
iii. The treatment duration is considerably
reduced, as multiple tooth movements are
possible simultaneously, e.g. correction of deep
bite, de-crowding and reduction of overjet.
iv. More precise tooth movements and detailing of
occlusion is possible using fixed appliances.
v. Fixed appliances can be used to treat most
malocclusions, including very complicated
ones.
vi. Fixed appliances offer better control over
anchorage.
vii. In cases where posterior segments have to be
moved forward, it can be done with fixed
appliances only.
viii. Teeth can be aligned better when compared
with removable appliances.
Q.3. Active parts of fixed appliances.

Ans.
[Ref LE Q.2]
Q.4. Passive components of fixed appliances.

Ans.
[Ref LE Q.2]
Q.5. Name a few fixed appliance techniques. Write

about any one technique?
Ans.
Fixed appliance techniques are as follows:
i. £-arch or expansion arch technique - Edward H. Angle
(1800s)
ii. Begg's appliance technique - Raymond Begg (1900s)
iii. Pin and tube appliance technique - Edward H. Angle
(1912)
iv. Edge-wise appliance technique - Edward H. Angle
(1928)
v. Straight wire appliance technique - L.F. Andrews
(1970s)
vi. Lingual orthodontic technique - Craven Kurz (1976)
Edge-wise appliance (Angle, 1928):
• In this technique, arch wire is inserted into the
bracket with narrow dimension placed occluso-
gingivally. This mode of insertion of wire is
called edge-wise, and hence the technique is
called edge-wise technique.
• This technique having unique feature of
rectangular arch wire in rectangular slot
allowed excellent control of tooth movement in
all the three planes of space.
• Certain bends incorporated in ideal arch wire are
used to accomplish desired tooth movements;
they are
i. First-order bends - in and out or
labiolingual corrections.
ii. Second-order bends - tip back bends
placed in posterior segments, they are
meant to achieve correct mesiodistal axial
inclinations of teeth.
iii. Third-order bends - They are placed by
twisting the arch wire, they are placed to
get correct buccolingual position by
moving the roots.
Advantages of edge-wise technique are as follows:
i. Ability to move the teeth in all the three
planes of space.
ii. Good control over tooth movement.
iii. Bodily tooth movement and precise
finishing are possible.
Disadvantages of edge-wise technique are as
follows:
i. Need for complex wire bending and
application of heavy force.
ii. Need for extraoral anchorage and
difficulty in opening deep bites.
A number of modifications have been proposed in
this technique over a period of many years.
Q.6. Name three fixed appliance techniques.

Differentiate between Begg's technique and edge-
wise technique.
Ans.
Fixed appliances are rigidly attached to the teeth by
remove it by themselves.
Fixed appliance techniques:
i. £-arch or expansion arch technique - Edward H.
Angle
ii. Pin and tube appliance technique - Edward H.
Angle
iii. Edge-wise appliance technique - Edward H.
Angle
iv. Begg's appliance technique - Raymond Begg
v. Straight wire appliance technique - L. F.
Andrews
vi. Lingual orthodontic technique - Craven Kurz
Differences between Begg's and edge-wise
techniques are as follows:
Components Begg's Edge-wise

i. Bracket Single point Rectangular in
contact cross section
ii. Buccal tube Round Rectangular
iii. Arch wire Round Rectangular
iv. Engagement of Using lock Using ligatures
wire pins
v.Forces Light Heavy
vi. Duration of Relatively Relatively slow
treatment early
vii. Head gear Not used Used
viii. Anchorage Not done Done
preparation
ix. Tooth movement Bodily Tipping movement
movement
x. Stages in treatment Three stages Three orders
xi. Final alignment Moderate Good
xii. Incidence of root Relatively Relatively more
resorption less
Q. 7. Pre-adjusted edge-wise appliances.

Ans.
Pre-adjusted edge-wise appliances or straight wire
appliances
• Straight wire technique was introduced in the
1970s by Lawrence F. Andrews.
• This technique has eliminated the complex wire
bending procedures by modifying the brackets;
hence it is known as pre-adjusted edge-wise
appliance.
• Bodily movement type of tooth movement is
achieved. Hence, anchorage preparation is vital in
pre-adjusted appliance technique.
• The angulations and torque values built into the
pre-adjusted bracket are called as appliance
prescription.
Stages of pre-adjusted edge-wise treatment:
Stage 1
i. Initial aligning and levelling of arches
done.
ii. Crowding correction and establishing
normal overjet.
Stage 2
i. Correction of molar relationship and
space closure.
ii. Establishing class I molar relation and
normal overjet.
Stage 3
i. Finishing and detailing
ii. Root movement and torque correction
This technique has reduced wire bending
substantially and enabled good finishing of the cases.
Q.8. Indirect bonding.

Ans.
Indirect bonding procedure consists of the attachment
of the brackets to the working cast using water soluble
resins initially, and then transferring it to the mouth
using a custom tray.
Technique:
• The indirect working casts are prepared by taking
alginate impressions 1 or 2 weeks prior to bonding
procedure.
• When the casts are dry, fill in any voids and remove
bubbles. Mark the position of the brackets with
pencil.
• Apply two thin coats of liquid separating medium to
the facial surf aces of the teeth on the cast, and
allow it to dry.
• Position the brackets using light-/self-/heat-cure
unfilled resin on the models.
• Fabrication of transfer trays:
Inject silicone-based, addition-cured elastomer of
medium viscosity, e.g. memosil over the brackets
with a syringe so that it covers all the buccal,
occlusal and lingual surfaces of the teeth to be
bonded. Allow the tray to set for 10 min.
• Soak the cast and memosil tray in cold water for 20
min and then separate both trays from the cast.
The brackets will easily release from the stone and
remain seated in the tray. Trim the trays.
• Chair side bonding procedure:
i. Etch the teeth to be bonded.
ii. Paint a thin layer of unfilled resin over
the etched enamel and over the cured
composite in the tray.
iii. Place the memosil tray in the mouth, and
light-cure each tooth for 30 s.
iv. Peel away the transfer tray from the
teeth or cut the Memosil with a scalpel if
necessary to remove it easily.
Advantages of indirect bonding
• More precise location of brackets is possible.
• Indirect bonding reduces the chair side bonding
process.
• Patient comfort and hygiene are improved.
• T+ ;,,._ TTl"'\...,..TT "h.nl'V'\ti,1 ;""' 1;,....,.....,,,...l h"'"""',..l;,....,..... +n,...."h'"r'\;,...,..-,,n
.
• Patient comfort and hygiene are improved.
• It is very helpful in lingual bonding technique
where visualization is difficult.
Disadvantages of indirect bonding
• Indirect bonding is technique-sensitive.
• Additional set of impressions are needed.
• Increased laboratory time.
• Achieving consistent and predictable adhesion is
difficult.
• Failure rates are slightly higher (Zachrisson and
Brobakken).
• Closer fitting of bracket base is better achieved in

direct bonding than in indirect bonding.
Q.9. Direct bonding.

Ans.
• Direct bonding refers to the direct attachment of the
bracket to the etched enamel using self- or light-cure
agent. Widely used as it is simple and reliable.
• The steps involved in direct bonding on facial or
lingual surface are as follows:
i. Cleaning
ii. Conditioning of enamel
iii. Application of sealants
iv. Bonding
i. Cleaning
• The first step in bonding is removal of plaque
and organic pellicle that normally cover all
teeth.
• Thorough cleaning of teeth with water slurry
of pumice or prophylaxis paste is essential to
achieve this.
ii. Conditioning enamel
• This step involves two procedures, namely:
a. Moisture control
b. Enamel pretreatment
a. Moisture control: Complete dry working
field is absolutely essential for effective
bonding. This can be achieved by using
the:
• Lip and cheek retractors
• Saliva ejectors, salivary duct
obstructors
• Tongue guards with bite blocks
• Cotton or gauze rolls
• Antisialogogue, e.g. atropine
sulphate or probanthine bromide
b. Enamel pretreatment or acid etching:
• After drying the tooth, an etchant,
usually 37°/o phosphoric acid
solution or gel, is applied lightly
over enamel surface with a pellet
or brush for 15-60 s.
• Etching is also done by 10°/o
polyacrylic acid or 10°/o maleic
acid.
• Etchant is rinsed off with abundant
water spray for about 15 s. If
salivary contamination occurs
after etching, re-etch for another
30 s.
• Dry the tooth thoroughly to obtain
dull frosty white appearance.
The rationale for acid etching is as follows:
removes about 3-10 microns of enamel surface.
• It increases the wettability and surface area
of enamel substrate.
• Primary attachment mechanism of resin is
'resin tags'. Resin tags penetrate up to the
depth of 80 microns or more and provide a
micromechanical bond.
iii. Application of sealants
• Sealants are unfilled resins with low
viscosity. After etching, a thin layer of
sealant may be painted over entire enamel
surface. It is best applied with a small foam
pellet or brush. It should be thin and even.
• Sealants might be necessary to achieve
proper bond strength and to improve
resistance to micro leakage.
• Moisture control may not be extremely
important after sealant application.
• Sealant might permit easier bracket removal
and protects against enamel tear-outs during
de-bonding.
• Sealants are either self-cured or light-cured.
a. Self polymerizing sealants: polymerize
poorly, exhibit drift, have low resistance
to abrasion.
b. Light-polymerizing sealants: protect
enamel adjacent to brackets from
dissolutions and subsurface lesions.
iv. Bonding
The recommended bracket bonding procedure
consists of the following steps:
i. Transferring the brackets
ii. Positioning of bracket
iii. Fitting
iv. Removal of excess adhesive
Procedure:
• Use a reverse action tweezers to grip the
brackets.
• Apply adhesive to the bracket base and
place the bracket immediately on the tooth
close to its correct position.
• Proper horizontal and vertical positions of
bracket should be ensured. A placement
scaler is used to position the bracket
correctly.
• Once the bracket is in correct position, it is
pushed firmly towards the tooth surface.
The tight fit will result in good bond
strength.
• The last step in direct bonding is removal
of excess adhesive using a scaler.
Q.10. Orthodontic bands.

Ans.
{SN Q.18}
• Orthodontic bands are one of the passive components
of fixed orthodontic appliances.
Bands are thin strips of stainless steel which are
adapted to the contours of the tooth to which other
orthodontic attachments are welded or soldered,
e.g. buccal tubes, lingual sheaths, molar hooks,
lingual buttons and cleats.
• Bands are mainly used for the posterior teeth.
Nowadays with the advent of direct bonding of
brackets, bands are rarely used for anterior teeth.
Various classifications of bands are as follows:
a. Based on tooth used:
Teeth Size (inches)

Molar band 0.005 x 0.20 or 0.005 x 0.18
Premolar band 0.004 x 0.150
Incisor band 0.003 x 0.125
b. Based on fabrication:
i. Preformed - They are available ready-
made in assorted sizes.
ii. Custom-made - Specially made as per the
patient requirement. These are contoured
by the orthodontists using special pliers.
Q.11. Lingual orthodontics.

Ans.
• The technique of lingual orthodontics, also called
invisible orthodontics, was introduced in 1976 by
Craven Curz.
• Craven Curz developed plastic brackets on lingual
surface for easy reshaping and better fit. In 1976,
Ormco Company along with Craven Curz, Craig
Andreiko and Frank Miller developed first-
generation Curz bracket.
• The technique of lingual orthodontics involves
placement of brackets and other attachments on the
lingual surface of the teeth.
The indications for lingual orthodontic technique are as
follows:
• Cases with good gingival and periodontal health
having mild incisor crowding and those with
anterior deep bite.
• Long and uniform lingual tooth surfaces without
any restorations.
• Keen and compliant patient.
• In individuals with mesocephalic or mild/moderate
brachycephalic skull with skeletal class I pattern.
• Patients with adequate mouth opening.
Disadvantages of lingual orthodontic technique:
• Access is more difficult for orthodontist to place
brackets on the lingual surface.
• Tooth control is not very effective.
• There is limited scope for complex problem.
• Treatment is highly expensive.
• Indirect bonding is mandatory in lingual
orthodontics.
• Difficulty in speech and maintaining oral hygiene.
Q.12. Write about any one fixed appliance

techniques.
Ans.
[Same as SE Q.1]
Q.13. Active components of fixed appliance.

Ans.
[Same as SE Q.3]
Q.14. Differentiate between Begg's technique and

edge-wise technique.
Ans.
[Same as SE Q.6]
Short notes:
Q.1. Elastics.
Ans.
• Elastics are made up of latex rubber material.
• Elastics are available in different colours such as
yellow, pink, green, blue, white, red etc.
• Uses:
Elastics are used for a number of purposes like to
move the teeth, fix arch wire to the teeth,
separation of teeth, close the spaces, correct
crossbite, open bite and interarch relationship.
• Types of elastics:
Class I (intramaxillary) - placed between molars and
anteriors in the same arch. Used for space closure.
Class II (intermaxillary) - placed between
mandibular molars and maxillary anteriors. Used
for retraction of maxillary anterior teeth and
mesial movement of the mandibular molars.
Class III (intermaxillary) - placed between maxillary
molars and mandibular anteriors for correction of
class III.
Diagonal elastics - worn for midline corrections.
Crossbite elastics (intermaxillary) - used to correct
crossbites in buccal segment.
Box elastics - used to correct anterior open bites.
Q.2. Fixed appliance.
Ans.
• Fixed orthodontic appliances are those orthodontic
• They offer better control and to a large extent remove
the need for patient compliance or cooperation.
• It is possible to bring about various types of tooth
movements, e.g. tipping, bodily movement, rotation,
intrusion and extrusion.

• More precise tooth movements and detailing of
occlusion are possible using fixed appliances.
Q.3. Components of fixed appliance.

Ans.
[Ref LE Q.2]
Q.4. Fixed appliances versus removable appliances.

Ans.
Fixed appliances Removable appliances

i. Lessen the need for i. Patient cooperation is needed
patient to a large extent.
cooperation.
ii. Oral hygiene ii. Oral hygiene maintenance is
maintenance is easy.
more difficult.
iii. The treatment iii. The treatment duration is
duration is very prolonged in case of severe
less. malocclusion.
iv. More chair side iv. Less chair side time of
time is consumed orthodontist to fabricate them.
to fix them.
v. More expensive. v. Relatively economical.
vi. Requires special vi. Requires no special training.
training of the
operator.
Q.5. NiTi wires.

Ans.
• NiTi is commercially available as Chinese NiTi or
Japanese NiTi.
• Nitinol was introduced into orthodontics by G.
Andreasen and William F. Buehler.
• Clinical uses of NiTi alloy in orthodontics are as
follows:
i. Initial alignment and levelling arch wires
ii. Retraction coil springs
iii. Palatal expanders
iv. Devices for distalization of molars
Q.6. Edge-wise appliance technique.

Ans.
• In edge-wise technique, arch wire is inserted into the
bracket with narrow dimension placed occluso-
gingivally. This mode of insertion of wire is called
edge-wise, and hence the technique is called edge-
wise technique.
• This technique, having unique feature of rectangular
arch wire in rectangular slot, allowed excellent
control of tooth movement in all the three planes of
space.
• Certain bends incorporated in ideal arch wire are
used to accomplish desired tooth movements; they
are first-, second- and third-order bends.
• Bodily tooth movement and precise finishing are
possible.
• Need for complex wire bending and application of
heavy force are some of the disadvantages of this
appliance.
Q.7. Stages of Begg's appliance treatment.

Ans.
• There are three different stages in Begg's treatment:
Stage 1:
This stage is concerned with:
Alignment
Correction of spacing, crowding and overbite
correction
Achieving an edge-to-edge anterior bite
Stage 2:
Maintaining correction of achieved treatment in
stage one and space closure
Stage 3:
Involves achieving normal axial inclination of
teeth by uprighting and torquing
Q.8. Advantages of fixed appliances.

Ans.
Advantages of fixed appliances are as follows:
i. They offer better control and to a large extent remove
the need for patient cooperation.
ii. Various types of tooth movements are possible, e.g.
tipping, bodily movement, rotation, intrusion and
extrusion.
iii. The treatment duration is considerably reduced.
iv. More precise tooth movements and detailing of
occlusion are possible using fixed appliances.
Q.9. Disadvantages of fixed appliances.

Ans.
Disadvantages of fixed appliances are as follows:
i. Oral hygiene maintenance is more difficult.
ii. More chair side time is consumed to fix them.
iii. More expensive.
iv. Requires special training of the operator and are
invariably handled by specialized orthodontists.
Q.10. Classify brackets in fixed orthodontic

appliances.
Ans.
Orthodontic brackets can be compared to door handles.
They transmit the force from the active components to
the teeth.
Classification of orthodontic brackets:
They can be classified in a number of ways as
follows:
I. Based on the technique
i. Edge-wise type of brackets
ii. Pre-adjusted edge-wise brackets
iii. Begg's brackets
iv. Lingual orthodontic brackets
II. Based on the type of material used
i. Metallic brackets
ii. Plastic brackets
iii. Ceramic brackets
III. Based on the method of fixing
i. Bondable
ii. Weldable
Q.11. Class II elastics.

Ans.
• Elastics are made up of latex rubber material and are
colour-coded.
• Elastics are used for a number of purposes like to
move the teeth, fix arch wire to the teeth, for
superstation of teeth, close the spaces, correct
crossbite, open bite and interarch relationship.
• Class II (intermaxillary) elastics
i. Used to correct class II malocclusion.
ii. They are placed between mandibular molars
and maxillary anteriors, for retraction of
maxillary anterior teeth and mesial movement
of the mandibular molar teeth.
Q.12. Pre-adjusted edge-wise appliance.

Ans.
Pre-adjusted edge-wise appliance or straight wzre
appliance:
• Straight wire technique was introduced by Lawrence.
F. Andrews in the 1970s.
• This technique has eliminated the complex wire
bending procedures by modifying the brackets,
hence it is known as pre-adjusted edge-wise
appliance.
• Bodily movement type of tooth movement is
achieved. Hence, anchorage preparation is vital in
pre-adjusted appliance technique.
• The angulations and torque values built into the pre-
adjusted bracket are called appliance prescription.
• This technique has reduced wire bending
substantially and enabled good finishing of the cases.
Q.13. Ideal properties of orthodontic wires.

Ans.
Ideal properties of orthodontic wire are as follows:
i. The wire should deliver low constant force.
ii. It should have high strength and range.
iii. It should have low stiffness or good spring back.
iv. It should offer less frictional resistance between wire
and bracket base.
v. It should be easy to manipulate and biocompatible.
vi. It should be stable in the oral environment.
vii. It should be economical.
Q.14. What are the advantages of bonding over

banding?
Ans.
• The bonding is a method of fixing attachments
rlirPrtlu n,1Pr thP pn;:imPl c::11rf;:irp nf tnnth t ici n o
Q.14. What are the advantages of bonding over
banding?
Ans.
• The bonding is a method of fixing attachments
directly over the enamel surface of tooth using
adhesive resins.
• The advantages of bonding over banding are as
follows:
i. It is easier and faster to bond than to pinch
bands around teeth.
ii. Better oral hygiene maintenance.
iii. Superior aesthetics.

iv. Risk of caries under loose bands is eliminated.
v. It is the best method in case of partially erupted
and fractured teeth and teeth with abnormal
shapes.
Q.15. Enumerate the objectives of stage I of Begg's

technique.
Ans.
There are three different stages in Begg's treatment:
The objectives of stage I Begg's technique are as
follows:
Stage I is concerned with:
• Alignment
• Correction of spacing, crowding and rotation of teeth
• Overjet and overbite reduction
• Achieving an edge-to-edge anterior bite
Q.16. Molar tubes.

Ans.
• The orthodontic attachments that are generally used
for molars are called 'buccal tube or molar tubes'.
• They are generally used on molars and help to
provide better three-dimensional control of these
anchor teeth.
Classification of molar/buccal tubes:
A. Based on mode of attachment
i. Weldable
ii. Bondable
B. Based on lumen shape
i. Round
ii. Oval
iii. Rectangular
C. Based on number of tubes
i. Single
ii. Double
iii. Triple
D. Based on technique
i. Begg's tube
ii. Edge-wise tube
iii. Pre-adjusted edge-wise
Q.17. Metallic brackets.

Ans.
Brackets are passive orthodontic components. Metallic
brackets are the commonly used brackets.
• Advantages:
They are not expensive.
They can be sterilized and recycled.
They resist deformation and fracture.
They exhibit least friction at the wire-bracket
interface.
• Disadvantages:
They are not aesthetic and patient tends to have a
metallic smile.
They can corrode and cause staining of teeth.
Q.18. Orthodontic bands.

Ans.
[Ref SE Q.10]
Q.19. Ceramic brackets.

Ans.
Brackets are passive orthodontic components. Ceramic
brackets are the latest brackets.
• Ceramic brackets were introduced in the 1980s and
are made of aluminium oxide or zirconium oxide.
• Advantages:
They are durable and resist staining.
They are dimensionally stable and do not distort in
oral cavity.
• Disadvantages:
They are brittle and bulky in size.
They exhibit greater friction at wire-bracket
interface compared with metallic brackets.
Q.20. Types of elastics.

Ans.
[Same as SN Q.1]
Q.21. Parts of fixed orthodontic appliances.

Ans.
[Same as SN Q.3]
Topic 25 Myofunctional and
orthopaedic appliances
Long essays:
1. Classify myofunctional appliances. Discuss in
detail the mechanism of action, fabrication and

trimming of activator.
2. What are myofunctional appliances? Describe in
detail about preparation and uses of oral screen?
3. Classify functional appliances. Describe functional
appliances how do they work and modify growth.
4. Define and classify functional appliances. Write in
detail about Frankel appliance.
5. What is myofunctional appliance? Discuss about
bionator.
6. Enumerate various types of functional regulators
and describe the functional regulator II.
7. What are the functional appliances? Give
examples. Discuss any one appliance in detail?
[Same as LE Q.1]
8. What are myofunctional appliances? Classify
them. Explain activator in detail? [Same as LE Q.1]
9. What are functional appliances? Give examples.
Describe the trimming and mechanism of action of
Anderson appliance? [Same as LE Q.1]
10. Enumerate the uses of oral screen. How will you
fabricate an oral screen? [Same as LE Q.2]
11. Define a functional appliance. What are the
indications, mode of action of FR II appliances?
[Same as LE Q.4]
12. Discuss about various types of Frankel functional
regulators. [Same as LE Q.6]
13. Name the components ofFR2 (Frankel 2)
appliances and describe their action? [Same as LE
Q.6]
Short essays:
1. Catalan's appliances.
2. Jasper jumper.
3. Write briefly on upper anterior bite plane.
4. Activator.
5. Oral screen and their indications.
6. Twin block appliance.
7. Functional appliances - Classification.
8. Philosophy of Frankel appliance.
9. Difference between activator and Frankel
appliance.
10. Case selection for functional appliance.
11. Catalan's appliance. Mention disadvantages of
this appliance. [Same as SE Q.1]
12. Anderson activator. [Same as SE Q.4]
Short notes:
1. Oral screen - Uses. [Ref LE Q.2]
2. Lip bumper.
3. Components of FR II appliances.
4. Types of Frankel appliance. [Ref LE Q.6]
5. Bionator appliance.
6. Activator.
7. Catalan's appliance.
8. Define and classify myofunctional appliances.
9. Upper anterior bite plane - Mechanism of action.
10. Sved bite plane.
11. Advantages of Jasper jumper.
12. Fixed functional appliances - Classification and
advantages.
13. Action of functional appliances.
14. Mode of action of activator.
15. Indications of twin block.
16. Contra indications of activator. [Ref LE Q.1]
17. Denholtz appliance.
18. Orthopaedic force in orthodontics.
19. Chin cap.
20. Extraoral traction.
21. Describe various types of headgears available to
control the growth of maxilla.
22. Orthopaedic appliance - Components.
23. Effects of face mask.
24. Name the headgears used in orthodontics.
25. High pull headgear.
26. Enumerate various types of facemasks.
27. Mention various functional regulators? [Same as
SN Q.4]
28. Give indications for activator therapy. [Same as
SN Q.6]
29. Face mask therapy -Advantages. [Same as SN
Q.24]
30. Indications of face mask therapy. [Same as SN
Q.23]
31. Headgear - Uses. [Same as SN Q.24]
Solved answers
Long essays:
Q.1. Classify myofunctional appliances. Discuss in

detail the mechanism of action, fabrication and
trimming of activator.
Ans.
Classification of myofunctional appliances:
Myofunctional appliances can be classified in a
number of ways:
I. Tooth-borne active appliances
Tooth-borne passive appliances
Tissue-borne passive appliances
II. Myotonic appliances
Myodynamic appliances
III. Removable functional appliances
Fixed functional appliances
IV. Group I appliances
Group II appliances
Group III appliances
{SN Q.16}
Activator:
• Activator is also known as Norwegian appliance,
Monobloc, Andresen and Haupl appliance or
Andresen's appliance.
• It is developed by Andresen and Haupl.
• Activator is called so because the wearing of this loose
fitting appliance activates the muscles.
Indications:
i. Cases of class I malocclusion with open bite or
deep bite.
ii. Class II division 1 malocclusion
iii. Class II division 2 malocclusion
iv. Class III malocclusion
v. Phase I treatment before fixed appliance
treatment in children with lack of vertical
development in lower facial height
vi. As a retention appliance
vii. As a habit breaking appliance
viii. Used in obstructive sleep apnoea
{SN Q.16}
Contraindications:
The appliance cannot be used in:
• Class I with crowded teeth because of
disharmony between tooth size and jaw size.
• Children with excessive lower facial height and
extreme vertical mandibular growth.
• Children with severely procumbent lower
. .
incisors.
• Children with nasal stenosis caused by structural
problems within nose or chronic untreated
allergy.
• In non-growing individuals, it has limited
application.
Advantages:
• It uses existing growth of the jaws.
• Minimal oral hygiene problems during treatment.
• Long intervals between appointments.
• Need minimal adjustments hence require short
appointment.
• More economical.
Disadvantages:
• Good patient cooperation is required during
treatment.
• Post-treatment fixed orthodontic therapy may be
needed for detailing of the occlusion, as activator
cannot produce a precise detailing and finishing of
the occlusion.
• Activators are not used in cases of excessive lower
face height because they may produce moderate
mandibular rotation anteriorly and downwards.
Mode of action of activator is as follows:
Activator is a loose fitting appliance which was
designed by Andresen and Haupl to correct
retrognathic mandible.
There are different views and mechanisms by which
activator works.
a. First view:
• According to Andersen and Haupl, the activator
induces musculoskeletal adaptation
introducing a new pattern of mandibular
closure.
• The appliance loosely fits into the mouth and
closure.
• The patient has to move the mandible forward
to engage the appliance, this results in
stretching of the elevator muscles of
mastication which starts contraction, thereby
setting up a myotactic reflex.
• This generates kinetic energy which causes,
prevention of further forward growth of the
maxillary dentoalveolar process. Movement of
the maxillary dentoalveolar process distally
causes a reciprocal forward force on the
mandible.
• In addition to this myotactic reflex, a condylar
adaptation by backward and upward growth
occurs.
• A third factor is the force generated while
swallowing and during sleeping.
b. Second view:
• According to Harvold, Woodside and Herren,
passive tension caused by stretching muscles,
soft tissue, tendinous tissue, etc., are
responsible for the action, which they called
the viscoelastic property.
• Activator causes change in viscoelastic
properties of muscles and stretches soft tissues
and induces skeletal adaptation. This
mechanism is for vertical activators where
potential energy is utilized in extreme opening
of mandible (>10 mm).
c. Combination of kinetic and potential energy:
Vertical opening is 4-6 mm.
c. Combination of kinetic and potential energy:
Vertical opening is 4-6 mm.
d. Differential eruption of teeth: Selective grinding
leads to differential eruption of teeth.
Effects of activator treatment on:
A. Maxilla:
i. Slight intermolar
.
and intercanine
expansion
ii. Upper incisors are retracted
iii. Increase in the vertical height in
posterior teeth
iv. Restraining effect on the maxillary arch

as a unit
B. Mandible:
i. Lower incisors proclination and reduction
in deep bite
ii. Increase in the vertical height of
posterior teeth, downward and forward
translation of the mandible and the teeth
as unit
C. Soft tissue:
Potentially competent lips become sufficiently
competent and causes changes in lip posture.
Construction of activator:
Components:
• Labial bow
• Jack screw
• Acrylic portion
The steps in the fabrication of activator are
i. Preparation of models: Working and study
models
ii. Registration of construction bite:
Horizontal or vertical bites
iii. Articulation of models
iv. Wax-up and wire bending
v. Processing of appliance
vi. Trimming of activator
Registration of construction bite:
Horizontal bite: • Mandible advanced by 6- 7 mm
(H activator) • Vertical opening by 2-3 mm
Vertical bite CV-activator) • Mandible advanced by 2-3 mm
(High angle cases) • Vertical opening by 7-8 mm
Only vertical opening • In deep bite
Retrusive bite • Class III cases
Guidelines for bite registration:

i. Early mixed dentition:
• The mandible should be moved forward until
on an average, about 4-5 mm. Then the
upper primary canine occludes with
interproximal area between the lower
primary canine and the first primary
molars.
ii. Late mixed dentition:
• The mandible should be moved forward on
an average, around 6-8 mm until the upper
canine relates directly above the
interproximal between the lower cuspid and
first bicuspid.
iii. Anterior midline:
• When the bite registration is taken, the upper
and lower midlines should coincide.
• If there is skeletal midline deviation, bite
registration is done with midlines
coinciding.
• No attempt should be made to correct the
midlines if there is dental midline shift.
iv. Articulation:
• Reverse articulation provides good access
during acrylization of the appliance.
Wire bending:
• A passive labial bow is made with 0. 9 mm
wire. The labial bow should contact the middle
third of the labial surface of the upper anterior
teeth and the ends of the bow cross between
canine and first premolar or deciduous first
molar through the centre of interocclusal wax.
• It acts as a passive medium for the
transmission of muscular forces to the
maxillary teeth and arch.
Processing of appliance:
• This is done using either heat cure or cold cure.
• Appliance consists of maxillary part,
interocclusal part and mandibular part.
Trimming of activator:
After processing of the appliance, an interocclusal
block of acrylic is present between the upper and
lower posterior teeth. Guiding grooves are placed
in the interocclusal block to facilitate tooth
movement. Guiding grooves are created using
appropriate flame-shaped burs.
Trimming for vertical movement:
The intrusion and extrusion are two movements that
occur in vertical plane with activator treatment.
i. Intrusion:
• In deep bite cases intrusion of the incisor teeth
can be achieved by loading the incisal edges of
teeth.
• Molar intrusion is indicated in open bite cases
where it can be achieved by loading the cusps
alone of the molars and grinding away the
acrylic from fossae and fissures.
ii. Extrusion:
• Extrusion of the incisor teeth indicated in open
bite cases can be achieved by loading the
lingual surfaces above the area of greatest
convexity and it can be enhanced also by
placing the labial bow above the area of
convexity.
• Extrusion of molars indicated in deep bite cases
is achieved by loading the lingual surfaces
above the area of greatest convexity in maxilla
and below in mandible.
• During supra eruption of molars, selective
trimming is done. In this either upper or lower
molars are allowed to erupt individually or
both together.
Trimming for anteroposterior or sagittal
movements:
The following movements can be achieved in the
anteroposterior plane.
i. Protrusion of incisors:
• It can be produced by loading the entire
lingual surface of the incisors with acrylic.
Or
Only the incisal portion of the lingual surface is
loaded.
• Protrusion can also be achieved with
accessory elements like protrusion
springs, wooden pegs and gutta-percha.
ii. Retrusion of incisors:
• Retrusion is achieved by trimming away
the acrylic from lingual surface of the
incisors and using 'active labial bows'.
Distal movement of molars:
• For distalizing movements, the guide planes load
the molars on the mesiolingual surfaces and
extends to the area of greatest convexity.
• Active springs can also be used to achieve distal
movement of molars.
• Distal movement of upper molars is indicated in
class II, while lower molars is indicated in class III
malocclusions.
Mesial movement of molars:
• Mesial movement is achieved by the guide planes
contacting the teeth on the distolingual surfaces
and extending to the greatest lingual
circumference in the mesiodistal plane.
• In class III, malocclusion mesial movement of
posterior teeth in upper arch is indicated.
Transverse movements with activator:
• Activator may also be trimmed to stimulate
expansion of buccal segment. This is done by
allowing contact of acrylic on the lingual surfaces
of the teeth to be moved transversely.
• More better expansion can be achieved by
incorporating jackscrew in the activator.
Guidelines for clinical control:
• It is important to ensure during treatment that the
grooves maintain their contact.
• Reshaping of grooves and padding with fast setting
self-cure acrylic in contact areas should be carried
out.
• Wearing time of the appliance should be monitored.
Appliance is worn for 2-3 h during the first 2
weeks. Then increased to full night time wear.
• Any trauma or sore spots should be corrected.
Retention period:
• Retention period starts as the bicuspid exchange
has been completed, and an adult class I occlusion
is established.
• Following active treatment average retention
period is 6-8 months following which wearing of
the appliance is gradually tapered off over a period
of 2 to 3 months.
Modifications of activator:
• Eschler's modification
• Herren's modification
• Wunderer's modification
• Bow activator of A.M. Schwarz
• Karwetzky appliance
• Cut out or palate free activator
• The propulsor
• Elastic open activator
• Kinetor by Stockfish
Q.2. What are myofunctional appliances? Describe in

detail about preparation and uses of oral screen?
Ans.
{SN Q.1}
• Vestibular screen or oral screen was first introduced
by 'Newel' in 1912 (Fig. 25.1).
• Vestibular screens are also called lip moulders.
• Oral screen or vestibular screen is simple functional
appliance that takes the form of a curved shield of
acrylic placed in the labial vestibule.
• It is a functional appliance because it has no active
elements designed to produce force. It produces its
effect by redirecting the pressure of the muscles and
soft tissues like lips and cheek.
Principle:
• Vestibular screen works on the principle of both
force application as well as force elimination.
• The vestibular screen can be used either to apply
the forces of the circumoral musculature to certain
teeth or to relieve those forces from the teeth
thereby allowing them to move due to forces
exerted by the tongue.
I
I
I
I
I
I
I
I
I
I
I
I
FIG. 25.1 Vestibular screen.
{SN Q.1}
Indications/uses:
• Used mostly to intercept mouth breathing habit and
can also be used to intercept other habits like
thumb sucking, tongue thrusting, lip biting and
cheek biting.
• Used for correction of mild distocclusions and mild
anterior proclination.
• Used to perform muscle exercises that help in
correction of hypotonic lip and check muscles.
• Correction of flaccid hypotonic orofacial
musculature.
• Used as both active and passive appliances.
• Counteract deficiencies in lip posture and function.
Steps in the fabrication of oral screen are as follows:
i. Appliances are preferably made in clear acrylic.
ii. Upper and lower impressions are made and
working models are poured, reproducing
depths of vestibular sulcus.
iii. Upper and lower casts are occluded in normal
intercuspation and sealed together using
plaster.
iv. A construction bite plane should be taken to
advance the mandible in case the appliance is
being used for correction of distocclusion.
v. Vestibular screen should extend into the sulcus
to the point of mucosal tissue reflects outwards
and should not impinge on frenum and muscle
attachments. Posteriorly it should extend up to
the distal margin of the last erupted molar.
vi. Models are covered with 2-3 mm of wax over
the labial surface of the teeth and alveolar
process. In case of proclined teeth which need
to be retracted the wax relief is removed to
expose the incisal one-third of the teeth.
vii. Appliance is fabricated in either self-
cure/heat-cure acrylic resin.
viii. It is trimmed and polished.
Management of appliance:
• Ask the patient to wear the appliance at night and
2-3 h during day time and patient is instructed to
maintain lip seal.
• The areas of appliance causing irritation to sulcus
and frenum are carefully trimmed.
• Padding with quick setting self-cure acrylic is done
in areas where tooth contact is present. Padding is
done with pink acrylic.
• Breathing
. holes should be gradually reduced in
size.
Modifications of the vestibular screen:
Number of modifications of vestibular screen are as
follows:
i. Hotz modification
ii. Double oral screen
iii. Screen with breathing holes
iv. Oral screen used in open bite cases
v. Rehak's modification
i. Hotz modification:
The oral screen can be fabricated with a metal ring
projecting between upper and lower lips. This
ring can be used to carry out various muscle
exercises.
ii. Double oral screen by Krauss:
• Useful in patients with abnormal tongue
posture and tongue thrust.
• In patients with tongue thrust habit an
additional screen is placed on the lingual
aspect of the teeth. This is attached to
vestibular screen by means of a thick wire
that
. . runs through
.
the bite in the lateral
incisor region.
iii. Oral screen with breathing holes:
• In case of mouth breathers, the vestibular
screen should be fabricated with a
number of holes that are gradually closed
in a phased manner as nasal breathing
takes over.
• Place breathing holes in the labial aspect of
the oral screen.
• A button with a string attached is placed on
the lingual aspect.
• Patient is instructed to perform exercises
by pulling the string through the breathing
hole.
iv. Oral screen used in open bite cases:
• The tongue is kept away from the dentition
by an acrylic projection.
v. Modification of Rehak:
• In this a nipple is combined with the screen
which projects out. The nipple has to be
retained by the lips. Therefore to increase
the effects of oral screen, the natural
sucking movements are used.
Advantages:
• Simple and versatile appliance for early
interceptive treatment.
• The appliance establishes a better muscle balance
between the tongue and buccinators mechanism.
• Corrects the abnormal relationships of upper and
lower lips to each other and makes it possible to
achieve near normal lip seal.
• Develops effective mechanism for reducing or
eliminating hyperactive mentalis muscle.
• Contributes to the development of a proper
functioning occlusion.
Disadvantages:
• It is not a complete mechanotherapy.
• It forms only an initial or phase 1 correction of
Q.3. Classify functional appliances. Describe

functional appliances how do they work and modify
growth
Ans.
• Functional appliances are defined as loose fitting or
passive appliances which harness natural forces of
the orofacial musculature that are transmitted to the
teeth and alveolar bone through the medium of the
appliance.
• These appliances either transmit, eliminate or guide
the natural forces of the musculature and are used
for growth modification procedures that are aimed
at intercepting and treating jaw discrepancies.
They can bring about the following changes:
• An increase or decrease in jaw size
• A change in spatial relationship of the jaws
• Change in direction of growth of the jaws
• Acceleration of desirable growth
Treatment principles:
Functional appliances work on two major
principles:
i. Force application
ii. Force elimination
i. Force application:
• Most of the fixed and removable function
appliances work on this principle.
• Compressive stress and strain act on the
surrounding structures involved and
primarily result in an alteration in form
with a secondary adaptation in function.
ii. Force elimination:
• This principle allows optimal development of
dentition by elimination of abnormal and
restrictive environmental influences on the
dentition.
• Thus function is rehabilitated with a
secondary change in form.
Mode of action offunctional appliances:
Functional appliances are capable of producing the
following changes:
i. Orthopaedic changes
ii. Dentoalveolar changes
iii. Muscular changes
i. Orthopaedic changes:
Capable of accelerating the growth in

the condylar region
Able to bring about remodelling of the

glenoid fo sa
FA can be
De izned
~ to have re trictive influence
on the growth of the ja,v
Change the direction of growth of

the jaw ·
ii. Dentoalveolar changes: I

Functional appliances can bring about dentoalveolar
changes in the:
a. Sagittal direction
b. Transverse direction
c. Vertical direction
Sagittal Transverse Vertical

Most FA allow the FA can bring FA can be designed
upper anteriors to about expansion to allow selective
tip palatally and of dental arches eruption of teeth.
lower anteriors to by incorporating
tip labially. screws in them
or by shielding the
buccal muscles
away from dental
arch.
iii. Muscular changes - Functional appliances can

improve the tonicity of the orofacial musculature.
Myofunctional appliances can be classified in a
number of ways as follows:
IL Myotonic appliances
Group II appliances
I. (a) Tooth-borne active appliances:
_..., • -, , -, • ,.... • • I"" • • ,
J. J. J.
I. (a) Tooth-borne active appliances:

They include modifications of activator and
bionator that include expansion screws or
other active components like springs to
provide intrinsic force for transverse or
anteroposterior changes.
(b) Tooth-borne passive appliances:
For example: activator, bionator and Herbst
appliance
They have no intrinsic force generating
components such as springs or screws.
They depend on the soft tissue stretch and

muscular activity to produce desired
treatment results.
(c) Tissue-borne passive appliances:
For example: functional regulator of
Frankel
They are mostly located in the vestibule and
have little or no contact with the
dentition.
II (a) Myotonic appliances:
They are dependent on muscle mass for
their action.
(b) Myodynamic appliances:
They depend on the muscle activity for their
function.
III (a) Removable functional appliances:
They can be removed and inserted into the
mouth by the patient.
For example: activator, bionator
(b) Fixed functional appliances:
They are fitted on the teeth by the operator
and cannot be removed by the patient at
will.
IV. (a) Group I appliances:
For example: oral screen and inclined
planes
They consist of appliances that transmit the
muscle force directly to the teeth for the
purpose of correction of the malocclusion.
(b) Group II appliances:
For example: activator and bionator.
These appliances reposition the mandible
and the resultant force is transmitted to
the teeth and other structures.
(c) Group III appliances:
For example: Frankel appliance and vestibular
screen
These appliances also reposition the mandible but
their area of operation is vestibular, outside the
dental arch.
Visual treatment objective:
Is an important diagnostic test undertaken before
making a decision to use a functional appliance. It
is performed by asking the patient to bring the
mandible forward. An improvement in profile is
considered as a +ve indication for the use of
functional appliance.
In case the profile worsens, then other treatment
modalities have to be considered.
Q.4. Define and classify functional appliances. Write

in detail about Frankel appliance.
Ans.
• Functional appliances are defined as 'loose fitting or
passive appliances which harness the natural forces
of the orofacial musculature that are transmitted to
the teeth and alveolar bone through the medium of
appliance'.
Classification of functional appliances:
i. Functional appliances:
Tooth-borne passive appliances (Profitt, 1993)
• They are tooth-borne appliances that have no
intrinsic
. force generating components such as
springs or screws.
• They depend on the soft tissue stretch and
muscular activity to produce the desired
treatment results.
For example: Andresen/Haupl activator, Woodside
activator, Balter's bionator and Herbst appliance
Tooth-borne active appliances:
• They include modifications of activator and
bionator.
• These include expansion screws or other active
components like springs to provide intrinsic
force for transverse or anteroposterior
changes.
For example: elastic open activator (EOP), modified
bionator, stock fish appliance
Tissue-borne passive appliances:
• Tissue-borne appliances are usually located in
the vestibule and have little or no contact with
the dentition.
For example: oral screen and lip bumpers
Tissue-borne active appliances:
For example: Frankel appliance
Other classification:
ii. Myotonic appliances:
• They are functional appliances that depend on
the muscle mass for their action.
For example: Andresen appliance, Woodside
activator
Myodynamicappliances:
the muscle activity for their function. EOP,
modified bionator and Bimler.
iii. Removable functional appliances:
They are myofunctional appliances that can be
removed and inserted into the mouth by the
patient.
For example: activator, bionator and Frankel'
appliance
• Semifixed functional appliances:
For example: Denholtz, Bass appliance
• Fixed functional appliances:
They are functional appliances that are fitted on
the teeth by the operator and cannot be removed
by the patient at will.
For example: Herbst, Jasper jumper, Saif spring
According to Graber:
• Group I appliances:
They consist of appliances that transmit the muscle
force directly to the teeth for the purpose of
correction of the malocclusion.
For example: oral screen and inclined planes
• Group II appliances:
These appliances reposition the mandible and the
resultant force is transmitted to the teeth and
other structures.
For example: activator and bionator
• Group III appliances:
These appliances also reposition the mandible but
their area of operation is the vestibule, outside
the dental arch.
screen
Frankel appliance:
• Frankel appliances or functional regulators (FR) are
functional appliances introduced by Professor Dr
Rolf Frankel of Germany.
• Functional regulator is also called functional
corrector or vestibular appliance or Frankel
appliance or oral gymnastic appliance or orofacial
orthopaedic appliance.
• Functional regulators are tissue-borne type of
functional appliance. As the name implies,
treatment with this appliance is directed towards
the functional disorders responsible for dental or
skeletal malformations.
Mode of action of Frankel appliance:
The concepts pertaining to the mechanism of action
of functional regulators can be dealt under the
following headings:
i. Vestibular area of operation:
• According to Frankel, malocclusion is a result of
faulty muscle posture and muscle imbalance.
• It prevents the aberrant muscular force from
acting on the teeth with the help of buccal and
lips shields. By removal of the restraining
influence it enables outward development of the
arches.
• The major part of Frankel appliance is confined
to the oral vestibule. The buccal shields and lip
pads hold the labial and buccal musculature
away from the teeth and prevents buccinator
mechanism from acting on the dentition.
• The primary aim of functional regulator is re-
establishment of adequate space condition in the
lower part of the oral functioning space.
• Functional regulator helps in the correction of
faulty muscle posture by acting as oral
gymnastics device.
ii. Exercise device:
• Frankel appliance also acts as exercise device
apart from restricting the faulty muscle posture.
• It stimulates normal function while eliminating
aberrant muscle activity. Hence full time wear of
the appliance is recommended.
iii. Tongue function:
Though Frankel appliance gives more importance
to buccinator mechanism, tongue also plays
significant role in moulding the arches. Tongue
force causes passive expansion of the arches.
iv. Anteroposterior correction:
Stimulation of lateral pterygoid muscle
!
Increased activity of the retrodiscal pad
!
Increased growth of condylar cartilage
Postero-superior
!
deposition of bone in condyle
!
Growth of mandible anteroposteriorly
v. Maxillary restraining effect:

Frankel appliances have a restraining effect on the
maxillary teeth and arch.
vi. Decrowding during eruption:
• Decrowding during eruption is a feature of all the
Frankel appliances.
• The tension created in the soft tissues by vestibular
screen causes outward bending of the thin buccal
plate, thereby facilitating outward drift of the
teeth.
vii. Differential eruption:
• Maxillary molars are prevented from downward
and forward movement by Frankel appliances.
• Establishment of correct sagittal relationship by 1-2
mm is possible due to differential eruption of
lower molars.
viii. Periosteal matrix stimulation:
The tension created in vestibule by buccal shields
and lin narls =lir-its nPrin~tPr1 l null anr] rr111~P~ hnnP
The tension created in vestibule by buccal shields
and lip pads elicits periosteal pull and causes bone
deposition.
Periosteal matrix stimulation causes maxillary arch
expansion and mandibular anterior extension.
Q.5. What is myofunctional appliance? Discuss

bionator.
Ans.
Bionator was developed by Balters in 1950s.
Three types:

• Standard appliance
• Class III appliance
• The open bite appliance
Indications:
i. In class II division 1 with following
features:
• Well-aligned dental arches
• Retruded mandibule
• Not very severe skeletal discrepancy
• Labial tipping of upper incisors
ii. Class III malocclusion where reverse
bionator can be used.
iii. Open bite cases where open bite
bionator can be used.
Standard appliance:
It consists of·
• Slender acrylic body fitted to the lingual aspects of
mandibular arch and part of the maxillary arch.
• Acrylic extends up to the distal of the first
permanent molars. The maxillary plate covers only
the molars and the premolars with anterior region
remaining uncovered. Acrylic extends 2 mm below
the gingival margin.
.--.. Palatal arch

(1. 2 mm diameter)
Wire component arc
Ve tibular wire
.............
(0. 9 mm wire)
• Palatal arch emerges opposite middle of the first

premolar and follows contour of palate following a
curve that reaches distal surface of first permanent
molars. It is kept 1 mm away from the mucosa.
• Vestibular wire (0. 9 mm SS wire) emerges from
acrylic below the contact point between canine and
first premolar. It rises vertically and is bent at right
angles to go distally along the middle of the upper
premolar crowns. Mesial to the molar, a round bend
is made so that the wire runs at the level of lower
papilla up to mandibular canine where it is bent to
reach the upper canines. It forms mirror image on
the opposite side.
• The vestibular wire is kept away from the surface of
incisors by the thickness of a sheet of paper. The
lateral portions of wire are sufficiently away from
the teeth to allow expansion of the arch.
Class III appliance:
• Used in mandibular prognathism.
• Acrylic parts are similar to standard appliances.
Palatal arch is placed in opposite direction, so that
rounded arch is placed anteriorly. Vestibular wire
runs over the lower incisors instead of terminating
at lower canines.
The open bite appliance:
• Used in open bite cases
• The palatal arch and vestibular wires - same as
standard appliance
Maxillary acrylic portion is modified - Even anterior
area is covered.
• Its purpose is to prevent tongue from thrusting
between the teeth as the tongue is responsible in
most cases for the open bite.
Q.6. Enumerate various types of functional

regulators and describe the functional regulator II.
Ans.
{SN Q.4}
• Functional regulators are tissue-borne type of
functional appliance. As the name implies, treatment
with this appliance is directed towards the functional
disorders responsible for dento-skeletal
malformations.
Types of functional regulators:
A. Functional regulator I (FR 1):
This is used for treatment of class I and class
II, division 1 malocclusion.
The FR 1 is divided into the following three
types:
FR 1 a - It is used for class I malocclusion
where there is minor crowding.
It is also used for class I deep bite cases and
delayed development of basal bone and
dental structures.
FRI b - It is used for class II division 1
malocclusion with deep bite and where
overjet does not exceed 5-7 mm.
FR 1 c - It is used for severe class II, division 1
malocclusion in which the overjet is more
than 7 mm.
B. Functional regulator II (FR 2):
This is used for correction of class II division 1
and division 2.
C. Functional regulator III (FR 3):
This is used for treatment of class III
malocclusion due to maxillary deficiency.
D. Functional regulator IV (FR 4):
This is used for treatment of open bite and
bimaxillary protrusion.
E. Functional regulator V (FR 5):
This is a functional regulator that incorporates
headgear. It is indicated in high angle cases and
vertical maxillary excess.
Functional regulator II (FR 2):
Among all of the above Frankel II (FR2) is the most
commonly used appliance and is discussed in
detail below:
• The FR 2 consists of acrylic parts and wire
components.
The acrylic parts include:
a. Buccal shields
b. Lip pads
c. Lower lingual pad
The wire components include:
a. Labial bow
b. Palatal bow
c. Canine loops/extensions
d. Upper lingual wire
e. Lingual crossover wire
f. Support wire for lip pads
g. Lower lingual springs
The acrylic parts are described below:
a. Buccal shields:
• The buccal shields are also called the
vestibular shields.
• It extends as deep into the vestibule as
possible within the confines tissue
attachment and patient comfort.
• These shields stand away from the teeth and
basal alveolar bone and helps in
unrestricted dentoalveolar development. In
addition they also cause periosteal bone
deposition.
• Functions of buccal shield are physiotherapy,
training of cheek muscles to adopt to
functional performance and correction of
spatial disorders.
b. Lip pads/labial pads:
• The lower lip pads are called pelots.
• The lip pads are rhomboid shaped and fit on
labial surface of mandibular alveolar
process.
• The lip pads help in elimination of abnormal
perioral muscle activity, i.e. hyperactive
mentalis muscle activity.
• Lower lip pads help in eliminating lower lip
trap which causes or accentuates the
proclination of upper incisors.
• Function: physiotherapy as well as forced
training to prevent hyperactive mentalis
from raising the lower lip.
c. Lingual shield/pad:
• Lingual shied is situated or placed below the
gingival margin of the mandibular teeth and
extends up to the distal surface of the second
premolar.
• It is positioned in place by the two connecting
wires to the buccal shield.
• Functions: Forced training in mandibular
retrusion cases to keep mandible in
advanced position by supporting action of
lingual and labial shields. It also stimulates
protractor muscles of mandible by activating
proprioceptors.
The wire components are described as follows:
a. Labial bow:
• The maxillary labial bow originates from the
vestibular shields and runs in the middle
3rd of the labial surface of the maxillary
incisors. It runs gingivally at right angles
between lateral incisor and canine.
• It forms a gentle curve distally at the height
of middle of canine root and re-embedded in
buccal shield.
• The labial bow should be bent in an ideal
contour and it should be passive in nature.
b. Palatal bow:
• Has a slight curve in a distal direction and
stands clear of the palatal tissues
• Crosses the palate and runs interdentally
between the maxillary first molar and
second premolar or deciduous second molar
and enters the acrylic buccal shield
• Makes a loop into the buccal shield and
emerges to form an occlusal rest in molar
• Makes a loop into the buccal shield and
emerges to form an occlusal rest in molar
between the mesiobuccal and distobuccal
cusps
• Provides maxillary anchorage and stabilizing
action
c. Canine loops:
• The canine loops are also called canine
guards.
• They start with its tags in buccal shield and
runs palatally to the lingual surface of the
canine for a distance of about 1 mm, then

crosses the interproximal contact between
canine and lateral incisor.
• They are kept 2-3 mm way from the buccal
surface of the canines.
• They help in keeping the perioral activity
away. from canine
. and. thereby
. help in
passive expansion in canine area.
d. Upper lingual wire or lingual stabilizing
bow:
• This wire is also called upper lingual wire or
protrusion bow.
• An upper palatal protrusion bow is present
behind upper incisors. This wire prevents
the lingual tipping of the incisors during
treatment.
• It originates from the vestibular shields and
passes between the upper canines and first
deciduous molars and curves along the
lingual surface of the upper incisors at the
level of the cingulum.
e. Lingual crossover wire:
• It is made of 1. 25 mm stainless steel wire
that connects the lingual shield with buccal
shields.
• It runs 3-4 mm below the lingual gingival
margin and follows the contour of the
lingual mucosa.
• It is placed 1-2 mm away from the mucosa.
• It runs between the mandibular first and
second premolars.
f. Support wire for lip pads:
• Labial support wire is made of o. 9 mm wire.
It serves as the skeleton and offers support
for the lip pad.
• This wire should be placed at least 7 mm
below the gingival margin. The central wire
is inverted 'V' shaped to accommodate the
lower labial frenum. Another wire emerges
from the lip pad and gets embedded in the
buccal shields.
• Lower labial wires or vestibular wires are the
connecting wires between the labial pad and
the buccal shield.
g. Lower lingual springs:
• These recurved springs are embodied in the
lingual pad. They are two in number rest
against the lingual surface of the lower
anteriors.
• The main uses of the lingual springs are as
follows:
i. Prevent supraeruption of the lower
. .
incisors
ii. .Screen
.
the tongue pressure from lower
incisor.
iii. For proclining the lower incisors actively
iv. Cause bite opening by relative intrusion
Q. 7. What are the functional appliances? Give

examples. Discuss any one appliance in detail?
Ans.
[Same as LE Q.1]
Q.8. What are myofunctional appliances? Classify

them. Explain activator in detail?
Ans.
[Same as LE Q.1]
Q.9. What are functional appliances? Give examples.

Describe the trimming and mechanism of action of
Anderson appliance?
Ans.
[Same as LE Q.1]
Q.10. Enumerate the uses of oral screen. How will

you fabricate an oral screen?
Ans.
[Same as LE Q.2]
Q.11. Define a functional appliance. What are the

indications, mode of action of FR II appliances?
Ans.
[Same as LE Q.4]
•
Q.12. Discuss about various types of Frankel
functional regulators.
Ans.
[Same as LE Q.6]
Q.13. Name the components of FR-2 (Frankie 2)

appliances and describe their action?
Ans.
[Same as LE Q.6]
Short essays:
Q.1. Catalan's appliances.

Ans.
• Catalan's appliance is also called 'lower anterior
inclined plane'.
• It is used to treat maxillary teeth in crossbite and is
constructed on the lower anterior teeth.
• It can be made of acrylic or cast metal and can be
designed to treat single tooth or a segment of the
upper arch in crossbite.
• The inclined plane is designed to have a 45°
angulation which forces the maxillary teeth in
crossbite to a more labial position.
Indications:
• Crossbite cases with adequate space in the arch for
the alignment of the maxillary teeth
• Cases where the crossbite is due to a palatally
placed maxillary incisors
Disadvantages:
• Speech problems during therapy.
• Patient has to follow certain dietary restrictions.
• Use of the appliance for more than 6 weeks can
result in anterior open bite due to supra-eruption
of the posteriors.
• The appliance may need frequent recementation.
Q.2.Jasper jumper.
Ans.
Jasper jumper is a flexible fixed tooth-borne functional
appliance introduced by J.J. Jasper in 1980.
Appliance design:
i. The appliance uses a modular system commonly
known as Jasper jumper, which can be attached
to fixed appliances that are placed on the U/L
arches.
ii. Jasper jumper is constructed of stainless steel
coil that is attached at both ends to SS end caps.
The module is given an opaque polyurethane
covering for purpose of hygiene and comfort.
The end caps are attached to fixed appliance at
the maxillary posterior and mandibular
anterior region.
iii. The force module is attached posteriorly to
maxillary arch by a ball pin that passes through
the facebow tube of the maxillary first molar.
Anteriorly the module is anchored to the lower
arch wire distal to the mandibular canine by a
small bayonet bend and lexan bead.
iv. The Jasper modules are available in seven sizes
ranging from 26 mm to 38 mm in length.
Indications:
• Basically indicated in class II malocclusion with
maxillary excess and mandibular deficiency
Mechanism of action:
• Selection of force module is by measuring the
distance between mesial aspect of upper
facebow tube and distal aspect of the lexan ball
distal to mandibular canine. Add 12 mm to this
length to get the required length of the force
module.
• When the teeth come into occlusion, the force
module being longer tends to curve, thereby
producing a mesial force on the mandibular
arch and a distal force on the maxillary arch.
Effects ofJasper jumper:
It brings about both skeletal and dentoalveolar
changes in the ratio of 40:60.
a. Skeletal effects:
• Holds and displaces the maxilla distally with
a small shift of point A distally
• Clockwise rotation of mandible
• Forward movement of condyles
Dental changes:
• Posterior tipping and intrusion of upper molar
and palatal tipping of maxillary incisors
• Anterior translation and tipping of mandibular
teeth and intrusion of mandibular incisors
Advantages:
• Produces continuous forces.
• Compared to Herbst appliance, it allows greater
degree of mandibular freedom.
• It is easier to maintain better oral hygiene.
Q.3. Write briefly on upper anterior bite plane.

Ans.
• Bite plane is the simplest form of functional
appliance. It is nothing but extension of base plate
which serves various functions apart from forming
the framework of the appliance.
• Upper anterior bite plane consists of acrylic platform
parallel to the occlusal plane which is present behind
the upper incisor teeth on which the lower incisors
bite.
Mechanism of action
• Anterior bite plane causes differential eruption of
posterior teeth and they also cause relative
intrusion.
• When appliance is worn the posterior teeth are
r , ,... . • . • , , • , .,
freed from mastication and occlusion and they
supraerupt causing reduction of deep overbite,
otherwise known as 'opening the bite'.
• The bite opening should not interfere with normal
freeway space and posterior teeth should be
maintained at 2-3 mm separation.
• Anterior bite planes are more successful in patients
with large interocclusal clearance.
Bite plane with labial bow:
• Labial proclination of upper incisors is the
important side effect of anterior bite plane which

can be minimized by placing a labial bow.
• The labial bow should not be activated for
retraction with bite planes.
Sved bite plane:
• Modification of bite plane by extending the acrylic
plate over to cover incisal edges of upper anterior
teeth is known as Sved bite plane.
• This eliminates forwarded component of force
which causes proclination.
• Using Sved bite plane is another method to prevent
labial proclination of upper incisors.
Q.4. Activator.
Ans.
• It is developed by Andresen and Haupl.
• Activator is called so because the wearing of this loose
fitting appliance activates the muscles.
Advantages:
• It uses existing growth of the jaws.
• Minimal oral hygiene problems during treatment.
• Long intervals between appointments.
• Need minimal adjustments hence require short
appointment.
• Tissues are not injured.
• Appliance is worn at night time only and helps to
eliminate abnormal habits.
• More economical.
Disadvantages:
• Good patient cooperation is required during
treatment.
• Post-treatment fixed orthodontic therapy may be
needed for detailing of the occlusion, as activator
cannot produce a precise detailing and finishing of
the occlusion.
• Activators are not used in cases of excessive lower
face height because they may produce moderate
mandibular rotation anteriorly and downwards.
• It is bulky and uncomfortable.
• Little value in cases with crowding and very little or
no response in older patients.
Q.5. Oral screen and their indications.

Ans.
• Vestibular screen or oral screen was first introduced
by 'Newel' in 1912.
• Oral screen or vestibular screen is a simple functional
appliance that takes the form of a curved shield of
acrylic placed in the labial vestibule.
• It is a functional appliance because it has no active
elements designed to produce force. It produces its
effect by redirecting the pressure of the muscles and
soft tissues like lips and cheek.
Principle:
• Vestibular screen works on the principle of both
force application and force elimination.
• The vestibular screen can be used either to apply
the forces of the circumoral musculature to certain
teeth or to relieve those forces from the teeth
thereby allowing them to move due to forces
exerted by the tongue.
Indications/uses:
• Used mostly to intercept mouth breathing habit and
can also be used to intercept other habits like
thumb sucking, tongue thrusting, lip biting and
cheek biting.
• Used for correction of mild distocclusions and mild
anterior proclination.
• Used to perform muscle exercises that help in
correction of hypotonic lip and check muscles.
• Correction of flaccid hypotonic orofacial
musculature.
• Used as both active and passive appliances.
• Counteract deficiencies in lip posture and function.
Q.6. Twin block appliance.

Ans.
• Twin block appliance was introduced by William
Clark.
• It is a highly successful and most popular appliance
which effectively combines inclined planes with
intermaxillary and extraoral traction.
• Appliance design:
It has an acrylic part and wire components.
a. The acrylic part consists of (i) lower block
and (ii) upper block.
b. Wire components include (i) clasps, (ii)
labial bow and (ill) construction bite.
• The appliance consists of upper and lower plates
having simple bite blocks that modify the occlusal
inclined plane efficiently.
• Twin block has two separate pieces of appliance and
it permits all functional movements and as well
eating and speaking are possible with the appliance.
• Twin block should be worn full time (8-10 h/day).
• They correct the maxilla-mandibular relationship
through the functional displacement.
• Twin block produces rapid functional correction of
malocclusion by guiding the mandible forward into
correct occlusion where the forces of occlusion are
used to correct the malocclusion.
• In severe skeletal discrepancy cases extraoral traction
is used. A concorde facebow is used along with twin
block that combines extraoral traction with
intermaxillary traction.
• A prescribed extraoral traction of 200 g each side for
8-10 h per day and intermaxillary force of 150 g
from lower appliance to facebow can be applied with
twin block.
• Indications:
i. Class I with open bite
ii. Class I with closed bite
ill. Class II division I and division II
iv. Class III
v. Lateral arch constriction and TMJ problems
Q.7. Functional appliances - Classification.

Ans.
• Functional appliances are defined as 'loose fitting or
passive appliances which harness the natural forces
of the orofacial musculature that are transmitted to
the teeth and alveolar bone through the medium of
appliance'.
Classification of functional appliances:
i. Functional appliances:
Tooth-borne passive appliances (Profitt, 1993)
• They are tooth-borne appliances that have no
intrinsic force generating components such as
springs or screws.
• They depend on the soft tissue stretch and
muscular activity to produce the desired
treatment results.
For example: Andresen/Haupl activator,
Woodside activator, Balter's bionator and
Herbst appliance
Tooth-borne active appliances:
• They include modifications of activator and
bionator.
• These include expansion screws or other active
components like springs to provide intrinsic
force for transverse oranteroposterior
changes.
For example: EOP, modified bionator and stock
fish appliance
Tissue-borne passive appliances:
• Tissue-borne appliances are usually located in
the vestibule and have little or no contact with
the dentition.
For example: oral screen and lip bumpers
Tissue-borne active appliances:
For example: Frankel appliance
Other classification:
ii. Myotonic appliances:
• They are functional appliances that depend
on the muscle mass for their action.
For example: Andresen appliance and Woodside
activator.
Myodynamicappliances:
the muscle activity for their function. EOP,
modified bionator and Bimler.
iii. Removable functional appliances:
They are myofunctional appliances that can be
removed and inserted into the mouth by the
patient.
For example: activator, bionator and Frankel
appliance
• Semifixed functional appliances:
For example: Denholtz and Bass appliance
• Fixed functional appliances:
They are functional appliances that are fitted
on the teeth by the operator and cannot be
removed by the patient at will.
For example:
. Herbst, Jasper jumper and Saif
spring
According to Graber:
• Group I appliances:
They consist of appliances that transmit the
muscle force directly to the teeth for the
purpose of correction of the malocclusion.
For example: oral screen and inclined planes
• Group II appliances:
These appliances reposition the mandible and
the resultant force is transmitted to the teeth
and other structures.
For example: activator and bionator
• Group III appliances:
These appliances also reposition the mandible
but their area of operation is the vestibule,
outside the dental arch.
screen
Q.8. Philosophy of Frankel appliance.

Ans.
Philosophy or mode of action of Frankel appliance:
The concepts pertaining to the philosophy of Frankel
appliance are as follows:
i. Vestibular area of operation:
According to Frankel, this appliance is designed to
prevent the aberrant muscular force from acting
on the teeth with the help of buccal and lip
shields.
• By removal of the restraining influence, it
enables outward development of the arches.
• The primary aim of functional regulator is re-
establishment of adequate space condition in
the lower part of the oral functioning space.
• Functional regulator helps in the correction of
faulty muscle posture by acting as oral
gymnastics device or exercise device.
ii. Tongue function:
Though Frankel appliance gives more
importance to buccinator mechanism,
tongue also plays significant role in
moulding the arches. Tongue force causes
passive expansion of the arches.
iv. Anteroposterior correction:
Stimulation of lateral pterygoid muscle leads
to increased activity of the retrodiscal pad
resulting in increased growth of condylar
cartilage and postero-superior deposition of
bone in condyle resulting in growth of
mandible anteroposteriorly.
v. Maxillary restraining effect:
Frankel appliances have a restraining effect on
the maxillary teeth and arch.
vi. Decrowding during eruption:
• Decrowding during eruption is a feature of all the
Frankel appliances.
• The tension created in the soft tissues by
vestibular screen causes outward bending of the
thin buccal plate, thereby facilitating outward
drift of the teeth.
vii. Differential eruption:
• Maxillary molars are prevented from downward
and forward movement by Frankel appliances.
• Establishment
"" ,.... ------ ..: ...
of..:,_,correct
__ ,
sagittal relationship
...... _,..:.tc .... :_,
by
.... ..: _
• Establishment of correct sagittal relationship by
1-2 mm is possible due to differential eruption
of lower molars.
The tension created in vestibule by buccal
shields and lip pads elicits periosteal pull
and causes bone deposition.
Periosteal matrix stimulation causes maxillary
arch expansion and mandibular anterior
extension.
Q.9. Difference between activator and Frankel

appliance.
Ans.
Differences between activator and functional
regulator are as follows:
Activator Functional regulator

It is a tooth-borne loose It is a tissue-borne appliance
fitting appliance. having firm maxillary
anchorage.
It activates the muscles This appliance is designed to
hence called the prevent the aberrant muscular
activator. force from acting on the teeth
and dental arches.
Bulk of the appliance is Bulk of the appliance is placed
placed within the outside the dental arches in
dentition. oral vestibule.
Activator has a single Functional regulator has three
acrylic and only one acrylic parts joined by multiple
wire component. wire components.
Worn only during night Worn throughout the day and
time. night.
It does not act as a It acts as oral gymnastics device or
gymnastic/exercise exercise device.
device.
Mandibular Only minimum advancement of
advancement is mandible by 2.5-3 mm is
possible by 6- 7 mm. possible.
It is bulky and Speech not impaired.
uncomfortable.
Speech is not possible
with the appliance in
mouth.
Q.10. Case selection for functional appliance.

Ans.
A wider range of cases are being treated in recent years
using functional appliances.
The factors to be considered in selecting a case for
functional appliance are as follows:
i. Age:
• Only in growing patients the growth modification
therapy using functional appliances is possible.
• According to most authors, the age between 10
years and pubertal growth phase is the optimum
time for myofunctional therapy.
ii. Social consideration:
• Unfortunately all cases cannot be treated with
functional appliance alone. Patients who live far
away from the clinic or those attending boarding
school may benefit from this appliance provided
they fulfil all other criteria for case selection.
iii. Dental consideration:
• A case that is devoid of gross local irregularities of
teeth like rotation and crowding is considered as
an ideal case for functional appliance therapy.
• A malocclusion can be treated satisfactorily by
functional appliance alone only in uncrowded
cases.
iv. Skeletal consideration:
• A case with moderate-to-severe class II
malocclusion is ideally suited for functional
appliance treatment.
• Mild class III occlusion which presents a reverse
overjet and an average overbite can be regarded as
potentially treatable with functional appliances.
• Low angle cases, i.e. horizontal growers respond
well and the high angle cases with deep overbite
are successfully treated using functional appliance
while the open bite type of cases pose a special
problem.
Q.11. Catalan's appliance. Mention disadvantages of

this appliance.
Ans.
[Same as SE Q.1]
Q.12. Anderson activator.

Ans.
[Same as SE Q.4]
Short notes:
Q.1. Oral screen - uses.

Ans.
[Ref LE Q.2]
Q.2. Lip bumper.

Ans.
• The lip bumper or lip plumper is a functional
component that is used along with lower and upper
fixed appliance.
• Types of lip bumpers:
a. Based on their ability to be removed:
i. Combined fixed removable
ii. Component of fixed appliance
b. Based on arch used:
i. Maxillary lip bumper or Denholtz
appliance
ii. Mandibular lip bumper
• Mechanism of action:
The lip bumper prevents hyperactivity of mentalis
muscles and abnormal force acting on the incisors.
• Uses:
i. Correction of lip trap
ii. Uprighting molars and as anchorage savers
iii. Distalization of molars and reduction overjet
by proclination of mandibular incisors
Q.3. Components of FR II appliances.

Ans.
Functional regulator II (FR 2):
Among all of the above Frankel II (FR2) is the most
commonly used appliance.
• The FR 2 consists of acrylic parts and wire
components as follows:
The acrylic parts include:
a. Buccal shields
b. Lip pads
c. Lower lingual pad
The wire components include:
a. Labial bow
b. Palatal bow
c. Canine loops/extensions
d. Upper lingual wire
e. Lingual crossover wire
f. Support wire for lip pads
g. Lower lingual springs
Q.4. Types of Frankel appliance.

Ans.
[Ref LE Q.6]
Q.5. Bionator appliance.

Ans.
• Bionator appliance was developed by Balters in
1950s.
• Three types of bionator:
i. Standard appliance
ii. Class III appliance
iii. The open bite appliance
Indications:
i. In class II division 1 malocclusion with
well-aligned dental arches, retruded
mandible with not very severe skeletal
discrepancy
ii. Class III malocclusion where reverse
bionator can be used
iii. Open bite cases where open bite
bionator can be used
Q.6. Activator.
Ans.
• Indications:
i. Cases of class I malocclusion with open bite or
deep bite
ii. Class II division 1 and division 2 malocclusion
iii. Class III malocclusion
iv. Phase I treatment before fixed appliance
treatment in children with lack of vertical
development in lower facial height
v. As a retention appliance and as well as habit
breaking appliance
vi. Used in obstructive sleep apnoea
Q. 7. Catalan's appliance.
Ans.
• Catalan's appliance is also called lower anterior
inclined plane.
• It is constructed on the lower anterior teeth can be
used to treat maxillary teeth in crossbite.
• The inclined plane can be made of acrylic or cast
metal and can be designed to treat single tooth in
crossbite or a segment of the upper arch in crossbite.
Q.8. Define and classify myofunctional appliances.

Ans.
Myofunctional appliances are defined as loose fitting or
passive appliances which harness natural forces of the
orofacial musculature that are transmitted to the teeth
and alveolar bone through the medium of the appliance.
Myofunctional appliances can be classified
in a number of ways as follows: I
II. Myotonic appliances
- .,,..., ,.
Group II appliances
Q.9. Upper anterior bite plane - Mechanism of

action.
Ans.
• Bite plane is the simplest form of functional
appliance.

• Upper anterior bite plane consists of acrylic platform
parallel to the occlusal plane which is present behind
the upper incisor teeth on which the lower incisors
bite.
Mechanism of action
• Anterior bite plane causes differential eruption of
posterior teeth and they also cause relative
intrusion.
freed from mastication and occlusion and they
supraerupt causing reduction of deep overbite,
otherwise known as 'opening the bite'.
• The bite opening should not interfere with normal
freeway space and posterior teeth should be
maintained at 2-3 mm separation.
• Anterior bite planes are more successful in patients
with large interocclusal clearance.
Q.10. Sved bite plane.

Ans.
• Modification of upper anterior bite plane by
extending the acrylic plate over to cover incisal
edges of upper anterior teeth is known as Sved bite
plane.
• This eliminates forwarded component of force which
causes proclination.
• Using Sved bite plane is another method to prevent
labial proclination of upper incisors.
Q.11. Advantages of Jasper jumper.

Ans.
• Jasper jumper is a flexible fixed tooth-borne
functional appliance introduced by J.J. Jasper in
1980.
• Basically indicated in class II malocclusion with
maxillary excess and mandibular deficiency.
It brings about both skeletal and dentoalveolar
changes in the ratio of 40:60.
• Advantages:
i. It produces continuous forces.
ii. Compared to Herbst appliance, it allows greater
degree of mandibular freedom.
iii. It is easier to maintain better oral hygiene.
Q.12. Fixed functional appliances - classification and

advantages.
Ans.
Emil Herbst introduced the concept of fixed functional
appliances.
• They are classified as follows:
A. Flexible fixed functional appliances
For example: Jasper jumper, Amoric torsion coils,
Bite fixer
B. Rigid fixed functional appliances
For example: Herbst appliance, FORSUS (Fatigue-
resistant device) and Ritto appliance
• Advantages:
i. It is designed to wear 24 h continuously
and thereby reducing need for patient
cooperation.
ii. Over all treatment time and efforts are
reduced.
iii. Smaller in size and is better adapted to
functions like mastication, swallowing
and speech
iv. As appliance cannot be removed by the
patient, it allows greater control by
orthodontist.
Q.13. Action of functional appliances.

Ans.
• Functional appliances are defined as loose fitting or
passive appliances which harness natural forces of
the orofacial musculature that are transmitted to the
teeth and alveolar bone through the medium of the
appliance.
• These appliances either transmit, eliminate or guide
the natural forces of the musculature and are used
for growth modification procedures that are aimed
at intercepting and treating jaw discrepancies.
Mode of action offunctional appliances:
Functional appliances are capable of producing the
following changes:
i. Orthopaedic changes
ii. Dentoalveolar changes
iii. Muscular changes
Q.14. Mode of action of activator.

Ans.
Mode of action of activator is as follows:
There are different views and mechanisms by which
activator works.
a. First view:
• According to Andersen and Haupl, the activator
closure, which generates kinetic energy
resulting in prevention of further forward
growth of the maxillary dentoalveolar process
and a reciprocal forward force on the
mandible.
• In addition to this myotactic reflex, a condylar
adaptation by backward and upward growth
occurs.
• A third factor is the force generated while
swallowing and during sleeping.
b. Second view:
• According to Harvold, Woodside and Herren,
passive tension caused by stretching muscles,
soft tissue, tendinous tissue, etc., is responsible
for the action, which is known as the
viscoelastic property.
c. Combination of kinetic and potential energy.
d. Differential eruption of teeth.
Q.15. Indications of twin block.

Ans.
• Twin block appliance was introduced by William
Clark.
• It is a highly successful and most popular appliance
which effectively combines inclined planes with
intermaxillary and extraoral traction.
• Indications:
i. Class I with open bite
ii. Class I with closed bite
iii. Class II division 1 and division 2
iv. Class III
v. Lateral arch constriction and TMJ problems
Q.16. Contraindications of activator.

Ans.
[Ref LE Q.1]
Q.17. Denholtz appliance.

Ans.
• Denholtz appliance is another name for maxillary lip
bumper.
• Mechanism of action:
The lip bumper prevents hyperactivity of mentalis
muscles and abnormal force acting on the incisors.
• Uses:
i. Correction of lip trap
ii. Uprighting molars and as anchorage savers
iii. Distalization of molars and reduction overjet
by proclination of mandibular incisors
Q.18. Orthopaedic force in orthodontics.

Ans.
• The forces employed in orthodontic practice are
basically of two types:
i. Orthodontic force
ii. Orthopaedic force
• Orthopaedic force is that which affects the deeper
craniofacial structures.
• The orthopaedic forces are heavy forces of over 400 g
that bring about a change in the skeletal tissue.
• Thus the orthopaedic appliances utilize the teeth as
handles to transmit the forces to the adjacent skeletal
structures.
• Amount of orthopaedic force:
Heavy forces of over 400 g totally compress the
periodontal ligament on the pressure side and
cause hyalinization which prevents tooth
movement. These heavy forces are conducted to
the skeletal structures to produce an orthopaedic
effect.
• Duration of force:
Intermittent forces ranging from 12 to14 ha day are
believed to bring about minimum tooth movement
but maximum skeletal change. Thus most extraoral
orthopaedic appliances are worn 12-14 ha day.
• The commonly used orthopaedic appliances are
headgear, face mask and chin cup.
Q.19. Chin cap.

Ans.
• Chin cap or chin cup is an extraoral orthopaedic
device which exerts upward and backward force on
mandible by applying pressure to chin and thereby
preventing its forward growth.
Indications:
• Skeletal class III cases due to mandibular
prognathism.
• Increased anterior facial height.
• Anterior open bite.
• It is used to restrict forward and downward growth
of the mandible.
Types:
• They are of two types: (i) occipital pull chin cup and
(ii) vertical pull chin cup.
i. Occipital pull chin cup:
• Most commonly used type and it derives
anchorage from occipital region of head.
• Used in cases of class III malocclusion with
mild-to-moderate prognathism.
ii. Vertical pull chin cup:
• It is used to correct anterior open bite cases.
Force magnitude and duration of wear (biomechanics):
Force at the start of treatment: 150-300 g/side.
After 2 months, force is r to: 450-700 g/side.
Duration to wear appliance to achieve desired
results: 14 ha day with a range of 10-16 h.
Q.20. Extraoral traction.

Ans.
• Extraoral traction is a form of reinforced anchorage
where
.,
in the anchorage units are situated outside the
Q.20. Extraoral traction.
Ans.
• Extraoral traction is a form of reinforced anchorage
where in the anchorage units are situated outside the
mouth.
• It is used to correct skeletal problems.
• Various sites used for extraoral traction are as
follows:
For example:
Occipital region - chin pad and high pull headgear
Back of the neck - cervical headgear
Forehead - reverse pull headgear

Chin - chin cap
Q.21. Describe various types of headgears available

to control the growth of maxilla.
Ans.
• Headgear is an extraoral orthopaedic appliance used
to restrain the downward and forward growth of
maxilla.
• Headgears are classified into three types:
i. High pull or occipital headgear: It exerts
superior and distal force.
ii. Combi pull/straight headgear/medium pull-
distal and slight upward force is exerted.
iii. Cervical or low pull headgear-distal/extrusive
force is exerted on first molars.
• Cervical headgear is also known as Kloehn headgear
and it tends to move upper jaw distally.
Q.22. Orthopaedic appliance - Components.

Ans.
• Orthopaedic appliance is defined as any manipulation
that alters the skeletal system and associated motor
organs.
• Following are the components of orthopaedic
appliance:
a. Facebow - outer bow and inner bow
b. Anchorage source - head strap
c. Force element - high pull or occipital headgear
Combi pull/straight headgear or medium pull
Cervical low pull headgear
Q.23. Effects of face mask.

Ans.
• Face mask or the reverse pull headgear is an
extraoral traction appliance used for correction of
skeletal class III malocclusion. It was popularized by
Delaire in 1960s.
Indications:
i. Correction of class III skeletal malocclusion in
young children due to maxillary retrognathism.
ii. Correction of centric relation and centric
occlusion discrepancy in pseudo-class III
malocclusion.
iii. As a retention device after surgical correction
of skeletal class III malocclusion.
Effects offacemask:
i. Forward movement of maxilla and proclination
of maxillary teeth
ii. Correction of crossbite, both posterior and
anterior
iii. Rotation of the mandible downwards and
backwards
Advantages:
i. It is the only extraoral traction device for
correction of maxillary deficiency with rapid
improvement.
ii. Rapid treatment progress and good patient
compliance.
Q.24. Name the headgears used in orthodontics.

Ans.
Headgear is an extraoral orthopaedic appliance.
Types of headgears:
Based on the site of anchorage, headgears can be
three types:
i. Cervical headgear
ii. Occipital headgear
iii. Combination headgear
Uses of headgear are as follows:
i. Orthopaedic effect:
In the correction of skeletal class II due to
prognathic maxilla in young individuals
ii. Anchorage:
It can be used for reinforcement of anchorage
during fixed orthodontic therapy.
iii. Distalization of maxillary first molars.
iv. Uprighting of molars.
iv. Retention.
v. Space maintenance and regaining.
vi. Overjet reduction.
vii. Intrusion of molars and incisors.
Q.25. High pull headgear.

Ans.
• According to site from which anchorage is gained
headgears are of three types:
a. High pull
b. Medium pull
c. Low pull
• High pull headgears derive anchorage from back
of the head in occipital region or junction of
parietal and occipital regions.
• They produces a distally and superiorly directed
force on maxillary teeth and as well as maxilla.
• When forces exerted on molars it results in
distalization and intrusion of molars.
• It is used in treating high mandibular angle
cases.
Q.26. Enumerate various types of facemasks.

Ans.
• The facemask is an extraoral traction appliance.
• The various types of face masks available are as
follows:
i. Bickham - reverse pull headgrear
ii. Delaire's facemask
iii. Petit's facemask
iv. Tubinger facemask
Q.27. Mention various functional regulators.

Ans.
[Same as SN Q.4]
Q.28. Give indications for activator therapy.

Ans.
[Same as SN Q.6]
Q.29. Face mask therapy - advantages.

Ans.
[Same as SN Q.23]
Q.30. Indications of face mask therapy.

Ans.
[Same as SN Q.23]
Q.31. Headgear - uses.

Ans.
[Same as SN Q.24]
Topic 26 Management of common
malocclusions
Long essays:
1. Describe the causes of midline diastema and
explain how will you correct the same?

2. Discuss features and management of class I
malocclusion.
3. Discuss the causes and treatment of anterior
crowding of teeth.
4. Describe the causes of median diastema and the
measures to correct it? [Same as LE Q.1]
5. Enumerate the aetiologic factors causing crowding
of the teeth. Mention their treatment. [Same as LE
Q.3]
6. A child in the mixed dentition reports to you with
crowding in the lower anterior teeth. Discuss your
line of treatment. [Same as LE Q.3]
Short essays:
1. Management of midline diastema.
2. Clinical features of crowding of anterior teeth.
[Ref LE Q.3]
3. Aetiology of spacing.
4. Aetiology and treatment of midline diastema.
[Same as SE Q.1]
5. Midline diastema. [Same as SE Q.1]
Short notes:
1. Maxillary midline diastema - aetiology. [Ref LE
Q.1]
2. Lower anterior crowding. [Ref LE Q.3]
3. Spacing.
4. Rotation.
5. Imbrications.
6. Abnormal labial frenum.
7. Derotation of teeth.
8. Blanch test.
9. Midline diastema diagnosis and its causes. [Same
as SN Q.1]
10. Aetiology of diastema. [Same as SN Q.1]
11. Causes of crowding. [Same as SN Q.2]
12. Localized spacing. [Same as SN Q.3]
13. Aetiology and treatment of imbrications. [Same
as SN Q.5]
Solved answers
Long essays:
Q.1. Describe the causes of midline diastema and

explain how will you correct the same?
Ans.
{SN Q.1}
• Median or midline diastema is a form of localized
spacing between the two maxillary central incisors.
• It is one of the most frequently seen malocclusions
which is easy to treat but often difficult to retain.
Aetiology:
The midline diastema can be a result of a number
of causes such as:
a. Normal/developmentai:
i. Physiologic median diastema
ii. Ethnic and familial
iii. Imperfect fusion at midline of
pre maxilla
b. Tooth material deficiency:
i. Microdontia, peg laterals and
missing laterals
ii. Macrognathia
iii. Extracted tooth
c. Physical impediment
i. Retained deciduous teeth
ii. Mesiodens, midline pathology, etc.
iii. Enlarged labial frenum
iv. Deep bite
d. Habits
i. Thumb sucking, tongue thrusting,
etc.
ii. Frenum thrusting
e. Other causes
i. RME
ii. Milwaukee braces
a. Normal/developmental:
• Transient malocclusion: Midline diastema is very
often seen as an incipient malocclusion that is self-
correcting.
• A midline spacing can occur during the mixed
dentition period associated with the eruption of
the permanent canines, i.e. the ugly duckling stage.
This condition usually corrects by itself when
canines erupt and the pressure is transferred from
the roots to the coronal area of the incisors.
b. Tooth material-arch length discrepancy:
• A disparity where the arch length exceeds the tooth
material can result in midline diastema in
conditions such as missing teeth, microdontia,
macrognathia and extractions with resultant
drifting of adjacent teeth.
c. Physical impediment:
• Abnormal frenal attachment: The presence of a
thick and fleshy labial frenum gives rise to a
midline diastema. It prevents the two central
incisors from approximating each other due to the
fibrous connective tissue interposed between
them.
d. Habits:
• Abnormal pressure habits like thumb sucking and
tongue thrusting also predispose to midline
diastema.
• These patients generally present with proclination
and generalized anterior spacing.
• Spacing in the midline can be caused by midline
soft tissue and hard tissue pathologies, e.g. cysts,
tumours and odontomes.
• Presence of an unerupted mesiodens between the
roots of the two central incisors also predispose to
midline diastema.
e. Other causes:
• Midline diastemas can occur when certain
therapeutic procedures are undertaken.
For example: The appearance of a midline spacing
is an important prognostic sign during rapid
maxillary expansion and it indicates the opening
of the intermaxillary suture.
• Racial predisposition: The presence of midline
spacing also has a racial and familial background.
The Negroid race shows the greatest incidence of
midline diastema.
Investigations:
i. A proper history and clinical examination
ii. Blanch test
iii. Any pernicious oral habits
iv. Periapical radiograph
v. Model analysis
• A proper history and clinical
examination is necessary to
confirm whether it is localized or
part of generalized spacing.
• A blanch test is performed by
pulling the upper lip outwards, the
blanching of the tissue in the
incisive papilla region palatal to
the two central incisors confirms
the presence of a thick and fleshy
frenum.
• Look for any pernicious oral habits.
• An intraoral periapical radiograph
reveals V-shaped notching present
between the central incisors and as
well they are a valuable aid in
diagnosing midline pathology that
.
causes spacing.
• Tooth material-arch length
discrepancies can be determined
using model analysis.
Treatment of midline diastema:
The treatment of midline diastema consists of
three phases:
a. Identifying and removal of cause
b. Active treatment
c. Retention
a. The first phase (identifying and removal of
cause)
• It involves removal of the aetiology.
• Habits should be eliminated using
fixed or removable habit breaking
appliances.
• Unerupted mesiodens should be
extracted.
• Frenectomy should be perf armed.
• Any midline pathology should be
treated as indicated.
b. The second phase (active treatment)
It consists of active treatment using removable or
fixed appliances.
i. Removable appliances:
• Simple removable appliances
incorporating finger springs or a
split labial bow can be used to
close a midline spacing.
• Finger springs can be given distal to
the two central incisors. An
alternative would be to use a split
labial bow. The labial bows are
made to extend up to the distal
aspect
. .
of the opposite central
incisor.
ii. Fixed appliances:
• Fixed appliances incorporating
elastics or springs bring about the
most rapid correction of midline
diastema.
• Elastics can be stretched between
the two central incisors in order to
close the space. Elastic thread or
elastic chain can be used between
the two central incisors for the
same purpose. An alternative is to
stretch a closed coil spring
between the two central incisors.
'M' shaped springs incorporating
three helices can be inserted into
the two central incisor brackets.
This spring is activated by closing
the helices.
c. The third phase (retention)
• This phase of treatment involves retaining
c. The third phase (retention)
• This phase of treatment involves retaining
the treated malocclusion.
• Midline diastema is often considered easy to
treat but difficult to retain.
• The key to its successful management is the
elimination of the aetiologic factors involved
and long-term retention using suitable
retainers. Since prolonged retention is
indicated, it is advisable to use lingual
bonded retainers. The other retainers that
can be used include banded retainers,

Hawley's retainer, etc.
Other methods of treatment:
i. Role of cosmetic restorations:
Aesthetic composite resins are generally
used to close very small midline diastema
especially in adult patients.
ii. Prosthetic management:
If the diastema is big, closure by light-cure
composite will be unaesthetic. In these
cases, if the arch is well-aligned closure by
giving an implant or bridge is suggested.
iii. Surgical management:
Surgery is done in some cases where there is
a median diastema in otherwise normal
occlusion
iv. Prosthesis/crown:
Presence of peg shaped laterals or teeth with
other anomalies of shape and size require
prosthetic rehabilitation. Missing teeth
should be replaced with fixed or
removable prosthesis.
v. Physiologic median diastema that occurs
during ugly duckling stage of eruption is a
self-correcting condition that requires no
treatment.
Q.2. Discuss features and management of class I

malocclusion.
Ans.
Class I malocclusion is characterized by the mesiobuccal
cusp of maxillary first permanent molar occluding with
mesiobuccal groove of mandibular first permanent
molar and presence of normal interarch molar relation.
Angle's class I malocclusion (neutro-occlusion):
Molar relation:
The mesiobuccal cusp of the upper first molar
occludes with the mesiobuccal groove of the
lower first molar.
Canine relation:
The mesial incline of the upper canine occludes
with the distal incline of the lower canine
whereas the distal incline of the upper canine
occludes with mesial incline of lower first
premolar.
Class I bimaxillary protrusion:
i. Class I bimaxillary malocclusion is a
condition where both the key of occlusion
and line of occlusion are not altered.
ii. The upper and lower anteriors are
proclined and exist usually in an edge-
edge relationship.
Features of class I malocclusion are as follows:
Extraoral:
i. Straight profile
ii. Competent/incompetent lips
iii. Normal/shallow/deep mentolabial sulcus
Intraoral:
Spacing and crowding
i. Spacing of teeth
ii. Crowding of teeth
iii. Rotation of teeth
Proclination and retroclination:
i. Proclination of teeth
ii. Retroclination of teeth
Protrusion and retrusion
i. Bimaxillary protrusion
ii. Bimaxillary retrusion
Deep bite, open bite and crossbite:
i. De p bite
Anterior
Po t rior
Lateral
Anteri r
iii. "ro .. bit
Po terior
Management of class I malocclusion with spacing:

• It can be managed by:
i. Removal of the aetiology
ii. Orthodontic treatment
iii. Combined orthodontic and
prosthodontic treatment
i. Removal of the aetiology:
The aetiologic cause for the spacing should
be diagnosed and eliminated.
For example:
• Spacing resulting from abnormal
pressure habits can be treated by
using habit breaking appliances.
• Surgical removal of cystic lesions is
indicted in cases of bony
pathology.
ii. Orthodontic appliances:
a. Active removable appliances
incorporating labial bows can be
used to close the space that occurs
in conjugation with proclination.
b. Fixed appliances along with elastic
chains or elastic threads are most
effective
. in closure of generalized
spacing.
c. Peg laterals or small teeth results in
spacing between the rest of the
teeth due to drifting. In such cases,
the space for the lateral incisor can
be regained by using a removable
appliance incorporating finger
spring or fixed appliances
incorporating an open coil spring.
iii. Prosthetic treatment:
a. The space regained in cases of peg
laterals can be used for a
prosthetic
. . crown on the lateral
incisor.
b. In cases of absence of maxillary
lateral incisors, they can be
replaced by a fixed or removable
partial prosthesis.
Management of class I malocclusion with
crowding:
Crowding is a common manifestation of class I
malocclusion which usually occurs due to tooth
material and arch length discrepancy.
Various methods of treating crowding are as follows:
a. Gaining space:
i. Normal alignment of crowded teeth
require space. On an average for
every 1 mm of crowding, an equal
amount of space is required for
correction.
ii. The various methods of gaining
space include:
• Proximal stripping
• Expansion
• Extraction
• Molar distalization
• Derotation
• Proclination of anterior teeth
b. Orthodontic appliances:
Once the provision for space is made,
teeth can be moved to normal
position using removable
appliances incorporating coil
springs, canine retractors, labial
bows, etc.
Fixed appliances with multilooped
arch wires or resilient nickel-
titanium wires are most effective
in correction of crowding.
The cases of mild crowding:
• Teeth can be aligned with
removable orthodontic appliances
incorporating labial bow and
springs such as Z-spring, T-spring
and flapper springs after gaining
space using expansion/proximal
stripping.
In case of moderate crowding
• Teeth can be aligned using
removable or fixed appliances
after gaining the space.
• Fixed appliances make use of
multilooped arch wires or resilient
nickel-titanium wires which are
very effective in correction of
crowding.
In case of severe crowding:
• In cases with sever crowding, the
extraction of premolars are
indicated to gain the space.
• Following space gaining, the stages
of treatment are as follows:
Stage I - retraction of canines using canine
retractor
Stage II - alignment of anterior teeth using
suitable labial bow
Stage III - retraction of the teeth using a
retention appliances like Hawley's
retainer
Management of class I malocclusion with
rotations:
• Rotated anterior teeth occupy less space hence
requires additional space for their derotation.
• Mild rotation of teeth can be corrected by using
removable appliances by creating couple forces
with the help of double cantilever spring CZ-spring)
and a labial bow.
• When multiple rotations are present, fixed
appliances are required to treat the case.
• When multiple rotations are present, fixed
appliances are required to treat the case.
• Derotation can be brought about by the use of
derotation springs/elastics.
Q.3. Discuss the causes and treatment of anterior

crowding of teeth.
Ans.
Crowding is a common condition in class I
malocclusion, where there is malalignment of teeth
caused by inadequate space.
Classification of crowding:

There are different methods of classification of
crowding.
B C
+D
Heredi·
! r-1-i rh
Environ· Prim· Second· Tertiary Simple Complex 1 ° 2° 3°
tary mental ary ary
• Primary crowding is determined genetically and is

caused by disproportionately sized teeth and jaws.
• Secondary crowding/acquired crowding is caused by
loss of arch length due to environmental cause.
• Tertiary crowding also called late incisor crowding is
due to late mandibular growth.
• Simple crowding is due to disharmony between the
size of the teeth and the space available for them
without skeletal, muscular or functional occlusal
problems.
• Complex crowding is caused and associated with
skeletal, muscular and functional occlusal problems.
• Crowding in mixed dentition is of three degrees:
i. First-degree crowding is due to slight
malalignment of the anterior teeth. No
abnormality in supporting zone.
ii. Second-degree crowding is pronounced
malalignment of anterior teeth. No abnormality
in supporting zone.
iii. Third-degree crowding is severe malalignment
of all four incisors.
Aetiology of crowding:
{SN Q.2}
Some of the common causes of crowding are as
follows:
i. Tooth material-arch length discrepancy is the
common reason for hereditary crowding.
Increased tooth material and decreased arch
length usually leads to crowding.
ii. Presence of supernumerary or extra teeth can
result in crowded arrangement of teeth.
iii. Prolonged retention of deciduous teeth.
iv. Discrepancy in individual tooth size and shape
like abnormally large teeth can predispose to
crowding.
v. Abnormal eruption path and altered eruption
sequence.
vi. Rotation and transposition of tooth.
vii. Ankylosed primary tooth.
viii. Premature loss of deciduous tooth results in
drifting of adjacent teeth into extraction space
predisposing to crowding.
ix. Prolonged retention of primary tooth.
[SE Q.2]
{Clinical features of class I crowding
The signs of crowding with class I molar relation are
as follows:
• Crowded mandibular incisor teeth
• Premature exfoliation of deciduous canines on
the crowded side due to displacement of
erupting tooth
• Reduced Leeway space
• Splaying out of maxillary permanent lateral
incisors and gingival recession on the labial
surface of prominent mandibular incisors
• Bulging of canines in the unerupted position
• If no treatment is given, impaction of second
permanent molar
• Vertical palisading of the permanent maxillary
first, second and third molars}
Diagnosis:
• Clinical examination:
Carried out to determine extent and location of
crowding.
• Model analysis:
Mixed dentition model analysis like Moyer's
analysis is carried out to find out the arch
length discrepancy.
Management of crowding:
A. Management of crowding in mixed
dentition is as follows:
Age - after eruption of 12 12
i. Slight crowding:
In case of slight changes in the position of
anterior teeth, just wait and watch, no
treatment is required.
ii. Moderate crowding:
Lack of space by width of one lateral incisor, can
wait till the eruption of premolars and at a
later date expansion and guidance of eruption
is the treatment required.
Minimal or moderate crowding can be
corrected by passive expansion achieved
with functional regulator and vestibular
appliance.
iii. Pronounced crowding:
• Immediate treatment is required.
• It can be treated with expansion, guidance
of eruption, serial extraction and
extraction followed by orthodontic
treatment.
Management of crowding in young adults:
Investigations:
• Arch length analysis for permanent dentition,
e.g. Carey's analysis should be carried out.
• Complete Kesling's diagnostic set-up should be
carried out.
• Treatment can be either by nonextraction or
extraction.
Treatment:
a. Nonextraction method of treatment:
• Indicated in cases with mild discrepancy.
• Proximal reduction and treatment with
either removable or fixed appliances.
• Lip bumpers are useful in increasing the arch
length.
• In cases of minor crowding arch expansion
procedures and molar distalization are other
methods to gain space.
b. Extraction method of treatment:
• Treatment planning includes the choice of
extraction. Following extraction, treatment
is done with preferably fixed appliance
mechanotherapy.
• If there is any unerupted tooth, it has to be
brought into occlusion.
Q.4. Describe the causes of median diastema and the

measures to correct it?
Ans.
[Same as LE Q.1]
Q.5. Enumerate the aetiologic factors causing

crowding of the teeth. Mention their treatment.
Ans.
[Same as LE Q.3]
Q.6. A child in the mixed dentition reports to you

with crowding in the lower anterior teeth. Discuss
your line of treatment.
Ans.
[Same as LE Q.3]
Short essays:
Q.1. Management of midline diastema.

Ans.
The treatment of midline diastema consists of three
phases:
a. Phase I - identifying and removal of cause
b. Phase II - active treatment
c. Phase III - retention
a. The first phase (identifying and removal of cause)
• It involves removal of the aetiologic cause of
midline diastema.
For example: Habits should be eliminated,
extraction of unerupted mesiodens, frenectomy,
surgical treatment of midline pathology if any.
b. The second phase (active treatment)
It consists of active treatment using removable or
fixed appliances.
• Simple removable appliances incorporating
finger springs or a split labial bow can be used
to close a midline spacing.
• Fixed appliances incorporating elastics or
springs bring about the most rapid correction
of midline diastema.
For example: Elastics can be stretched
between the two central incisors in order to
close the space 'M' shaped springs
incorporating three helices can be inserted
into the two central incisor brackets. This
spring is activated by closing the helices.
c. The third phase(retention)
• This phase of treatment involves retaining the
treated malocclusion.
The key to its successful management is the
elimination of the aetiologic factors and long-
term retention using suitable retainers. For
example: lingual bonded retainers, banded
retainers, Hawley's retainer.
Other methods of treatment:
i. Cosmetic restorations: Generally used to
close very small midline diastema.
ii. Prosthetic management: If the diastema
is big and the arch is well aligned.
Presence of peg-shaped laterals or teeth
with other anomalies of shape and size
require prosthetic rehabilitation.
iii. Surgical management.
iv. Physiologic median diastema that occurs
during ugly duckling stage of eruption is a
self-correcting condition that requires no
treatment.
Q.2. Clinical features of crowding of anterior teeth.

Ans.
[Ref LE Q.3]
Q.3. Aetiology of spacing.

Ans.
Spacing is of two types:
A. Localized spacing
R. !!en era lized snacins
Q.3. Aetiology of spacing.
Ans.
Spacing is of two types:
A. Localized spacing
B. generalized spacing
Localized spacing:
Localized spacing is condition where spacing is
present in localized regions or areas.
Various causes of localized spacing are
• Missing teeth:
Congenitally missing teeth causes localized
spacing but the problem may not be

restricted to one particular spot.
• Unerupted teeth: Impacted or unerupted tooth
causes localized spacing.
• Premature loss of primary teeth: In this situation,
decision has to be made whether to close the
space or maintain the space and replace with an
implant or bridge.
• Prolonged retention of primary teeth: This results
in ectopic eruption of permanent successor, and
when the primary tooth is exfoliated after
ectopic eruption of permanent successor space
results.
Generalized spacing:
The causes of generalized spacing are
• Microdontia: The presence of smaller teeth in the
normal jaws will result in generalized spacing.
• Macrognathia: The bigger size of arch with
normal
. size of teeth results in generalized
spacing.
• Macroglossia: An unduly large tongue causes
generalized spacing.
• Abnormal
. tongue posture also causes generalized
spacing.
• Certain sucking habits may also cause
generalized spacing.
Q.4. Aetiology and treatment of midline diastema.

Ans.
[Same as SE Q.1]
Q.5. Midline diastema.

Ans.
[Same as SE Q.1]
Short notes:
Q.1. Maxillary midline diastema - aetiology.

Ans.
[Ref LE Q.1]
Q.2. Lower anterior crowding.

Ans.
[Ref LE Q.3]
Spacing.
Ans.
• Spacing is defined as imperfections in the teeth
alignment and distance, wherein there is gap
between two teeth or many teeth.
• Presence of spacing between the teeth is the
commonest manifestation of the Class I
malocclusion. Spacing may be generalized or
localized.
• Localized spacing is condition where spacing is
present in localized regions or areas.
Causes of localized spacing are
• Missing teeth:
Congenitally missing teeth causes localized spacing
but the problem may not be restricted to one
particular spot.
• Unerupted teeth: Impacted or unerupted tooth
causes localized spacing.
• Premature loss of primary teeth.
• Prolonged retention of primary teeth results in
ectopic eruption of permanent successor, and
when the primary tooth is exfoliated after ectopic
eruption of permanent successor space results.
Q.4. Rotation.
Ans.
• Rotation can be defined as the spinning of the tooth
around its long axis.
• Types of rotation:
i. Centric rotation - only rotation around the long
axis
ii. Eccentric rotation - rotation with tipping of the
tooth also
• Derotation can be achieved by applying a couple. The
force required for rotation correction is 35-60 g.
• Rotation can be achieved by two ways: By using a
couple force, by using a single force and a stop.
• There is greater tendency for the rotation to relapse
after correction.
Q.5. Imbrications.
Ans.
• Imbrication denotes especially lower incisors
arranged in an irregular manner within the arch due
to lack of space.
• Some of the common causes of imbrications are as
follows:
i. Tooth material-arch length discrepancy
ii. Presence of supernumerary teeth
iii. Discrepancy in individual tooth size and shape
iv. Abnormal eruption path
v. Rotation and transposition of tooth
vi. Premature loss of deciduous or prolonged
retention of primary tooth
Q.6. Abnormal labial frenum?

Ans.
• Abnormal frenal attachment is a physical impediment
causing midline diastema.
• The presence of a thick and fleshy labial frenum gives
rise to a midline diastema.
• It prevents the two central incisors from
approximating each other due to the fibrous
connective tissue interposed between them.
• It can be surgically excised to correct midline
diastema.
Q.7. Derotation of teeth.

Ans.
• Derotation of teeth is a method of space gaining in
orthodontics.
• Derotation of posterior teeth occupies more spaces.
By correcting a rotated tooth little amount of space
can be gained.
• Derotation is best achieved with fixed appliances
incorporating springs or elastics using a force couple.
• Few removable appliances can correct rotation of
teeth by creating couple forces with the help of
flapper spring or double cantilever spring CZ-spring)
and a labial bow.
• Fixed appliances are best when multiple rotations are
present. Derotation can be brought about by the use
of derotation springs, elastics, etc.
• Semifixed appliances can also be used for the
correction of rotations.
For example: whip spring and high labial low with
soldered T-spring
Q.8. Blanch test.

Ans.
• The condition of abnormal labial frenum is diagnosed
by a + ve blanch test.
• A blanch test is performed by retracting or pulling the
upper lip outwards, the blanching of the tissue in the
incisive papilla region palatal to the two central
incisors confirms the presence of a thick and fleshy
frenum.
• If the blanching is present then the frenum is
responsible for the midline diastema.
Q.9. Midline diastema diagnosis and its causes.

Ans.
[Same as SN Q.1]
Q.10. Aetiology of diastema.

Ans.
[Same as SN Q.1]
Q.11. Causes of crowding.

Ans.
[Same as SN Q.2]
Q.12. Localized spacing.

Ans.
[Same as SN Q.3]
Q.13. Aetiology and treatment of imbrications.

Ans.
[Same as SN Q.5]
Topic 27 Management of class II
malocclusion
Long essays:
1. Discuss the treatment plan for Angle's class II
malocclusion patients in mixed dentition period?

2. Discuss in brief the aetiology, clinical picture and
treatment of Angle's class II malocclusion?
3. Discuss your treatment of choice of appliance for a
patient aged 8 years, presenting class II division 1
malocclusion with positive VTO? [Same as LE Q.1]
4. A child in a mixed dentition having a backwardly
placed chin with protrusion and spaces in upper
anterior teeth. Describe the line of treatment and
appliance used. [Same as LE Q.1]
5. A 12-year-old boy with receding chin, proclined
anteriors and deep bite reports to you. Discuss
your diagnosis and justify your diagnosis. [Same
as LE Q.1]
6. How will you set out a treatment of a class II
division 1 malocclusion case in the mixed
dentition with moderated crowding in the
anteriors? Justify your modality of treatment.
[Same as LE Q.1]
Short essays:
1. Treatment of mandibular retrusion.
2. Treatment planning for class II division I
malocclusion in adults.
Short notes:
1. Clinical features of class II division 2. [Ref LE Q.2]
2. Clinical features of class II division 1 malocclusion.
[Ref LE Q.2]
3. Define growth modulation and state its methods.
4. Camouflage.
Solved answers
Long essays:
Q.1.Discuss the treatment plan for Angle's class II

malocclusion patients in mixed dentition period?
Ans.
Angle's class II Division 1 malocclusion is characterized
by:
Molar relation:
The distobuccal cusp of the upper first permanent
molar occludes with the mesiobuccal groove of the
lower first permanent molar. Lower dental arch is
distally positioned in relation to upper arch.
The objectives of treatment planning in a growing child
for correcting a class II division 1 malocclusion are as
follows:
• Correction of class II molar and canine relationship
• Establishing stable class I incisor relationship and
normal overbite
• Correction of deep bite and deep curve of Spee
• To relieve crowding and irregularities of teeth and
proper alignment of crowded anterior teeth
• Correction or improvement of skeletal discrepancy
• Improvement of facial aesthetics
• Correction of any other problems in an individual
case
Treatment in mixed dentition period:
A. Correction of skeletal class II malocclusion:
Interception of abnormal skeletal patterns:
• During the mixed dentition period abnormal
skeletal patterns can be intercepted by means
of functional or orthopaedic appliances.
i. Mandibular retrognathism:
a. Retrognathic mandible with
average FMA angle and
lower facial height:
i. Activator or FR-I is
commonly used. While
bionator, biomodular,
cybernator, propulsor,
etc. are other
functional appliances,
which are less
commonly used.
ii. Functional appliance
acts by placing the
mandible in anterior
position and also by
eliminating functional
retrusion.
b. Retrognathic mandible with
higher FMA angle:
• Activator along with high pull headgear
should be used.
ii. Maxillary prognathism:
• To restrict the forward growth of the maxilla
extra-oral orthopaedic force in the form of
headgear should be used.
• Patients should wear the appliance for 12-14
days and the force applied is 350-450 g/side.
• For horizontal growing patients cervical pull
headgear is used.
• For vertically growing patients high pull or
occipital pull headgear is used.
• In cases of vertical maxillary excess,
maxillary intrusion splints are used.
iii. Combination of mandibular
retrognathism and maxillary
prognathism:
• Activator with headgear is used to restrict the
maxillary growth and promote mandibular
growth.
B. Correction of dentoalveolar class II malocclusion
with class I skeletal base:
• In dentoalveolar class II with normal skeletal
base, the defect lies in the dentoalveolar portion.
• As the normal incisor and molar relationship is
established, the other teeth usually settle in
normal position and function.
• Space is gained either by distalization of molars
or extraction for correction of crowding.
• In low angle case, deep bite correction is
achieved by using anterior bite planes.
• In high angle cases, utility arches are used to
achieve incisor intrusion and labial bows or
fixed appliance mechanotherapy is used for
retraction of incisors.
• Posterior crossbites are corrected using crossbite
elastics.
• Any habit should be corrected simultaneously.
• Retention after class II correction is achieved by
using Tweed's type B retention plan.
A brief diagramatic representation of treatment plan for
class II malocclusion in a growing child is as follows:
Class II in growing child
! i
DentolVeolar Skeletal
class II class II
!
Correction of
!
Growth modulation procedures
dentoalVeolar
structures i i i
Prognathic Retrognathic Combination
• Correction of molar
maxilla mandible
relation, deep bite
and crossbite
! ! !
Headgear
• Reduction of overjet
Headgear Functional with FA
appliance
Q.2. Discuss in brief the aetiology, clinical picture

and treatment of Angle's class II malocclusion?
Ans.
Class II malocclusion is characterized by a class II molar
6
relation (i.e. DB cusp of occludes in
buccal groove of
6 ).
Cla II,
divi ion 1
Cla II,
divi ion 2
{SN Q.2}
Class II division 1 malocclusion:
Class II molar relation with proclined maxillary
anterior teeth.
Clinical features:
Patient exhibits:
i. Class II molar relation (may vary
from end on molar to one that is
full-fledged class II).
ii. Proclined maxillary anteriors with
toverjet.
iii. Convex profile.
iv. Because of proclined upper
anteriors - Lower anteriors fail to
make contact with palatal surface
of upper anterior leading to t
overbite and excessive curve of
Spee.
v. Short hypotonic upper lip, lip trap
(patient places lower lip against
palatal surface of upper incisors).
vi. Lack of anterior lip seal due to
short upper lip. Normal lip seal is
essential to maintain teeth in their
corrected position.
vii. Patient exhibits abnormal muscle
activity:
• Abnormal buccinator - Leading to constricted narrow

activity upper arch with posterior crossbites.
• A hyperactive mentalis
muscle.
viii. Proclined lower anteriors, a

natural compensation to decrease
overjet.
Skeletal features:
Abnormal skeletal features most often found are
i. Maxillary protrusion
ii. Mandibular retrusion
iii. Combination of both of the above
Aetiology:
i. Heredity
Prenatal_.!!· Terat.o~enesis
111. lrradiation
iv. Intrauterine fetal posture
i. Improper forceps application
during delivery - Trauma to
condylar region - Leading to
ankylosed or librosed TMJ
Postnatal l with under developed
mandible
I. Traumatic injury to mandible and TMJ.

II. Long-term irradiation treatment of
skeletal craniofacial region.
111. Infectious conditions like rheumatoid
arthritis influences mandibular growth.
IV. Abnormal function - e.g. oral
respiration, abnormal swallowing
habits like thumb sucking.
Treatment objectives:
I. Reduction of overjet and overbite.
IL Correction of crowding and local irregularities,
unstable molar relationship and posterior
crossbites if any.
III. Normalizing the musculature.
Treatment ofAngle's class II malocclusion in brief is as
follows:

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Correction of deep bite and crossbite: Class II

malocclusion can be associated with anterior deep
bite and posterior crossbite.
Deep bites: can be treated by using:
i. Removable anterior bite planes
ii. Fixed appliances to intrude upper/lower
anteriors.
Crossbites: Can be corrected with appliances
incorporating screws/springs that expand
maxillary arch.
Class II division 2 malocclusion:
Characterized by class II molar relationship with
retroclined upper centrals that are overlapped by
the lateral incisors.
Includes variations like - retroclined centrals +
lateral incisors and very rarely include retroclined
canines as well.
{SN Q.1}
Clinical features:
ii. Retroclined central incisors and rarely
other anteriors as well
iii. Deep bite
iv. Broad square face with pleasing straight
profile
v. Backward path of closure
vi. Deep rnentolabial sulcus
vii. Absence of abnormal muscle activity
They have perfectly acceptable function as well as
facial appearance. In severe cases the bite is often
very deep and poses the risk of periodontal trauma
in maxillary palatal and mandibular labial aspects.
a. Correction of incisor relationship and
buccal segment relationship
b. Relief of gingival trauma
c. Relief of crowding and local irregularities
Deep anterior overbite:
i. Treated by 1 in incisal overbite and
alteration of incisor inclination.
ii. Deep bite can be reduced by use of
anterior bite plane or fixed
appliances incorporating anchor
bends or reverse curve of Spee.
iii. Incisor inclination treated by use
of torqueing springs to move the
upper incisor roots lingually and
crowns buccally.
Q.3. Discuss your treatment of choice of appliance

for a patient aged 8 years, presenting class II division
1 malocclusion with positive VTO?
Ans.
[Sarne as LE Q.1]
Q.4. A child in a mixed dentition having a

backwardly placed chin with protrusion and spaces
in upper anterior teeth. Describe the line of
treatment and appliance used.
Ans.
[Same as LE Q.1]
Q.5. A 12-year-old boy with receding chin, proclined

anteriors and deep bite reports to you. Discuss your
diagnosis and justify your diagnosis.
Ans.
[Sarne as LE Q.1]
Q.6. How will you set out a treatment of a class II

division 1 malocclusion case in the mixed dentition
with moderated crowding in the anteriors? Justify
your modality of treatment.
Ans.
[Sarne as LE Q.1]
Short essays:
Q.1. Treatment of mandibular retrusion.

Ans.
• Retrognathic mandible or mandibular retrusion
results in class II malocclusion.
• Growth stimulation of the mandible is induced using
functional appliances.
• Functional appliances act by placing the mandible in
anterior position and also by eliminating functional
retrusion.
• Commonly used functional appliances for correction
of class II cases are activator, Frankel, twin block and
bionator.
• During late mixed dentition in children with residual
postpubertal growth, fixed functional appliances like
Herbst and Jasper jumpers are used.
Q.2. Treatment planning for class II division I

malocclusion in adults.
Ans.
Class II division 1 malocclusion is characterized by class
II molar relation with proclined maxillary anterior
teeth.
I. Reduction of overjet and overbite
II. Correction of crowding and local irregularities,
unstable molar relationship, posterior
crossbites if any
III. Normalizing the musculature
Treatment procedures:
a. Skeletal class II malocclusion: Orthodontic
camouflage or surgery is carried out.
b. Dentoalveolar class II malocclusion:
Orthodontic correction
i. Orthodontic camouflage:
• Orthodontic camouflage refers to
repositioning the teeth without
correcting the skeletal problem.
• The objective of orthodontic
camouflage is to correct the
malocclusion which makes the
underlying skeletal problem less
apparent.
• Camouflage is best performed in
adolescents but it is also done in
adults.
• Extractions for camouflage are done
in three possible ways: extraction
of upper first premolars,
extraction of upper as well as
lower first premolars and
extraction of upper first and lower
second premolars.
• When only retraction of proclined
incisors is required, extraction of
upper first premolars alone is
done.
• If crowding correction or
proclination correction is required
in the lower arch then extraction
of both upper and lower first
premolars is done.
• For molar correction, extraction of
lower second premolar is done.
• Orthodontic camouflage is achieved
through fixed appliance.
ii. Surgery:
• Surgery is the suitable form of
treatment in severe class II skeletal
malocclusion.
• The various surgical procedures
carried out are
For correction ofprognathic maxilla:
Le Fort I osteotorny and anterior
maxillary osteotorny.
For correction of retrognathic
mandible:
Advancement procedures like sagittal
split and oblique osteotorny are
carried out.
In combination cases - bijaw surgery
with genioplasty if required.
iii. Orthodontic correction:
In dentoalveolar class II cases with normal
skeletal base, the defect lies in the
dentoalveolar portion.
• As the normal incisor and molar
relationship is established, the
other teeth usually settle in normal
position and function.
• Space is gained either by
distalization of molars or
extraction for correction of
crowding.
• In low angle case deep bite
correction is achieved by using
anterior bite planes and in high
angle cases, incisor intrusion is
achieved using utility arches.
• Crossbite elastics are used to correct
posterior crossbites.
• Retraction of incisors is achieved by
using labial bows or with fixed
appliance rnechanotherapy.
Short notes:
Q.1. Clinical features of class II division 2.

Ans.
[Ref LE Q.2]
Q.2. Clinical features of class II division 1

malocclusion.
Ans.
[Ref LE Q.2]
Q.3. Define growth modulation and state its methods.

Ans.
• The treatment procedures carried out during mixed
or early permanent dentition period prior to
cessation of growth to intercept abnormal skeletal
patterns leading to class II division 1 malocclusion by
means of functional or orthopaedic appliances are
known as growth modification methods.
For example:
i. Correction of mandibular deficiency or
retrognathisrn during mixed dentition
period by use of rnyofunctional
appliances like activator or functional
regulator.
ii. Correction of maxillary prognathism by
use of face bow with headgear to restrict
further maxillary growth.
iii. In case of combination of mandibular
retrognathisrn and maxillary
prognathisrn:
Activator with headgear is used to restrict
the maxillary growth and promote
mandibular growth.
Q.4. Camouflage.
Ans.
• Orthodontic camouflage refers to repositioning the
teeth without correcting the skeletal problem.
• The objective of orthodontic camouflage is to correct
the malocclusion which makes the underlying
skeletal problem less apparent.
• Camouflage is best performed in adolescents but it is
also done in adults.
Indications for camouflage treatment are
a. Patients too old for growth modulation
b. Mild or moderate skeletal class II
c. Good alignment of teeth and good vertical
proportions
• Extractions for camouflage are done
in three possible ways based on
situation:
i. Extraction of upper first
premolars
ii. Extraction of upper, lower
first premolar
iii. Extraction of upper first and
lower second premolars
• Orthodontic camouflage is achieved
through fixed appliance.
Topic 28 Management of class Ill
malocclusion
Long essays:
1. Discuss the clinical picture of Angle's skeletal class
III malocclusion and its clinical management?

2. Enumerate the differences between true and
pseudo-class III.
3. Enumerate various methods in treating a case of
class III malocclusion at an early age. [Same as LE
Q.1]
4. Discuss in brief the aetiology, clinical picture and
treatment of Angle's class III malocclusion. [Same
as LE Q.1]
Short essays:
1. Aetiology and treatment of pseudo-class III
malocclusion.
2. Aetiology of class III malocclusion. [Ref LE Q.1]
3. Treatment of Angle's class III malocclusion in
adults. [Ref LE Q.1]
4. Discuss your line of treatment for class III
malocclusion in mixed dentition. [Ref LE Q.1]
5. A 9-year-old boy reports to the department of
orthodontics with a chief complaint of prognathic
mandible. Discuss the growth modulation
procedures as a line of treatment. [Same as SE Q.4]
Short notes:
1. Management of mandibular prognathism in
adults.
2. Objectives of treatment of class III malocclusion.
Solved answers
Long essays:
Q.1. Discuss the clinical picture of Angle's skeletal

class III malocclusion and its clinical management?
Ans.
[SE Q.2]
• {Class III malocclusion is found in about 3°/oof the
population. It is also known as mesiocclusion or
prenormal occlusion.
• Class III malocclusion is a condition in which the
lower molar is positioned mesial to the upper molar.
Class III subdivision: Condition in which class III
molar relation is present only on one side with
normal molar relation on the other side is known
as class III subdivision.
True class III:
• This is a skeletal malocclusion, it could be due
to retrognathic maxilla, prognathic mandible
or combination of both.
• In this class III molar relation exists both in
centric occlusion and in rest position.
occlusion due to occlusal prematurities, it
slides forward into a pseudo-class III position.
• These patients show normal molar relationship
in rest position while class III relation in
centric occlusion.
Aetiology:
i. Heredity plays a major role in true or skeletal
ii. Class III malocclusions are said to have a very
strong genetic basis.
iii. It is seen commonly in certain races, e.g.
Hapsburg jaw in royal families of Germany.
iv. The habitual forward positioning of the
mandible due to occlusal premturities or
enlarged adenoids are the other causes of
prenormalcy.}
Clinical features of class III malocclusion are as follows:
A. Occlusal features:
i. Class III molar relation:
The lower dental arch is in anterior relation
to the maxillary arch. Mesiobuccal cusp of
the upper first permanent molar occludes
with the interdental space between the
lower first and second permanent molars.
ii. Class III canine relation:
Upper canine occludes with the interdental
space between lower first and second
premolars.
iii. Incisor relation:
• The incisors may be in an edge-to-edge
relationship or reverse overjet or it may
exhibit a normal incisal relationship.
iv. Line of occlusion:
Line of occlusion may or may not be altered
in the maxillary and mandibular arches.
v. The upper arch is frequently narrow,
while the lower arch is broad. Thus
posterior crossbites are a common
feature of class III malocclusion.
vi. It is common for the upper teeth to be
crowded
. as the arch is narrow and short
in some cases.
vii. The patients have a concave profile due
to the presence of a prominent chin.
viii. Vertical growers exhibiting an
increased intermaxillary height may have
an anterior open bite. In some patients a
deep overbite may be seen.
B. Skeletal features of class III malocclusion are as
follows:
• Class III malocclusions are quite often associated
with underlying skeletal malrelationships:
a. A short or retrognathic maxilla
b. A long or prognanthic mandible
c. A combination of the above two
C. Soft tissue features:
• Concave profile
• Anterior divergence
• Frequently incompetent lips
• Short upper lip
• Tongue more anteriorly placed
D. Functional features:
• Forward displacement of the mandible.
• When there is unilateral crossbite, lateral
mandibular displacement is found.
• In pseudo-class III, patients will have class I
skeletal pattern, the abnormality is due to tilting
of the teeth and the forward path of closure.
E. Growth:
• Unfavourable facial growth is seen in most of the
class III cases.
• Tendency to open bite increases with vertical
facial growth.
• Excessive horizontal growth worsens the reverse
overjet.
Diagnosis:
• The clinical examination: should include
observation of path of closure
• Study models
• Radiographs:
A lateral cephalogram offers valuable
information on the skeletal nature of the
malocclusion.
Treatment:
Occlusion should be recognized and treated
early due to the following reasons:
a. The severity of the
developing malocclusion can
be reduced by recognizing
the malocclusion at an early
age and it is possible to
intercept the abnormal
skeletal pattern.
b. The class III malocclusion
characterized by anterior
crossbites often results in
retarded maxillary growth
due to locking of the maxilla
within the mandible.
c. The occlusal forces on the
mandibular incisors exerted
by the maxillary incisors in
crossbite encourage the
continued forward growth of
mandible further worsening
the prenormalcy.
d. Skeletal class III
malocclusion requires early
treatment to intercept the
developing skeletal
malrelation.
[SE Q.4]
{Thefollowing are some of the growth modulation
procedures that can be carried out in growing
children:
a. During growth period to intercept a skeletal
class III case due to maxillary retrusion, a
Frankel III, a myofunctional appliance can be
used or other myofunctional appliances like
reverse activator, reverse bionator and twin
block may also be used.
b. Chin cup with high pull headgear are used to
intercept class III malocclusion due to
mandibular prognathism.
d. Severe class III malocclusions that are a result
of maxillary retrusion can be treated by
reverse pull headgear (face mask) to protract
the maxilla.
Treatment of anterior cross bite:
The lower anterior inclined planes or removable
appliances incorporating screws designed for
anterior expansion can be used to treat the mild
anterior crossbites.
Treatment of posterior crossbite:
Posterior crossbites are common with class III
malocclusions. They can be treated by rapid
Role of extractions:
• Class III malocclusion characterized by lower
arch length deficiency and anterior crossbite can
be treated by extracting the lower first
premolars followed by fixed appliances.
• The first premolars should be extracted in both
the upper and lower arches, in case of arch
length deficiency involving both the arches.}
[SE Q.3]
{Treatment of severe class III after growth:
• Camouflage can be used in mild skeletal class III
cases.
[SE Q.3]
{Treatment of severe class III after growth:
• Camouflage can be used in mild skeletal class III
cases.
• Severe class III malocclusion after growth
completion is treated by surgical and corrective
procedures.
• Class III due to maxillary deficiency is treated by
maxillary advancement procedures such as Le Fort
I osteotomy.
• Class III malocclusions that are a result of
mandibular prognathism are treated by

mandibular set back procedures.
Treatment of pseudo-class III:
• On removal of aetiology, the pseudo-class III
malocclusion that occurs as a result of occlusal
prematurity improves.
• In the early stages, patients can be treated by
equilibration of occlusion alone.
• Later treatment consists of correction of anterior
crossbite.
Correction of dentoalveolar structures:
• Removable or fixed appliances are effective in
correction of dentoalveolar structures.
• Inclined planes act as extension of the lower incisal
edges by contacting the palatal surfaces of
maxillary incisors. On closing, the mandible is
forced to be retruded. Maxillary teeth are tipped
labially.
• If the bite is shallow, then posterior bite blocks with
Z-spring are used to move the palatally placed
maxillary incisors.}
A brief summary of treatment of class III
malocclusion:
Face mask in
maxillary
retrognathism
Skeletal
Chin cap in
mandibular
Growing prognathism
patient
Removable
Dental
Class Ill 1..___.._/fixed
malocclusion _f -,,- orthodontic
Dental treatment
Mild-to-
Adult moderate
patient Cl Ill:
Orthodontic
camouflage
Skeletal
Severe
class Ill:
Surgical
maxillary
advancement
or mandibular
set back based
on case
Q.2. Enumerate the differences between true and

pseudo-class III.
Ans.
Class III malocclusion is found in about 3°/o of the
population. It is also known as mesiocclusion or
prenormal occlusion, in which the lower molar is
positioned mesial to the upper molar.
True class III:
• This is a skeletal malocclusion; it could be due to
retrognathic maxilla, prognathic mandible or
combination of both.
• In this class III, molar relation exists both in centric
occlusion and in rest position.
rest position while class III relation in centric
occlusion.
Differences between true and pseudo-class Ill are as follows:
True class
Features Pseudo-class III
III
i. Profile Concave Straight or concave
ii. Aetiology Heredity Habitual or developmental
iii. Skeletal Has a class Has a normal class I skeletal
relation III base
skeletal
base
iv. Molar Class III Class I
relation in
rest
position
v. Molar Class III Shift from class I to class III
relation in
centric
occlusion
vi. Absent Present
Premature
contacts
vii. Path of Forward Deviated
closure
viii. Gonial r or! Normal
angle
ix. Retrusion Not possible Possible
of
mandible
further
x. Treatment Orthopaedic Elimination of prematurities
or and replacement of last
surgical posterior teeth by
correction functional space
No further maintainers
changers If left untreated, becomes
occur if established into true class
left III malocclusion
untreated
Q.3. Enumerate various methods in treating a case of

class III malocclusion at an early age.
Ans.
[Same as LE Q.1]
Q.4. Discuss in brief the aetiology, clinical picture

and treatment of Angle's class III malocclusion.
Ans.
[Same as LE Q.1]
Short essays:
Q.1. Aetiology and treatment of pseudo-class III

malocclusion.
Ans.
Pseudo-class Ill/habitual class III:
rest position while class III relation in centric
occlusion.
Aetiology:
The causes of prenormalcy are as follows:
• The habitual forward positioning of the mandible
due to occlusal prematurities
• Enlarged adenoids
Treatment of pseudo-class III:
• On removal of aetiology, the pseudo-class III
malocclusion that occurs as a result of occlusal
prematurity improves.
• In the early stages, patients can be treated by
equilibration of occlusion alone.
• Later treatment consists of correction of anterior
crossbite.
Q.2. Aetiology of class III malocclusion.

Ans.
[Ref LE Q.1]
Q.3.Treatment of Angle's class III malocclusion in
adults.
Ans.
[Ref LE Q.1]
Q.4. Discuss your line of treatment for class III

malocclusion in mixed dentition.
Ans.
[Ref LE Q.1]
Q.5. A 9-year-old boy reports to the department of

orthodontics with a chief complaint of prognathic
mandible. Discuss the growth modulation
procedures as a line of treatment.
Ans.
[Same as SE Q.4]
Short notes:
Q.1. Management of mandibular prognathism in

adults.
Ans.
i. Chin cup with high pull headgear is used to intercept
class III malocclusion due to mandibular
prognathism in growing children.
ii. Class III malocclusions that are a result of mandibular
prognathism are treated by mandibular set back
procedures in adults who have completed their
growth.
Q.2. Objectives of treatment of class III malocclusion.

Ans.
The objectives of treatment of class III malocclusion are
as follows:
i. Correction of open bite
ii. Correction of anterior deep bite
iii. Correction of anterior and posterior crossbite
iv. Correction of buccal segment relationship
v. Correction of any other associated problems in an
individual case
Topic 29 Management of open bite,
crossbite and deep bite
Long essays:
1. Describe the probable aetiologic factors
responsible for anterior and posterior open bite

and also their treatment.
2. Discuss the aetiology, line of treatment and the
design of appliance in correction of anterior
crossbite.
3. Define preventive, interceptive and corrective
orthodontics. Enumerate about the various modes
of posterior crossbite correction and discuss in
detail any one mode of treatment.
4. Define and classify crossbite. Give aetiology,
clinical features and diagnosis of posterior
crossbite.
5. Aetiology and treatment of open bite. [Same as LE
Q.1]
6. Describe the construction and use of a removable
appliance in the treatment of anterior crossbite of
one or two teeth. [Same as LE Q.2]
7. An 8-year-old male child is having one of the upper
central incisors in anterior crossbite. What can be
the probable aetiology? Design an appliance for
the correction of the above case. What will be your
advice to the patient? [Same as LE Q.2]
Short essays:
1. Anterior open bite. [Ref LE Q.1]
2. Clinical features of anterior open bite. [Ref LE Q.1]
3. Catalans appliances.
4. Anterior crossbite.
5. Posterior crossbite - aetiology and clinical
features.
6. Management of crossbite.
7. Aetiology and treatment of deep bite.
8. Aetiology of open bite. [Same as SE Q.1]
9. Catalan appliances - Mention the disadvantage of
this appliance. [Same as SE Q.3]
10. Lower anterior bite plane. [Same as SE Q.3]
11. Treatment of crossbite. [Same as SE Q.6]
Short notes:
1. Open bite.
2. Anterior open bite. [Ref LE Q.1]
3. Treatment methods of anterior crossbite. [Ref LE
Q.2]
4. Catalan's appliance. [Ref LE Q.2]
5. Management of posterior crossbite.
6. Clinical features of skeletal deep bite.
7. Tongue blade therapy. [Ref LE Q.2]
8. Aetiology of deep bite.
9. Apertognathia. [Same as SN Q.1]
10. Clinical features of anterior open bite. [Same as
SN Q.2]
11. Deep overbite. [Same as SN Q.8]
Solved answers
Long essays:
Q.1. Describe the probable aetiologic factors

responsible for anterior and posterior open bite and
also their treatment.
Ans.
Open bite is a malocclusion that occurs in the vertical
plane characterized by lack of vertical overlap between
the maxillary and mandibular dentitions.
Open bite can be in the anterior or posterior region.
Skeletal
Anterior Anterior
region ,. open bite
Dental
Open bite
Posterior Posterior
region ,. open bite
Anterior open bite:

It is a condition where there is no vertical overlap
between the upper and lower anteriors.
[SE Q.1]
Anterior open bice cla ified as
Aetiology:
According to Fletcher (1975), aetiology of open bite is
classified under following headings:
A. Epigenetic factors
B. Environmental factors
A. Epigenetic factors:
i. Disharmony of skeletal growth
pattern between maxilla and
mandible
ii. Alterations in morphology of the
tongue
iii. Tongue posture
iv. Inherited factors - e.g. T tongue
size, abnormal skeletal growth
pattern
B. Environmental factors:
i. Prolonged thumb-sucking habit
Nature and severity of open bite are
affected by:
a. Posture of thumb
positioning
b. The intensity of sucking
c. The frequency of
sucking
ii. Tongue thrusting
iii. Nasopharyngeal airway
obstruction and associated mouth
breathing}
Clinical features:
(SN Q.2 and SE Q.2)
{(Skeletal anterior open bite exhibits following
features:
i. t Lower anterior facial height.
ii. ! Upper anterior facial height.
iii. t Anterior + ! posterior facial height.
iv. Patient exhibits vertical maxillary
increase and a long and narrow face,
small mandibular body ramus.
v. Steep anterior cranial base.
vi. Cephalometric evaluation reveals
downward and forward rotation of the
mandible with steep mandibular plane
angle.
vii. In some cases, upward tipping of
maxillary skeletal base can be observed.
viii. Divergent cephalometric planes.
Dental anterior open bite exhibits following features:
i. Proclination of upper anterior teeth.
ii. Patient may have narrow maxillary arch
due to lowered tongue posture due to any
habits.
iii. Upper and lower anteriors fail to overlap
each other resulting in a space between
incisal edges of maxillary and
mandibular anteriors.)}
[SE Q.1]
{Treatment of anterior open bite:
i. Removal of the cause or aetiology:
Either a removable or fixed habit breaking
appliances, e.g. palatal crib, can be used to
intercept the habit.
ii. Myofunctional therapy:
Skeletal anterior open bite is treated with
functional appliances, e.g. Frankel - IV or
modified activator, which incorporates
bite blocks interposed between the
posterior teeth which have an intrusive
action on upper and lower posterior teeth.
iii. Orthodontic therapy:
Mild-to-moderate open bites successfully
managed with fixed orthodontic therapy
in conjunction with box elastics, which
brings about extrusion of the upper and
lower anteriors. In severe skeletal open
bites this therapy is not advisable.
iv. Surgical correction:
Skeletal open bites in adults are best treated
by surgical procedures involving maxilla
and mandible.}
Posterior open bite:
Is characterized by lack of contact between the
posteriors when the teeth are in centric occlusion.
Aetiology:
i. Mechanical interference with eruption:
• Ankylosis of tooth due to trauma.
• Obstacles in path of eruption like
supernumerary teeth, nonresorbed
deciduous tooth roots and pressure from
soft tissues interposed between the teeth.
ii. Failure of the eruption mechanism of the
tooth.
Treatment:
Removal of aetiological factors is the primary aim
of treatment.
For example:
i. Lateral tongue spikes - to control
tongue thrust habit.
ii. Forceful extrusion of posterior
teeth.
iii. In cases of ankylosed teeth which
are in infra occlusion, crowns can
be given to posteriors to restore
the normalocclusal level.
I
Q.2. Discuss the aetiology, line of treatment and the
design of appliance in correction of anterior
crossbite.
Ans.
• Anterior crossbite is a condition in which one or more
primary or permanent maxillary incisors is lingual
to the mandibular incisor.
• It is also known as reverse overjet, reverse bite and
under bite.
Aetiology of anterior crossbite can be studied
under following categories:
A. Dental factors
B. Skeletal factors
C. Functional factors
A. Dental factors:
A dental anterior crossbite is because of abnormal
axial inclination of the maxillary incisors, which
may result from one of the following causes:
• Trauma to primary teeth or to the permanent
tooth bud
• Persistence of deciduous tooth
• Labially positioned supernumerary tooth
• Arch length - tooth material discrepancy which
causes lingual eruption of permanent tooth
• Abnormal habits, e.g. Lip biting, thumb sucking
and mouth breathing causes lowered tongue
position which no longer balances forces
exerted on teeth by buccal group of muscles.
This disharmony between external and
internal muscle forces results in narrowing of
upper arch resulting posterior crossbite.
• Surgically repaired cleft lip and palate.
B. Skeletal factors:
• Skeletal crossbite results due to excessive
mandibular growth.
• It is genetic or inherited malocclusion.
• Collapse of maxillary arch in children with
-- 0 ., r _ -·- ~ r -.r _.
• Skeletal crossbite results due to excessive
mandibular growth.
• It is genetic or inherited malocclusion.
• Collapse of maxillary arch in children with
cleft palates where there is retrognathic
maxilla.
C. Functional factors:
Functional interference of the mandible during
closure results in dental crossbite due to
premature tooth contact. This results in pseudo-

Treatment of anterior crossbite:
Factors to be considered in treating anterior
crossbite are as follows:
• Availability of mesiodistal space
• Sufficient overbite
• Position of the tooth
• Type of occlusion either class I or class III
• Extents of root formation
{SN Q.3}
Various methods of correction of anterior crossbite are
as follows:
• Tongue blade therapy
• Inclined planes
• Expansion appliances with either screws or
cantilever springs
• Fixed appliances
{SN Q.7}
Tongue blade therapy:
• Tongue blade can be used to treat developing
single-tooth anterior crossbites successfully,
provided there is sufficient space for the tooth to
be brought out.
• The tongue blade is a flat wooden stick resembling
an ice cream stick. It is placed inside the mouth
contacting the palatal aspect of the tooth in
crossbite. The blade is made to rest on the
mandibular tooth in crossbite which acts as a
fulcrum and the patient is asked to move the oral
part of the blade upwards and forward.
• This is continued for 1-2 h for about 2 weeks.
• This form of therapy can be successfully used to
treat most of the developing crossbites that are
recognized by the dentist at an early stage.
{SN Q.4}
Cation's appliance or lower anterior inclined
plane:
• This appliance is indicated when adequate space
exists in the arch for the alignment of the
maxillary teeth in crossbite.
• They are used only in those cases where the
crossbite
. . is due to a palatally displaced maxillary
incisor.
• Inclined planes constructed on the lower anterior
teeth can be used to treat maxillary teeth in
crossbite.
designed to treat a single tooth in crossbite or a
segment of the upper arch in crossbite.
The disadvantages of lower anterior inclined plane
include:
i. The patient encounters problems in
speech and dietary restrictions.
ii. If the appliance is used for more than 6
weeks, it can result in anterior open bite
due to supraeruption of the posteriors.
iii. The appliance may need frequent
recementation.
Expansion appliances:
i. Schwarz-type expansion plate with posterior
bite plane.
ii. Upper Hawley's appliance with cantilever
spring to move the in-standing tooth. Posterior
bite plane is added to the Hawley's appliance.
iii. Removable appliances with Z-spring or double
cantilever spring.
Use of double cantilever spring (Z-spring):
• Anterior crossbites involving one or two
maxillary teeth can be treated using a double
cantilever spring.
• The Z-spring is indicated only when there is
adequate space for labialization of the teeth in
crossbite.
• In case of a deep overbite the spring should be
given along with a posterior bite plane to help in
jumping the bite.
Fixed appliances:
• Fixed appliances are used to pull the in-locked
tooth or teeth into correct labial position.
• Dental anterior crossbite involving one or two
teeth can be treated with fixed appliances using
multilooped archwires.
Treatment of skeletal anterior crossbite during
growth period:
• Before termination of growth, a protraction face
mask or reverse head gear is used to treat
skeletal anterior crossbite that occurs as a result
of a retro-positioned maxilla.
• These face masks help in protraction of the
maxilla thereby normalizing the skeletal
crossbite.
• A chin cap should be used to intercept the
excessive mandibular growth leading to skeletal
anterior crossbites.
Q.3. Define preventive, interceptive and corrective

orthodontics. Enumerate about the various modes of
posterior crossbite correction and discuss in detail
any one mode of treatment.
Ans.
i. Preventive orthodontics:
Preventive orthodontics is the action taken to
preserve the integrity of what appears to be a
normal occlusion at a specific time.
ii. Interceptive orthodontics:
Interceptive orthodontics is defined as that phase of
the art and science of orthodontics employed to
recognize and eliminate potential irregularities
and malpositions of the developing dentofacial
complex.
iii. Corrective orthodontics:
Corrective orthodontics recognizes the existence of a
malocclusion and the need for employing certain
technical procedures to reduce or eliminate the
problem and the attendant squelae.
Posterior crossbite:
• A posterior crossbite is an abnormal buccolingual
relationship of a tooth or teeth between maxilla
and mandible when they are brought into centric
occlusion.
Factors to be considered in treating posterior
crossbite are
• Availability of mesiodistal space to correct the
crossbites
• Position of the apical portion of tooth after
treatment
• Types of tooth movement required
A. Single-tooth dental crossbites:
i. Crossbite elastics
B. Dentoalveolar contraction and crossbite:
a. Treatment of unilateral contraction
of maxillary arch:
i. Removable plates
ii. Quad helix
iii. W-arch
iv. Coffin spring
b. Treatment of bilateral contraction
of maxillary arch:
i. Quad helix
ii. W-arch
iii. Rapid maxillary expansion
(RME)
c. Mandibular dentoalveolar
contraction:
i. Quad helix spring
C. Skeletal crossbite
a. Narrow maxilla:
i. Mild cases - quad helix or W-
arch
ii. Severe cases - RME or
Minnesota expander
b. Narrow mandible - usually
associated with retrognathic
mandible
i. Functional appliances
Very severe cases are treated by surgery.
A. Single-tooth dental crossbite:
• Usually in single-tooth crossbite, where both
the antagonist teeth are tipped out of position,
simple crossbite elastics are effective.
• Single-tooth crossbite involving the molars can
be treated using elastics that are stretched
between the maxillary palatal surface and
mandibular buccal surface.
• These elastics are to be worn day and night.
The treatment should not be continued for
more than 6 weeks as the elastics can extrude
the teeth.
• Disadvantages: It requires banding of the teeth
and good patient cooperation.
B. Dentoalveolar contraction and crossbite:
First any functional interference present is
eliminated by occlusal equilibration.
Occlusal equilibration:
A dental bilateral lingual crossbite in the
primary dentition or mixed dentition may
be simply corrected by removing occlusal
interferences, usually in the cuspid areas.
This may sometimes need to be
accompanied by some appliances.
Appliances given after occlusal equilibration
are as follows:
Coffin spring:
• Walter Coffin designed the Coffin spring.
• It is a removable appliance that consists of
an omega-shaped wire (1.25 mm diameter)
placed in the mid-palatal region. The free
ends of the omega are embedded in an
acrylic plate that covers the slopes of the
palate.
• The spring . brings about dentoalveolar
expansion.
• When used in young patients, it is capable
of causing skeletal changes.
Quad helix:
• The quad helix is a spring that consists of
four helices.
• It is capable of causing dentoalveolar
expansion
. of the molar as well as premolar
region.
• It can bring about skeletal expansion when
used in younger individuals.
Removable plates:
• Removable appliances incorporating jack
screws are used to treat the unilateral
crossbites.
• This annlianca consists of a snlir acrvltc nlata.
- -
Removable plates:
• Removable appliances incorporating jack
screws are used to treat the unilateral
crossbites.
• This appliance consists of a split acrylic plate,
a jack screw and Adams clasps on the
posterior teeth to retain the plate. A labial
bow can also be incorporated into the
appliance for minor space closure and
retraction.
• The desired effect is achieved by sectioning
the plate in such a way that a small segment

and larger segment are formed. The two
segments are connected by one or more jack
screws. The smaller segment of the plate
adjoins the area in crossbite whereas the
larger segment is used for anchorage.
Fixed appliances
• Unilateral crossbites can also be treated by
using fixed appliances.
Removable W-arch appliance:
• Due to its reciprocal action, this appliance
should be limited to only bilateral dental
crossbite conditions.
• Caution should be exercised since a precise
control of the force being applied to the
teeth is difficult.
Rapid maxillary expansion:
• Rapid maxillary expansion is a skeletal type
of expansion that involves the separation of
the mid-palatal suture and movement of the
maxillary shelves away from, each other.
• Bilateral skeletal crossbite can be treated by
RMEwhere in the mid-palatal suture is split.
This is done by using appliances that
incorporate screws that are to be activated
at regular intervals.
• Expansion of the arches is the one of the
method of gaining the space in orthodontics.
• Orthodontic indications of RME are
i. In anterior
. crossbite to
gain space
ii. Collapsed maxillary
arch due to cleft palate
iii. Unilateral or bilateral
posterior skeletal
crossbite
• Principle of RME: Application of force to
widen the maxilla causes opening of the
mid-palatal suture, new bone formation is
induced and the space created in the midline
is filled with tissue fluids and blood. After 3-
4 months, new bone fills in the space.
Q.4. Define and classify crossbite. Give aetiology,

clinical features and diagnosis of posterior crossbite.
Ans.
• 'Crossbite' is defined as a condition where one or
more teeth may be abnormally malposed buccally or
lingually or labially with reference to the opposing
tooth or teeth.
A. Classification of crossbites:
a. Anterior crossbite:
i. Single tooth
ii. Segmental (multiple teeth)
b. Posterior crossbite:
i. Single-tooth crossbite
ii. Unilateral
iii. Bilateral
B. Another classification of crossbite:
a. Dental: (i) anterior and (ii) posterior
b. Skeletal: (i) anterior and (ii) posterior
c. Functional crossbite
• Anterior crossbite:
Condition in which one or more primary or
permanent maxillary incisors are lingual to
the mandibular incisors.
• Buccal crossbite:
Condition in which the maxillary posterior
teeth is buccal to the mandibular antagonist.
• Lingual crossbite:
Condition in which the maxillary posterior
teeth is lingual to mandibular antagonist.
• Scissors bite or telescopic bite:
Mandibular teeth are entirely lingual to the
maxillary arch.
Posterior crossbite:
relationship of a tooth or teeth between maxilla
and mandible when they are brought into centric
occlusion.
Clinical features:
• Posterior crossbite either unilateral or bilateral
presents as anyone or combination of the
following types:
i. Lingual crossbite
ii. Buccal crossbite
iii. Complete lingual crossbite
Aetiology:
Aetiology of posterior crossbite can be studied
under following headings:
a. Dental factors
b. Skeletal factors
c. Functional factors
a. Dental factors:
• Irregular eruption pattern, where
the tooth erupts out of position
• Insufficient arch length leading to
lingual or buccal deflection of
teeth during eruption
• Over-retained primary tooth and
ectopic eruption of permanent
teeth
• Prolonged thumb or finger-sucking
habit causes narrowing of the
arches and lingual tipping of the
posterior teeth
b. Skeletal factors:
i. Asymmetric growth of
maxilla or mandible due to
inherited growth pattern,
trauma or long-standing
functional problem
ii. Difference in basal width of
the maxilla and mandible
due to constricted maxilla
and cleft palate
c. Functional or muscular crossbite:
• Functional adjustments to tooth
interferences
Diagnosis:
i. Study models
ii. Grids
iii. Symmetroscope
iv. Boley gauge or divider
v. Radiographs: PA view or frontal cephalograms.
• Study models using wax bite in centric relation
is a useful diagnostic aid.
Study models will show which tooth is at fault
in the dental crossbite whether maxillary
tooth or mandibular tooth.
• A dental crossbite will exhibit an abnormal
buccal or lingual axial inclination.
• A skeletal crossbite may not exhibit abnormal
axial inclination of teeth.
• Symmetry of the dental arches can be assessed
using grids, symmetroscope, Boley gauge or
divider.
This helps in diagnosing the arch at fault in
skeletal crossbite.
• Assessment of midlines by (posteroanterior) PA
view radiographs or frontal cephalograms
should be done.
• Midline should be assessed in both rest and
centric position.
• Differential diagnosis of midline shift:
i. If midline shift is present only in centric
position, then it is functional crossbite.
ii. If midline shift is present in both centric and
rest positions, then it is true skeletal
crossbite.
Q.5. Aetiology and treatment of open bite.

Ans.
[Same as LE Q.1]
Q.6. Describe the construction and use of a

removable appliance in the treatment of anterior
crossbite of one or two teeth.
Ans.
[Same as LE Q.2]
Q.7. An 8-year-old male child is having one of the

upper central incisors in anterior crossbite. What
can be the probable aetiology? Design an appliance
for the correction of the above case. What will be
your advice to the patient?
Ans.
[Same as LE Q.2]
Short essays:
Q.1. Anterior open bite.

Ans.
[Ref LE Q.1]
Q.2. Clinical features of anterior open bite.

Ans.
[Ref LE Q.1]
Q.3. Catalan's appliances.

Ans.
• Catalan's appliance is also called as lower anterior
inclined plane or incisal capping.
• This appliance was introduced by Catalan 150 years
ago.
• It is the simplest of all the functional appliances used
for correction of a developing crossbite. It is used on
the lower anterior teeth.
Indications:
• When there is adequate space existing in the arch
for the alignment of the maxillary teeth in
crossbite
• In cases where the crossbite is due to a palatally
displaced maxillary incisor
Contraindications:
• Cases where the degree of overbite is less
• Crossbite, which is due to true mandibular
prognathism
Design:
designed to treat a single tooth in crossbite or a
segment of the upper arch in crossbite.
• It takes about 10-14 days for the correction of
crossbite. It should be used for a maximum
period of 2-3 weeks.
-
• When the appliance is either cemented or
attached with Adams clasp there is contact only
in the anterior region, where there is crossbite.
• During the functional movements like
swallowing, due to lack of contact of the
posterior teeth all the forces are transmitted to
the region of contact, which guides the teeth to
erupt into normal position.
Disadvantages:
• Patient encounters problems in speech during
therapy.

• Patient has to put up with dietary restrictions.
• If the appliance is used more than 6 weeks it can
results in anterior open bite due to supra-
eruption of the posteriors.
• The appliance may need frequent recementation.
Q.4. Anterior crossbite.

Ans.
• Anterior crossbite is a condition in which one or more
primary or permanent maxillary incisors are lingual
to the mandibular incisor.
• It is also known as reverse overj et, reverse bite and
under bite.
Aetiology of anterior crossbite can be studied
under fallowing categories:
A. Dental factors
B. Skeletal factors
C. Functional factors
A. Dental factors:
• A dental anterior crossbite is
because of abnormal axial
inclination
. . of the maxillary
incisors.
• Excessive mandibular growth.
• It is genetic or inherited
malocclusion.
• Collapse of maxillary arch in
children with cleft palates where
there is retrognathic maxilla.
C. Functional factors:
Functional interference of the mandible
during closure results in dental crossbite
due to premature tooth contact. This
results in pseudo-class III malocclusion.
Various methods of correction of anterior crossbite
are as follows:
• Tongue blade therapy
• Inclined planes
• Expansion appliances with either
screws or cantilever springs
• Fixed appliances
Tongue blade therapy:
• Tongue blade can be used to treat
developing single-tooth anterior
crossbites successfully, provided
there is sufficient space for the
tooth to be brought out.
• This form of therapy can be
successfully used to treat most of
the developing crossbites that are
recognized at an early stage.
Catlan's appliance or lower anterior inclined
plane:
• This appliance is indicated when
adequate space exists in the arch
for the alignment of the maxillary
teeth in crossbite.
• It can be made of acrylic or cast
metal and can be designed to treat
a single tooth in crossbite or a
segment of the upper arch in
crossbite.
• The inclined plane is designed to
have a 45° angulation which forces
the maxillary teeth in crossbite to a
more labial position.
Expansion appliances:
i. Schwarz-type expansion plate
with posterior bite plane.
ii. Upper Hawley's appliance
with cantilever spring to
move the in-standing tooth.
iii. Removable appliances with
Z-spring or double cantilever
spring.
Fixed appliances:
• Fixed appliances are used to pull the
in-locked tooth or teeth into
correct labial position.
• Dental anterior crossbite involving
one or two teeth can be treated
with fixed appliances using
multilooped archwires.
Treatment of skeletal anterior crossbite during
growth period:
• Before termination of growth, a
protraction face mask or reverse
head gear is used to treat skeletal
anterior crossbite that occurs as a
result of a retro-positioned
maxilla.
• A chin cap should be used to
intercept the excessive mandibular
growth leading to skeletal anterior
crossbites.
Q.5. Posterior crossbite - aetiology and clinical

features.
Ans.
A posterior crossbite is an abnormal buccolingual
relationship of a tooth or teeth between maxilla and
mandible when they are brought into centric occlusion.
In this condition, instead of the mandibular buccal
cusps occluding in the central fossae of the maxillary
posterior teeth, they occlude buccal to the maxillary
buccal cusps.
relationship of a tooth or teeth between maxilla and
mandible when they are brought into centric
occlusion.
• Aetiology of posterior crossbite can be studied under
following headings:
a. Dental factors
b. Skeletal factors
c. Functional factors
a. Dental factors:
• Irregular eruption pattern, where the
tooth erupts out of position.
• Insufficient arch length leading to lingual
or buccal deflection of teeth during
eruption.
• Over-retained primary tooth and ectopic
eruption of permanent teeth.
• Prolonged thumb or finger-sucking habit
causes narrowing of the arches and
lingual tipping of the posterior teeth.
b. Skeletal factors:
i. Asymmetric growth of maxilla or
mandible due to inherited growth
pattern, trauma or long-standing
functional problem.
ii. Difference in basal width of the maxilla
and mandible due to constricted maxilla
and cleft palate.
c. Functional or muscular crossbite:
• Functional adjustments to tooth
interferences.
Clinical features:
• Posterior crossbite either unilateral
or bilateral presents as anyone or
combination of the following
types:
i. Lingual crossbite
ii. Buccal crossbite
iii. Complete lingual crossbite
Q.6. Management of crossbite.

Ans.
According to Graber, crossbite is defined as a condition
where one or more teeth may be abnormally malposed
buccally or lingually or labially with reference to the
opposing tooth or teeth.
A. Fixed appliances:
• Dental anterior crossbite involving one or two
teeth can be treated with fixed appliances using
multilooped arch wires.
B. Removable appliances:
i. Tongue blade:
• Single-tooth anterior crossbites can
be successfully treated by using a
tongue blade.
• The blade is made to rest on the
mandibular tooth in crossbite
which acts as a fulcrum and the
patient is asked to rotate the oral
part of the blade upwards and
forward. This is continued for 1-2
h for about 2 weeks.
ii. Z-spring:
• Anterior crossbites involving
one/two maxillary teeth can be
treated by using a Z-spring/double
cantilever spring.
• It is indicated only in those cases
where there is an adequate space
for labialization of the teeth in
crossbite.
C. Functional appliances:
• Lower anterior inclined plane/Catalan's
appliance is used to treat a single tooth in
anterior crossbite or a segment of the
upper arch in crossbite.
• Catalan's appliance constructed on the
lower anterior teeth can be used to treat
maxillary teeth in crossbite.
D. Orthopaedic appliances:
i. Headgear:
• Skeletal anterior crossbites that
occur as a result of a retro-
positioned maxilla should be
treated before termination of
growth by using a protraction face
mask (reverse head gear).
• These face masks help in protraction
of maxilla, thereby normalizing
the skeletal crossbite.
ii. Chin cap:
• Excessive mandibular growth leading to
skeletal anterior crossbites should be
intercepted by use of a chin cap.
i. Crossbite elastics:
• Single-tooth crossbite involving the
molars can be treated by crossbite
elastics.
• These elastics are stretched between
the maxillary palatal surface and
mandibular buccal surfaces.
• These elastics are to be worn day
and night. The treatment should
not be continued for more than 6
weeks as the elastics can results in
extrusion of teeth.
ii. Removable plates:
• Unilateral crossbites can be treated
by removable appliances
incorporating Jackscrews.

• The appliance consists of an acrylic
plate, a jackscrew and an Adams
clasps on the posterior teeth to
retain the plate. A labial bow is
also incorporated for minor space
closure and retraction.
B. Fixed appliances:
• Unilateral crossbites can also be treated
with fixed appliances. Asymmetrically
expanded arch wires can bring about
correction of crossbite.
c. Expansion appliances:
i. Coffin spring:
• It is a removable appliance that
consists of an omega-shaped wire
of 1.25 mm diameter placed in the
mid-palatal region.
• It brings about dentoalveolar
expansion, but it is capable of
producing skeletal changes when
used in young patients.
ii. Quad helix:
• The quad helix appliance is capable
of producing dentoalveolar
expansion of the molar as well as
premolar region.
• It produces skeletal changes when
used in young patients.
iii. RME:
• Bilateral skeletal crossbite with a
deep palate and narrow maxilla
can be treated by RME.
• It is achieved by using appliance
that incorporates screws that are
to be activated at regular intervals.
Q.7. Aetiology and treatment of deep bite.

Ans.
• According to Graber, deep bite is a condition of
excessive overbite, where the vertical measurement
between maxillary and mandibular incisal margins
is excessive when the mandible is brought into the
habitual or centric occlusion.
Aetiology:
Skeletal deep bite:
• It is caused by convergent rotation of skeletal jaw
bases. The upward and forward rotation of the
mandible and as well downward and forward
inclination of the maxilla leads to deep bite.
Dental deep bite:
• Supraeruption of anterior teeth
• Premature loss of permanent teeth resulting in
lingual collapse of anterior teeth
• Infra-occlusion of molars due to tongue thrusting
• Anterior tipping of posterior teeth
• Lateral spreading low tongue posture
• Large size teeth
Treatment:
Deep bites can be treated by using removable, fixed
or myofunctional appliances.
Treatment mechanics/appliances used in
correction of deep bite:
I. Intrusion mechanics:
• Utility arches
• Burstone intrusion arch
• Arch wires with reverse curve of
Spee
• Arch wires with anchor bends/tip
back bends
II. Relative Intrusion mechanics:
• Activator
• Bionator
III. Extrusion mechanics:
• Anterior bite plane
i. Removable appliances (anterior bite
plane):
• Anterior bite plane is the most
commonly used removable
appliance for treatment of
the deep bite.
• Anterior bite plane is a
modified Hawley's appliance
with a flat ledge of acrylic
behind the maxillary
anteriors.
• When the patient bites, the
mandibular incisors contact
the bite plane thus disclosing
the posteriors, which are
free to erupt.
• The height of the anterior bite
plane should be just enough
to separate the posteriors by
1.5-2.0 mm as the posterior
teeth erupt the height of the
bite plane is gradually
increased.
• Fixed orthodontic appliances
can be used to intrude the
anteriors.
Anchor bends:
• Anchorage bends are given in the arch
wire mesial to the molar tubes so that the
anterior part of the arch wire lies gingival
to the bracket slot.
• When these arch wires are pulled
occlusally and engaged into the brackets, a
gingivally directed intrusive force is
exerted on the incisors, which reduces the
deep bite.
Arch wires with reverse curve of Spee:
• They are used to intrude the anteriors.
• When these arch wires are inserted into
the molar tubes, the anterior segment
curves gingivally.
• This anterior segment is forced occlusally
into the bracket slot resulting in an
intrusive force on the incisors.
iii. Myofunctional appliances:
• Deep bite with infra-occlusion of molars can
be treated by using activator and bionator.
• The design of functional appliance is
modified to allow the extrusion of the
posterior teeth.
Q.8. Aetiology of open bite.

Ans.
[Same as SE Q.1]
Q.9. Catalan appliances - Mention the disadvantage

of this appliance.
Ans.
[Same as SE Q.3]
Q.10. Lower anterior bite plane.

Ans.
[Same as SE Q.3]
Q.11. Treatment of crossbite.

Ans.
[Same as SE Q.6]
Short notes:
Q.1. Open bite.

Ans.
• Open bite is a malocclusion that occurs in the vertical
plane characterized by lack of vertical overlap
between the maxillary and mandibular dentition
• It is of two types: Anterior open bite and posterior
open bite.
• Aetiology:
i. Disharmony of skeletal growth pattern
between maxilla and mandible.
ii. Alterations in morphology and posture of
the tongue
iii. Prolonged thumb-sucking habit and
tongue thrusting
iv. Nasopharyngeal airway obstruction.
• Treatment of the open bite:
i. Removal of the aetiological cause.
ii. Orthodontic therapy
iii. Myofunctional therapy
iv. Surgical correction
v. In cases of posterior open bite due to
infra-occlusion, placement of crowns on
posterior teeth to restore normal occlusal
level is the best treatment.
Q.2. Anterior open bite.

Ans.
[Ref LE Q.1]
Q.3. Treatment methods of anterior crossbite.

Ans.
[Ref LE Q.2]
Q.4. Catalan's appliance.

Ans.
[Ref LE Q.2]
Q.5. Management of posterior crossbite.

Ans.
Various appliances used in treatment of posterior
crossbite are
i. Crossbite elastics
ii. Removable plates
B. Fixed appliances
C. Expansion appliances:
i. Coffin spring
ii. Quad helix
iii. RME
Q.6. Clinical features of skeletal deep bite.

Ans.
• According to Graber, deep bite is a condition of
excessive overbite, where the vertical measurement
between maxillary and mandibular incisal margins
is excessive when the mandible is brought into the
habitual or centric occlusion.
• Clinical features of skeletal deep bite are as follows:
i. Deep curve of Spee is seen in mandibular
dentition.
ii. Reverse curve of Spee is seen in maxillary
dentition.
iii. Gummy smile.
iv. Decreased lower facial height.
Q.7. Tongue blade therapy.

Ans.
[Ref LE Q.2]
Q.8. Aetiology of deep bite.

Ans.
According to Graber deep bite is a condition of excessive
overbite.
Aetiological causes of deep bite are as follows:
• Convergent rotation of skeletal jaw bases.
• The upward and forward rotation of the mandible.
• Downward and forward inclination of the maxilla
leads to deep bite.
• Supraeruption of anterior teeth.
• Premature loss of permanent teeth resulting in
lingual collapse of anterior teeth.
• Infra-occlusion of molars due to tongue thrusting.
• Anterior tipping of posterior teeth.
• Large size teeth.
Q.9. Apertognathia.
Ans.
[Same as SN Q.l]
Q.10. Clinical features of anterior open bite.

Ans.
[Same as SN Q.2]
Q.11. Deep overbite.

Ans.
[Same as SN Q.8]
Topic 30 Cleft lip and palate
Long essays:
1. Describe the aetiology, classification and clinical
picture of cleft lip and palate patients.
2. Describe in brief about the malformations of

dental arches in cleft lip and palate cases. Write
about aetiology and orthodontic management of
cleft lip and palate cases.
3. What are the causes of cleft lip and palate? How
will you manage the problems associated with
them? [Same as LE Q.1]
4. Briefly discuss the treatment protocol from birth
to adulthood of a child born with cleft lip and
palate. [Same as LE Q.2]
Short essays:
1. Orthodontic management of cleft palate.
2. Enumerate various classifications of cleft lip and
palate and describe Veau's classification of cleft
lip and palate. [Ref LE Q.1]
3. Surgical closure of cleft lip? Describe briefly any
one technique.
Short notes:
1. Aetiology of cleft lip and palate. [Ref LE Q.2]
2. Name various techniques of cleft lip closure. [Ref
SE Q.3]
3. Name surgical management procedures of cleft
palate.
4. NAM.
5. What is 'team approach' in rehabilitation of cleft
lip/palate patients? [Ref LE Q.2]
Solved answers
Long essays:
Q.1. Describe the aetiology, classification and clinical

picture of cleft lip and palate patients.
Ans.
Cleft lip and palate are congenital abnormalities that
affect the upper lip and the hard and soft palate. This
abnormality may range from a small notch in the lip to
a complete fissure extending up to the roof of mouth
and nose.
• Cleft lip is more common in males while cleft palate is
more common in females.
• Incidence: 1 in every 600-1000 births.
• Negroid race has least incidence (1 in every 2000
births).
• Mongoloids have the highest incidence.
Unilateral cleft -+ 80°/o (clefts involving left side
account for 70°/o of cases)
Bilateral cleft --. 20°/o
Aetiology:
Genetic and environmental factors causing cleft lip
and palate are:
i. Heredity: Is an important aetiologic factor.
Clefts of the lip and palate may be
transmitted as a dominant or a recessive
trait.
ii. Environment: Another possible
environmental factor is teratogenesis.
Some of known toratogens are rubella virus,
cortisone, mercaptopurine, methotrexate,
valium and dilantin.
iii. Multifactorial aetiology: Recent studies
have shown that aetiology of cleft lip and
palate cannot be attributed solely to
either genetic or environmental factors. It
seems to involve more than one factor.
• Predisposing factors: Factors that believe to
increase risk of cleft lip and palate incidence are
i. Increased maternal age
ii. Racial (mongoloids have greatest
percentage of incidence)
iii. Blood supply (any factor that decreases
blood supply to the nasomaxillary area
during embryological development
predisposes to clefts)
[SE Q.2]
• {Various classifications of cleft lip and palate are
(a) Davis and Ritchie classification (1922)
(b) Veau's classification (1931)
(c) Classification by Fogh Andersen (1942)
(d) Schuchardt and Pfeifer's symbolic
classification
(e) Kernahan's stripped 'Y' classification
(f) LAHSHAL classification}
(a) Davis and Ritchie classification:
This is a morphological classification based
of location of cleft relative to the alveolar
process.
Classified into three groups:
• Group I ---+-• Bilateral

(Pre-alveolar cleft )
Involve only the lip
• Group II (postalveolar clefts): Includes different

degrees of hard and soft palate clefts that extend up
to alveolar ridge.
• Group III (alveolar clefts): Complete clefts involving
palate+ alveolar ridge +lip
nilateral Bilat ral Median
[SE Q.2]
{b. Veau's classification (1931)
Four groups:
Group 1: Cleft involving soft palate only
Group 2: Cleft involving hard and soft palate
extending up to incisive foramen
Group 3: Complete unilateral clefts involving-soft
palate + hard palate + lip and alveolar ridge
Group 4: Complete bilateral clefts affecting-soft
palate + hard palate + lip and alveolar ridge}
c. Classification by Foghandersen (1942)
.--... Single (unilateral

or median clefts)
......__. Double (bilateral

clefts)
.....-. Unilateral
Group 2: Clefts of lip + plate
Single double
-
Group 3: Clefts of the palate extending up to incisive

foramen.
d. Schuchardt and Pfeifer's symbolic classification:
• Classification makes use of a chart made of three
pairs of rectangles which represent lip, alveolus
and hard palate as we go down.
• One inverted triangle at bottom represents soft
palate.
• Areas affected by clefts are shaded in the chart.
Advantage: Simplicity
Disadvantage: Difficulty in writing typing and
communication.
Left Right
Lip
Alveolus
Total cleft Hard palate

Partial cleft
Soft palate
e. Kernahan's stripped 'Y' classification:

Symbolic Classification - uses a stripped 'Y' having
numbered blocks, which represents specific areas
of the oral cavity.
Block 1 and 4 -+ lip
Block 2 and 5 -+ alveolus
Block 3 and 6 ---. hard palate anterior to incisive
foramen
Block 7 and 8 -+ hard palate posterior to incisive
foramen
Block 9 -+ soft palate
The boxes are shaded in areas where the cleft has
occurred
5
6 \
f. LAHSHAL classification:
Simple classification by Okriens (1987).
f. LAHSHAL classification:
Simple classification by Okriens (1987).
LAHSHAL is a paraphrase of the anatomic areas
affected by the cleft.
L-Lip
A-Alveolus
H - Hard palate
S - Soft palate
H - Hard palate
A-Alveolus
L-Lip
Areas involved in cleft are denoted by specifically

indicating the alphabet standing for it.
For example: (1) L ... S ... (cleft if right lip and soft
palate).
(2) L A... S ... L (stand for right lip, alveolus and soft
palate together with left cleft lip).
This classification is based on the fact that:
The clefts of lip, alveolus and hard palate
Bilateral
While clefts involving soft palate are
usually >
Unilateral
Clinical picture and problems associated with
clefts:
A cleft lip and palate patient can be afflicted by a
number of problems which can be broadly
classified as:
A. Dental
B. Aesthetic
C. Speech and hearing
D. Psychologic
A. Dental problems: Presence of the cleft is
associated with division, displacement
and deficiency of oral tissue. Cleft lip and
palate patients can have one or mode of
following features:
i. Congenitally missing teeth (most
212
common I )
ii. Presence of natal and neonatal
teeth
iii. Presence of supernumerary teeth
iv. Ectopically erupting teeth
v. Anomalies of tooth morphology, i.e.
microdontia, macrodontia, fused
teeth, aberrations in crown shape
and enamel hypoplasia
vi. Mobile and early shedding of the
teeth due to poor periodontal
support
vii. Posterior and anterior crossbite
viii. Protruding premaxilla
ix. Deep bite
x. Spacing/crowding
B. Aesthetic problems:
• Clefts involving lip can result in facial
disfigurement (mild to severe).
• Orofacial structures may be malformed
or congenitally missing.
• Deformities of nose can also occur.
Thus aesthetics is greatly affected.
C. Hearing and speech: Cleft lip and palate
are sometimes associated with middle ear
disorders that affect hearing.
Presence of hearing cause Difficultic in language

problems uptake and peech
D. Psychological problems:
These patients are under a lot of
psychological stares. Due to their
abnormal facial appearance they have to
put up with staring, curiosity, pity, etc.
They face problems in getting jobs and
making friends. They fare badly in
academics as a result of hearing
impairment speech problems and
frequent absence from school.
Q.2. Describe in brief about the malformations of

dental arches in cleft lip and palate cases. Write
about aetiology and orthodontic management of
cleft lip and palate cases.
Ans.
• The malformations of dental arches associated with
cleft lip and palate are as follows:
i. Dental aberrations
ii. Aesthetic and growth problems
i. Dental aberrations include:
a. Malalignment of alveolar arches
b. Posterior and anterior crossbites
c. Spacing, crowding and various anomalies
of tooth morphology etc.
ii. Aesthetic and growth problems:
The severity of cleft lip or palate affects degree of
deformity of dentofacial structures.
a. Midface deficiency with
characteristic concave profile.
b. Hypoplastic maxilla with shortened
columella on the cleft side.
c. Grossly deficient premaxilla in
bilateral clefts.
d. Hypoplastic muscles of soft palate.
e. Nasal tip is widened and flattened.
{SN Q.1}
Aetiology of cleft lip and palate:
Genetic and environmental factors causing cleft lip
and palate are:
i. Heredity: Is an important aetiologic factor.
Clefts of the lip and palate may be
transmitted as a dominant or a recessive
trait.
ii. Environment: Another possible
environmental factor is teratogenesis.
Some of known toratogens are rubella
virus, cortisone, mercaptopurine,
methotrexate, valium and dilantin.
iii. Multifactorial aetiology: Recent studies
have shown that aetiology of cleft lip and
palate cannot be attributed solely to
either genetic or environmental factors. It
seems to involve more than one factor.
Management of cleft lip and palate patient:
The treatment protocol from birth to adulthood of a
child born with cleft lip and palate is as follows:
{SN Q.5}
• The complexity of the problem requires that a
number of health care practitioners cooperate to
ensure comprehensive care and successful
rehabilitation of the patient.
• This led to the concept of multidisciplinary cleft
palate team comprising:
Paediatrician
P aedodon tist
Orthodontist
Oral and maxillofacial surgeon
Prosthodontist
Social worker
Genetic scientist
ENT surgeon
Plastic surgeon
Psychiatrist
A speech pathologist
• The cleft palate team has been described as close,
cooperative, democratic, multiprofessional union
devoted to single cause, i.e. patient well-being.
• The management of cleft lip and palate can be
divided into following stages:
A.
Stage
- Birth to 18 months of age
1
B. __, 18 months to 5th year of life (primary
Stage dentition stage)
2
c. __, 6-11 year of age (mixed dentition stage)
Stage
3
D. __, 12-18 year of age (permanent dentition
Stage stage)
4
A. Stage 1 treatment:
Treatment modalities carried out during first stage
include:
(a) Fabrication of a passive obturator
(b) Presurgical orthopaedics
(c) Surgical management of cleft lip
(d) Surgical management of cleft palate
(a) Fabrication of passive maxillary obturator:
• It is an intraoral prosthetic device fabricated
using clod cure acrylic.
• Clasps can aid in retention. In case of
insufficient retention, wings made of thick
wire can be embedded in acrylic and can be
stabilized against cheeks using micropore
adhesive tape.
• It fills palatal cleft and provides a false
roofing against which the child can suckle.
• It reduces incidence of feeding difficulties
like insufficient suction, excessive air intake
and choking.
• It provides maxillary cross arch stability, thus
preventing arch from collapsing.
(b) Presurgical orthopaedics:
• The aim of presurgical orthopaedics is to
achieve upper arch from that conforms to
the lower arch.
• The orthodontist should try to correct the
displacement such as outward displacement
of premaxilla (in bilateral cleft) and
displacement of greatest segment (in
unilateral clefts) by extra-oral strapping
across the premaxilla attached directly to
the face or to some form of head cap. A
micropore adhesive tape can also be
strapped across the premaxilla.
• In case of a narrow, collapsed maxillary arch
- expansion can be achieved by a suitable
appliance incorporating screws or springs.
• Advantages of presurgical orthopaedic phase
are
i. ! size of clefts thereby aiding in surgery
ii. Partial obturation of clefts assists feeding
iii. Improved speech - As size of defect !
iv. Reassures the parents at a crucial time
(c) Surgical lip closure:
Surgery should he perf orrned

within 45 day') of birth. The
early surgery improve, the
Earl) - facial appearance and
r schoo I
,u1H!c,t,
therefore nnprov e') child
acceptance and J, parent
Surge!") should he performed
wi thin .is days of birth. The
early surgery improves the
Early - facial appearance and
school therefore improv C!) child
-,uggc'>t, acceptance and J. parent
apprehension.
Two
schoolv The surgery should be
postponed till the
completion of dentition.
Reason being that the tivsue

The late - would be able to grow and
school mature. thereby g1 \ i ng the
surgeon more muscle n1a,:,,
to \\ ork on.
Millard suggested rule of 10:

Surgery should be performed in a child at the age not
less than 10 weeks of age and body weight not less
there 10 pounds and Hb0/o not less than 10 g0/o.
(d) Surgical palate closure:
• Palate repair should be attempted between
12 and 24 months of age; this facilitates
normal speech, hearing and improves
swallowing.
• Repair is done using bone transplants from
rib, iliac bone, mandibular symphysis, tibial
bone or outer table of parietal bone.
B. Stage two treatment:
This stage of treatment is carried out during primary
dentition period.
The procedures include:
(a) Adjustments in the intraoral obturator to
accommodate the erupting deciduous teeth
(b) To maintain a check on eruption pattern and
timing
(c) Oral hygiene instructions
(d) Restoration of decayed teeth
No orthodontic treatment is usually initiated during
this phase.
C. Stage three treatment:
It includes treatments carried out during mixed
dentition phase.
Orthodontic procedures usually carried out are
(a) Correction of anterior crossbites with
removable or fixed appliances.
For example: removable appliance with Z-
spring to treat anterior crossbite
(b) Buccal segment crossbites are treated using
quad helix or expansion screws.
D. Stage four treatment:
• Consists of treatment during permanent dentition -
with fixed orthodontic appliance.
• All local irregularities - crowding, spacing,
crossbites and overjet lover bite problems are
corrected.
• Patients with hypoplastic maxilla - are given face
mask to advance the maxilla.
• In case of missing teeth - prosthesis can be given
after completion of orthodontic treatment.
• Following completion of orthodontic treatment long
retention phase is required in these patients.
Because of inadequate bone support, absence of
some teeth presence of stretched scar tissue.
These patients should be treated with sympathy
and concern in addition to flexibility and
multidisciplinary approach.
Q.3. What are the causes of cleft lip and palate? How
will you manage the problems associated with them?
Ans.
[Same as LE Q.1]
Q.4. Briefly discuss the treatment protocol from

birth to adulthood of a child born with cleft lip and
palate.
Ans.
[Same as LE Q.2]
Short essays:
Q.t. Orthodontic management of cleft palate.

Ans.
Orthodontic treatment of cleft lip and palate can be
studied under four stages:
i. Infancy stage
ii. Late primary and mixed dentition period
iii. Early permanent dentition period
iv. After growth completion
i. Infancy stage:
• Infantorthopaedics is usually carried out at 3-6
weeks of age so as to facilitate lip closure done at
about 10 weeks of age.
• Different orthopaedic solutions to reposition the
maxillary segments and retract premaxilla are:
light elastic strap across premaxillary segment,
orthodontic appliance pinned to the segments in
severe cases and pressure from repaired cleft lip.
• Construction of feeding plates to assist the child in
feeding.
ii. Late primary and mixed dentition period:
• Orthodontic treatment is not required at this stage.
iii. Early permanent dentition period:
• Fixed appliance orthodontic treatment is started at
this age, as there is tendency to develop posterior
crossbites.
• Space closure is carried out after successful bone
grafting.
iv. After growth completion:
• Comprehensive orthodontic treatment using pre-
adjusted edge-wise appliances for precise
positioning of teeth.
• Chin cup can be used to redirect the mandibular
growth.
• Maxillary protraction by using orthognathic
surgery.
• Maxillar distraction osteogenesis that provides
simultaneous maxillary advancement as well as
expansion of soft tissues.
Q.2. Enurnerare various classifications of cleft lip

and palate and describe Veau's classification of cleft
lip and palate.
Ans.
[Ref LE Q.1]
Q.3. Surgical closure of cleft lip? Describe briefly any

one technique.
Ans.
• Surgical closure of cleft lip is known as cheiloplasty.
• There are three principles in closure of a cleft lip:
i. The positioning of structures in their
anatomically most appropriate position
(primary muscle continuity)
ii. Reconstruction of a muscle sphincter
iii. The avoidance of a straight line lip scar
Principles of symmetry:
• Primary muscle continuity
• Proper philtral shape and size
• Formation of median tubercle from lateral
labial elements
{SN Q.2}
Various techniques of cleft lip repair are:
i. Tension - Randall repair (triangular flap repair)
ii. Lemesurier (1949) technique (quadrangular
flap repair)
iii. Millard (1976) lip repair (rotation and
advancement tech)
iv. Delaires technique
v. Modified Millard's technique
Tennison-Randall repair:
• This technique deploys triangular flap.
• Points in technique: Mathematical precision in
measurement is necessary (Randall 1971).
Advantages:
i. Skin incision can be combined with a
muscle dissection and repositioning.
ii. Straight line scar is avoided.
iii. The cupids bow in preserved by
advancing a triangular flap into the free
edge of the medial lip to bring the
vermilion down, thereby equalizing the
columella length on cleft and noncleft
side.
emu,.
Disadvantages:
i. Philtrum is broken up by triangular flap.
ii. Secondary correction can be difficult.
Le mesurier technique:
(Le mesurier right-angled flap lip repair)
lnc,slon marked
This technique uses quadrilateral flap to achieve a

nonstraight line closure.
Advantages:
• As a quadrilateral flap was raised comprising full
thickness skin, muscle and mucosa, it provides
much tissue for closing a wide cleft by bringing
musculocutaneous flap from upper part of the
lateral lip down to fill the deficiency in the lower
part of the lip defect.
Disadvantages:
i. The workings are made preoperatively on
the basis of arbitrary measurements and
no modification can be made during
operation.
ii. The quadric lateral scar has a horizontal
element which does not approximate to
any natural structure of the lip and will
always look unnatural.
iii. Thus procedures accidentally reorientate
muscle bundles within quadrilateral flaps
in a nonfunctional way. Thus muscle
tissue may even be denervated.
iv. Later revision of the scar can be
extremely difficult if the lip is too long or
too short.
Millard lip repair:
, , , 1 , 1 , , •
Millard lip repair:
• Most popular technique in current times
internationally.
• The technique is described as skin rotation
advancement.
• The entire cupids bow and dimple component is
lowered (rotation) by incising in the line of the
hypoplastic or missing philtral column. This opens
a gap into which the lateral lip element and flared
alar base can be placed (advancement).
• Points of technique:
The vertical component of the scar seems nearly

always to be short and this should perhaps be
designed a little longer than is necessary.
Incision mal1<ed Closure after freely of rolation nap

(1) and advancement flap (2)
Advantages:
i. The flaps can be modified after initial cutting
(cut as you go) to bring down the cleft side to
the level of the noncleft side.
ii. This technique sacrifices some little amount of
tissue from the margin of the cleft.
iii. Dissection of the muscle as a separate layer is
relatively straight forward and a three layer
closure can be achieved.
iv. Scar is excellent for later revision.
v. It stimulates normal philtral column and
technique provides best possible nasal
philtrum.
Disadvantages of Millard's lip repair:
i. The scar is almost always little short.
ii. Even when the static length of new philtral
column is satisfactory, dynamic motion will not
be natural.
iii. In a wide cleft the large closure can be difficult
to achieve and it can seem as a very radical
procedure when the cleft is very minimal.
In spite of some disadvantages the Millard's
technique remains the most versatile
technique and probably the best available.
Short notes:
Q.1. Aetiology of cleft lip and palate.

Ans.
[Ref LE Q.2]
Q.2. Name various techniques of cleft lip closure.

Ans.
[Ref SE Q.3]
Q.3.Name surgical management procedures of cleft
palate.
Ans.
Various surgical procedures in management of cleft
palate are as follows:
i. Bardach's two flap technique
ii. Cutting's technique
iii. Salyer's modified two flap technique
iv. Oxford technique
v. Oslo technique
vi. Delaires technique
Q.4. NAM.
Ans.
i. Nasoalveolar moulding (NAM) is a nonsurgical
technique developed by Dr Court Cutting and Dr
Barry Grayson at New York University.
ii. They combined the moulding techniques used in
orthodontic treatment and latest cosmetic surgical
techniques to develop nasoalveolar moulding.
iii. NAM is only effective in infants below the age of 6
months as their cartilage is malleable.
iv. Advantages of NAM:
• NAM device reduces the number of surgeries
required during patient's life time thereby
reducing the facial scarring, trauma,
inconvenience and cost involved in additional
surgeries.
• It also helps with feeding.
• Nose has been lifted and narrowed by the time of
surgery, smaller gap in cleft region reduces tension
when surgeon closes the cleft.
Q.5. What is 'team approach' in rehabilitation of cleft

lip/palate patients?
Ans.
[Ref LE Q.2]
Topic 31 Surgical orthodontics
Long essays:
1. Classify surgical orthodontics. Discuss about
minor surgical orthodontic procedures.
2. What is surgical orthodontics? Enumerate the

minor and major surgical orthodontic procedures.
Discuss any three minor surgical orthodontic
procedures. [Same as LE Q.1]
3. Define surgical orthodontics. Give objectives,
classification of surgical orthodontics and discuss
in detail about minor surgical orthodontic
procedures. [Same as LE Q.1]
Short essays:
1. Genioplasty.
2. Enumerate the surgical modalities in correction of
mandibular prognathism. Describe any one in
brief.
3. Enumerate minor surgical procedures in
orthodontics. Write briefly about transplantation
of teeth.
4. Sterilization in orthodontics.
5. Cosmetic surgeries. [Same as SE Q.1]
Short notes:
1. Pericision. [Ref LE Q .1]
2. Surgical orthodontics. [Ref LE Q.1]
3. Genioplasty. [Ref SE Q.1]
4. Impacted upper permanent canine.
5. Frenectomy.
6. Orthognathic surgery in the maxilla.
7. Resection.
8. Supracrestal fibrotomy. [Same as SN Q.1]
9. Surgical aids in orthodontics. [Same as SN Q.2]
10. Minor surgical procedures. [Same as SN Q.2]
11. Cosmetic surgeries. [Same as SN Q.3]
12. Osteotomies. [Same as SN Q. 7]
Solved answers
Long essays:
Q.1. Classify surgical orthodontics. Discuss about

minor surgical orthodontic procedures.
Ans.
{SNQ.2}
• Surgical orthodontics is a term that refers to surgical
procedures carried out as an adjunct to or in
conjunction with orthodontic treatment.
• Surgical orthodontic procedures are broadly
classified as minor surgical procedures and major
surgical procedures.
A. Minor surgical procedures:
i. Extractions:
a. Therapeutic extractions
b. Serial extractions
c. Extraction of carious teeth
d. Extraction of malformed teeth
e. Extraction of supernumerary teeth
f. Extraction of impacted teeth
ii. Surgical uncovering/exposure of teeth
iii. Frenectomy
iv. Pericision
v. Transplantation of teeth
vi. Corticotomy
vii. Removal of soft tissue barrier
viii. Removal of cysts and odontomes
ix. Orthodontic implants
B. Major surgical procedures:
i. Orthodontic surgeries
ii. Cosmetic surgeries
iii. Surgical corrections in cleft lip and
palate patients
iv. Surgical assisted rapid maxillary
expansion
v. Distraction osteogenesis
• Various minor surgical procedures are discussed in
detail below:
i. Extractions:
These are the most commonly undertaken minor
surgical procedures in conjunction with
orthodontic therapy.
a. Therapeutic extractions:
• Undertaken mainly to gain the space.
• Preoperative radiographs are valuable
aid in planning and execution of
extraction.
b. Serial extraction:
Involves removal of some deciduous teeth
followed by specific permanent teeth in an
orderly sequence to guide the rest of the
permanent teeth into a more favourable
position during mixed dentition period.
c. Extraction of supernumerary, impacted
and ankylosed teeth:
The presence of supernumerary, impacted
and ankylosed teeth are important local
causes of malocclusion prior to removal of
these teeth their exact location and their
relationship with adjacent structures
should be ascertained by radiographs.
ii. Surgical uncovering of impacted teeth:
Impacted teeth due to presence of mucosa! and
bony barriers that prevent their eruption
should be managed in the following steps:
• Location of the tooth - Clark's technique or
right angle technique
• Evaluation of favourability- consider
favourable whenever apex of canine is close to
its normal position
• Evaluation of space adequacy.
• Surgical excision and bone removal - overall
tooth
• Fixing orthodontic attachments
iii. Frenectomy:
Maxillary midline frenum, mandibular labial
and lingual frenum might contribute to
Frenectomy is a surgical procedure performed
to excise the frenum and remove the deeply
embedded fibrous tissue.
Timing of frenectomy
!
i
According to one school According to another school
of thought
!
It should be performed prior
!
It should be performed after
to orthodontic closure of orthodontic space closure
midline diastema. as it reduces the risk of
scar tissue formation
that can prevent closure
of the midline diastema.
The following points should be remembered during

frenectomy regardless of timing when the procedure
in performed.
a. The frenum should not merely be clipped. It
should be totally excised to bone level.
b. Any palatally attached fibrous tissue should be
removed.
c. Fibrous tissue attached to the intermaxillary
suture area should be removed.
d. The mucosa of the lip is undermined to prevent
reattachment of the fibrous tissue.
iv. Corticotomy:
• Usually undertaken in patients having dental
proclination with spacing and in median diastema
without any other features of malocclusion.
• It involves sectioning of the dentoalveolar region
into multiple small units to speed up orthodontic
tooth movement.
• Surgical steps in corticotomy are as follows:
a. Raising labial flaps.
b. Interdental bony cuts are made parallel
to long axis of teeth.
c. Joining of the cuts together by a
horizontal bony cut above the apices of
the roots.
d. Following surgery orthodontic tooth
movements is reiterated using fixed
appliances.
{SN Q.1}
v. Pericision:
• Pericision is also known as supracrestal fibrotomy,
circumferential supracrestal fibrotomy, sulcus slice
procedure and Edwards procedure.
• Pericision is a minor surgical procedure that is
undertaken under local anaesthesia to counter the
relapse tendency of the stretched gingival fibres.
The transeptal and alveolar crest group of gingival
fibres remains stretched and do not readily
readapt to the new tooth position following
correction of rotation, hence causing relapse.
• Pericision involves surgical sectioning of these
fibres by passing a sharp narrow scalpel through
the gingival sulcus around the tooth to a depth of
2-mm apical to the alveolar crest.
• Pericision is generally undertaken as an adjunctive
retention procedure after the correction of
rotations.
Q.2. What is surgical orthodontics? Enumerate the

minor and major surgical orthodontic procedures.
Discuss any three minor surgical orthodontic
procedures.
Ans.
[Same as LE Q.1]
Q.3. Define surgical orthodontics. Give objectives,

classification of surgical orthodontics and discuss in
detail about minor surgical orthodontic procedures.
Ans.
[Same as LE Q.1]
Short essays:
Q.1. Genioplasty
Ans.
{SN Q.3}
• Cosmetic surgeries are surgical procedures carried
out to improve the aesthetic appearance of the
patient.
{SN Q.3}
• Cosmetic surgeries are surgical procedures carried
out to improve the aesthetic appearance of the
patient.
• Cosmetic surgery of the

Genioplasty:
• Surgical correction of chin is known as genioplasty.
• It is of following types:
Augmentation and reduction of genioplasties.
i. Single section horizontal sliding genioplasty for
augmentation of chin. Transosseous wires are
placed to decrease the possibility of relapse.
Slight overcorrection is employed.
ii. Double section horizontal sliding genioplasty. The

additional section allows for greater augmentation of
chin prominence
iii. Genioplasty for length reduction of chin prominence.

Osteotomy bony incisions are made in more vertical
plane and a section equal to the desired reduction is
removed.
iv. Genioplasty for height reduction of anterior portion

of mandible.
Q.2. Enumerate the surgical modalities in correction

of mandibular prognathism. Describe any one in
brief.
Ans.
The mandibular prognathism can be corrected by
various surgical procedures like:
i. Mandibular body osteotomy
ii. Mandibular ramus osteotomy
iii. Sagittal split technique
iv. C and L osteotomies
v. Vertical subsigmoid osteotomy
Sagittal split technique:
• One of the most widely used procedure for
mandibular reduction is bilateral sagittal split
osteotomy (BSSO).
• It is a versatile intraoral surgical procedure
performed under general anaesthesia.
• Asymmetry and crossbite corrections are possible
with this procedure.
Surgical steps:
• On the medial aspect of the ram us, a horizontal
cut is done only in the cortical bone above the
mandibular foramen.
• The cut is stopped just behind the mandibular
foramen. The cut is then taken just medial to the
lateral oblique ridge to the horizontal ramus
about 2.5 mm below the bony cervical margin.
This is brought up to the level of second molar or
a little anterior.
• The vertical cut of the bone is done from the
anterior end of the cut downward to the inferior
border.
• Bone splitting is started at the anterior aspect of
the medial cut on the vertical ramus using a 4
mm osteotome. Spreader (Smith bone spreader)
is engaged in the split and the split is spread out
to completion. Care should be taken not to cut
the inferior alveolar nerve.
• All the above-mentioned steps are repeated on
the opposite side.
• Mandibular setback is achieved and the
prefabricated splint is placed in proper occlusion
and intermaxillary fixation is done.
• BSSO can be used to correct mandibular
prognathism, mandibular retrognathism and
facial asymmetry.
• Depending on the purpose of the surgery,
mandibular setback is done for mandibular
prognathism, mandibular advancement is done
for retruded mandible and mandibular
repositioning is done for facial asymmetry.
Q.3. Enumerate minor surgical procedures in

orthodontics. Write briefly about transplantation of
teeth.
Ans.
Surgical orthodontic procedures are broadly classified
as minor surgical procedures and major surgical
procedures.
A. Minor surgical procedures include:
i. Extractions:
a. Therapeutic extractions
b. Serial extractions
c. Extraction of carious teeth
d. Extraction of malformed teeth
e. Extraction of supernumerary teeth
f. Extraction of impacted teeth
ii. Surgical uncovering/exposure of teeth
iii. Frenectomy
iv. Pericision
v. Transplantation of teeth
vi. Corticotomy
vii. Removal of soft tissue barrier
viii. Removal of cysts and odontomes
ix. Orthodontic implants
Transplantation or transpositioning of teeth:
• It is a technique of reimplanting tooth after being
removed into a newly created socket.
For example: Teeth most commonly transplanted
are 3rd molars into first molar region.
• Criteria for selection of case: Sufficient space
should be available and minimum trauma to the
prepared socket and tooth to be reimplanted
should have a wide open apex, should be
extracted atraumatically without damaging
periodontal ligament and cementum.
• Procedure:
a. After the preparation of recipient site,
tooth to be transplanted is uncovered
extracted a traumatically.
b. Extracted tooth is placed in the prepared
bony socket.
c. Wound is closed and sutured with 3-0
black silk.
Q.4. Sterilization in orthodontics.

Ans.
Various methods of sterilization commonly used are
i. Hot air oven
ii. Boiling water
iii. Autoclave
iv. Cold sterilization
The best method of sterilization used is autoclave:
• It provides moist heat in the form of saturated
steam under pressure.
• Holding temperature is 121 °c for 20 min under 15
lb pressure or 134 -c for 3 min.
• It is most effective and time-efficient method.
• It kills microorganisms by coagulation and
denaturation of proteins.
Q.5. Cosmetic surgeries.

Ans.
[Same as SE Q.1]
Short notes:
Q.1. Pericision.
Ans.
[Ref LE Q.1]
Q.2. Surgical orthodontics.

Ans.
[Ref LE Q.1]
Q.3. Genioplasty.
Ans.
[Ref SE Q.1]
Q.4. Impacted upper permanent canine.

Ans.
• Impacted teeth due to presence of mucosal and bony
barriers that prevent their eruption should be
managed in the following steps:
i. Location of the tooth and their relation with
adjacent structures should be confirmed by
radiographs - Clark's technique or right angle
technique.
• Evaluation of favourability.
• Evaluation of space adequacy.
• Depending on location, tooth should be surgically
approached by either a buccal or palatal flap and
adequate amount of bone should be removed
using rotary cutting instruments.
• Fixing orthodontic attachments, the tooth can be
aligned in occlusion if possible, otherwise it is
extracted and the wound is closed with sutures.
Q.5. Frenectomy.
Ans.
• Frenectomy is a surgical procedure performed to
excise the frenum and remove the deeply embedded
fibrous tissue.
• Timing of frenectomy: According to one school, it
should be performed prior to orthodontic closure of
midline diastema and according to another school of
thought, it should be performed after orthodontic
thought, it should be performed after orthodontic
space closure.
• Regardless of timing when the procedure is
performed, the following points should be
remembered during frenectomy:
a. The frenum should be totally excised to bone
level.
b. Fibrous tissue attached palatally or to the
intermaxillary suture area should be removed.
c. The mucosa of the lip is undermined to prevent
reattachment of the fibrous tissue.

Q.6. Orthognathic surgery in the maxilla.
Ans.
• Orthognathic surgery is an art and science of
diagnosis, treatment planning and execution of
treatment to correct musculoskeletal, dento-osseous
and soft tissue deformities of orofacial region.
• Orthognathic surgeries are major surgical procedures
carried out along with orthodontic therapy to correct
dentofacial or orofacial deformities.
• Maxilla is corrected using Le Fort I osteotomy as per
requirement by individual case as following:
i. Maxillary retrusion or hypoplasia: Le Fort I
osteotomy with maxillary advancement.
ii. Maxillary protrusion: Maxillary segmental
setback.
iii. Maxillary deficiency: Le Fort I osteotomy to
advance and impact maxilla.
iv. Maxillary vertical excess: Le Fort I osteotomy
with maxillary impaction.
Q.7. Resectionor osteotomies.

Ans.
• The fundamental or basic biology behind all
orthognathic surgical procedures is that the bones of
maxilla and mandible are intentionally sectioned
and repositioned to desired sites to correct
dentofacial deformities.
• Osteotomies refers to simple bone cuts, whereas
ostectomy or resection means removal of a portion
of bone.
For example:
i. Le Fort I osteotomy to correct maxillary
retrusion or hypoplasia
ii. Mandibular ramus osteotomy
iii. C and L osteotomies for repositioning of
body and dentoalveolar segment of
mandible
iv. BSSO (bilateral sagittal split osteotomy)
for mandibular reduction
Q.8. Supracrestal :fibrotomy.

Ans.
[Same as SN Q.1]
Q.9. Surgical aids in orthodontics.

Ans.
[Same as SN Q.2]
Q.10. Minor surgical procedures.

Ans.
[Same as SN Q.2]
Q.11. Cosmetic surgeries.

Ans.
[Same as SN Q.3]
Q.12. Osteotomies.
Ans.
[Same as SN Q.7]
Topic 32 Retention and relapse
Long essays:
1. Define retention and relapse. Write briefly about
causes of relapse.
2. Enumerate theories of retention.

3. What is retention? Describe in brief various
retention appliances commonly used in
orthodontic practice.
4. Define retention and relapse in orthodontics. What
are the causes of relapse and how would you
prevent them? [Same as LE Q.1]
5. Discuss the role of periodontium and growth in
causing relapse. Write in brief four other causes
of relapse? [Same as LE Q.1]
6. Define retention and discuss various theories of
retention. [Same as LE Q.2]
7. Write the theories of retention and types of
retention. [Same as LE Q.2]
8. Classify retention appliances and describe in
detail the Hawley retainer. [Same as LE Q.3]
9. Explain in detail retention after treatment of
malocclusion. [Same as LE Q.3]
Short essays:
1. Retention in orthodontics.
2. What is relapse? What are the causes of relapse?
[Ref LE Q.1]
3. Fixed retainer.
4. Theories of retention. [Ref LE Q.2]
5. Define retention. Explain the schools of retention.
6. Permanent retention. [Same as SE Q.1]
7. Relapse in orthodontics. [Same as SE Q.2]
8. Define relapse. Add a note on the role of third
molars in causing relapse. [Same as SE Q.2]
Short notes:
1. Relapse in orthodontics. [Ref LE Q.1]
2. Hawley's retainer. [Ref LE Q.3]
3. Permanent retention. [Ref SE Q.1]
4. Retention appliance. [Ref LE Q.3]
5. 'Relapse' and 'retention'. [Ref SE Q.1]
6. Name different schools of thought for retention.
7. What is the role of third molar in causing the
relapse?
8. Adjunctive periodontal surgeries to minimize
relapse.
9. Riedel's theorems of retention and relapse. [Ref LE
Q.2]
10. Define retention period.
11. Give an example of natural or self-retention. [Ref
SE Q.1]
12. What is relapse? How to prevent relapse?
13. Define and classify retention giving examples.
[Ref SE Q.1]
14. Upper Hawley's appliance. [Same as SN Q.2]
15. Retainers. [Same as SN Q.4]
16. Define retention. [Same as SN Q.5]
17. Types of retention. [Same as SN Q.13]
Solved answers
Long essays:
Q.1. Define retention and relapse. Write briefly

about causes of relapse.
Ans.
• Retention has been defined by Moyer's as
'maintaining newly moved teeth in position, long
enough to aid in stabilizing their correction'.
(SN Q.1 and SE Q.2)
• {(Relapse can be defined as 'the loss of any correction
achieved by orthodontic treatment'.
Or in simple terms it is the tendency of teeth to
return back to original position post-treatment.
• Causes of relapse:
Numerous causes are attributed to relapse. There
is no single factor that can be said to be the sole
cause of relapse. In most cases, relapse occurs
due to a combination of causes.
• The main aetiologic causes of relapse are as follows:
i. Periodontal ligament traction
ii. Relapse due to growth-related changes
iii. Bone adaptation
iv. Muscular forces
v. Failure to eliminate the original cause
vi. Role of 3rd molars
vii. Role of occlusion)}
[SE Q.2]
{i. Periodontal ligament traction:
• Orthodontic treatment causes -
Stretching of periodontal ligament
and gingival fibres; there fibres
can contract and cause relapse.
• The principle fibres of periodontal
ligament rearrange themselves
quite rapidly to the new position
within about 4 weeks time. The
supra-alveolar gingival fibres take
around 40 weeks to rearrange
around new position and thus
predispose to relapse provided
proper retention period is not
continued.
II. Relapse due to growth-related changes:
• Patients with skeletal Class II, Class
III, open bite or deep bite
malocclusion may exhibit relapse
due to continuation of abnormal
growth pattern after orthodontic
treatment.
• Hence prolonged retention is
indicated until active growth is
completed.
III. Bone adaptation:
• Teeth moved recently are
surrounded by lightly calcified
osteoid bone. Thus the teeth are
not adequately stabilized and have
a tendency to move to their
original position.
• Normally bony trabecular are
arranged perpendicular to long
axis of teeth, whereas during
orthodontic treatment, they get
aligned parallel to direction of
force. During retention phase they
revert back to their normal
alignment.
IV. Muscular forces:
Muscle imbalance at the end of
orthodontic treatment result in
reappearance of malocclusion.
V. Failure to elucidate original cause:
Failure to remove the aetiology of
malocclusion can result in relapse.
VI. Role of 3rd molars:
• Most patients would have completed
their orthodontic treatment by the
time 3rd molars start erupting, i.e.
around 18-21 years of age.
• The pressure exerted by erupting
3rd molars is believed to cause late
anterior crowding, predisposing to
relapse.
VII. Role of occlusion:
• The CR and CO should coincide or
the slide from centric should not
be >1.5-2 mm in order to have
greater stability of orthodontic
treatment results.
• Presence of certain occlusal
mannerisms such as clenching,
grinding, nail biting and lip biting
are important causes of relapse.}
Q.2. Enumerate theories of retention.

Ans.
[SE Q.4]
{Retention has been defined by Moyer's as
Stabilizing the treatment results by retention
procedures is an integral part of orthodontic therapy
and therefore provision should be made in the
treatment plan for adequate retention keeping in mind
the destabilizing factors.
(SE Q.4 and SN Q.9)
{(There are about 10 theorems on retention. The first
nine theorems are put forward by Riedel, while tenth
theorem was included by Moyer.
Theories of retention are as follows:
i. Theorem 1:
• 'Teeth that have been moved tend to return to their
former position'.
• The causes for this relapse are many and a single
aetiology cannot be highlighted.
• This theorem mainly applies to correction of
rotations. The apical base, trans-septal fibres and
musculature may be responsible for teeth to go
back to their original position.
ii. Theorem 2:
• 'Elimination of the cause of malocclusion will
prevent relapse'.
• The cause for the malocclusion should be identified
at the time of diagnosis and adequate steps should
be taken during the treatment plan to eliminate it.
• Failure to remove the cause r relapse potential. This
theorem can be applied in cases of malocclusion
where the cause is obvious, e.g. thumb sucking,
tongue thrusting and not in any malocclusion
where the cause is elusive.
iii. Theorem 3:
• 'Malocclusion should be over-corrected as a safety
factor'. So as to give a Leeway for a certain amount
of relapse.
• This is being practised by many orthodontists, to
allow some amount of relapse so that after relapse
the occlusion will be normal.
For example, overcorrection is done in treating
class II and III malocclusions and rotations.
iv. Theorem 4:
• 'Proper occlusion is a potent factor in holding teeth
in their corrected positions'.
• Post-treatment stability is increased by good
occlusion.
• Obtaining correct intercuspation and proper
functional occlusion are essential factors in
occlusal stabilization.
v. Theorem 5:
• 'Bone and adjacent tissues must be allowed timely
to reorganize around newly positioned teeth'.
• When teeth are moved orthodontically, numerous
changes occur in the bone and surrounding
tissues. It takes considerable time for the
reorganization to be completed.
vi. Theorem 6:
• 'If the lower incisors are placed upright over basal
bone they are more likely to remain in good
alignment'.
• Most stable results are obtained by placing the
mandibular incisors upright over the basal bone.
vii. Theorem 7:
• 'Corrections carried out during periods of growth
are less likely to relapse'.
• Treatment modalities carried out during the active
growth period allows the tissue systems to adapt
well and therefore reduce the relapse potential.
• Especially in skeletal malocclusion, early treatment
planning offers greater advantage in long-term
stability.
viii. Theorem 8:
• 'The farther the teeth have been moved, the lesser
is the risk of relapse', i.e. farther the teeth are
moved, lesser the risk of it returning to its original
position.
• There is only a little evidence to support this
concept.
ix. Theorem 9:
• 'Arch form particularly in the mandibular arch,
cannot be permanently altered by appliance
.
ix. Theorem 9:
• 'Arch form particularly in the mandibular arch,
cannot be permanently altered by appliance
therapy'.
• Alteration of existing arch form results in t risk of
relapse.)}
[SE Q.4]
x {Theorem 10:
• 'Many treated malocclusions require permanent
retaining devices'. This theorem was subsequently
added by Moyer.
• This is true in cases that have not been treated to

achieve occlusal goals that stand for stability.
• No permanent retention is required in correction of
certain malocclusions with specific occlusal goals
and regard to growth and functional aspect.}
Q.3. What is retention? Describe in brief various

retention appliances commonly used in orthodontic
practice.
Ans.
• Retainers are passive orthodontic appliances that
help in maintaining and stabilizing the position of
teeth long enough to permit reorganization of the
supporting structures after the active phase of
• Ideal requirements of a good retainer are as follows:
i. It should restrain all teeth that have been moved
into desired positions.
ii. It should allow the normal functional forces to
act freely on the dentition.
iii. It should be self-cleansable and should permit
oral hygiene maintenance.
iv. It should be as inconspicuous as possible.
v. It should be strong enough to achieve the
objectives of retention.
{SN Q.4}
• Retainers can be classified into:
Removable retainers Fixed retainers

(These are passive (These retainers are fixed or
appliances that can be fitted onto teeth and cannot
removed by the patient be removal and reinserted
and reinserted at will.) by the patient.)
a. Hawley's appliance a. Banded canine-to-canine
b. Begg retainer retainer
c. Clip-on retainer/spring b. Bonded canine-to-canine
aligner lingual retainers
d. Wrap around retainer c. Band and spur retainer
e. Kesling tooth d. Antirotation band
position er
f. Essix retainer/invisible
retainers
g.Functionalappliances
Removable retainers:
{SN Q.2}
a. Hawley's appliance:
• It was designed by Charles Hawley in 1920 and is
most commonly used retentive appliance.
• Classic Hawley's appliance consists of clasps on
molar teeth and a short labial bow which spans
from canine to canine with adjustment loops.
• Several modifications to suit specific
requirements are as follows:
i. A long labial bow instead of a short labial
bow used in cases of first premolar
extraction, helps to prevent wedging effect
in extracted
.
site and closes spaces distal to
carune.
ii. Soldering labial bow to the bridge of Adam's
clasp, is another alternative in extraction
cases to offer excellent retention and avoid
risk of space opening between canine and
premolar.
iii. Incorporation of anterior bite planes helps
to control overbite or correct deep bite
cases.
• Advantages of this appliance are:
Ease of fabrication, simple design, minimal
patient discomfort and highly acceptable
by
.
the patients
.
and is relatively
inconspicuous.
b. Begg retainer:
• Begg retainer is made up of a single wrap
round labial bow extending from the distal
of second molar to the opposite second
molar.
• Advantages:
i. The wrap around wire eliminates the
potential occlusal interferences and
allows vertical settling of occlusion
ii. In extraction cases it maintains canine
and second premolar in tight contact,
thereby eliminating the risk of space
opening up.
c. Clip-on retainer/springaligner:
• This is widely used in lower anterior region
in correcting minor rotations of anterior
teeth.
• This appliance is made up of a wire frame
work which runs labially as well lingually
over incisors passing between canine and
premolar. Both labial as well as lingual wire
segments are embedded in a strip of clear
acrylic.
• Advantage:
It is well tolerated by the patients and can be
used to realign lower incisors.
d. Wrap around retainer:
• This is an extended version of spring aligner
that covers all the teeth.
• It consists of a wire reinforced plastic bar
made with clear acrylic along the labial and
lingual surfaces of the teeth.
• This is not routinely used in orthodontic
practice.
• This retainer splints the teeth together firmly
and is usually used in stabilizing the
periodontally weak dentition.
e. Kesling tooth positioner:
• A tooth positioner devised by Kesling is
usually used as a finishing appliance,
sometimes itself can be used as a retaining
appliance.
• Advantage: It maintains intra arch tooth
position and also occlusal relationships.
• Disadvantage: Bulky, has different pattern of
wear compared to retention appliance, has
tendency to deepen the bite, speech
difficulties and risk of TMJ problems.
f. Invisible retainers:
• The invisible retainers are standard Essix
canine-to-canine retainers made of ultra thin
clear thermoplastic sheets.
• Advantage:
They are aesthetically acceptable and in
extraction cases they are extended to
cover the extraction site.
g. Functional appliances:
• They are used in the subjects who have still
growth potential. For example, activators
and oral screen.
Fixed retainers:
They are used in conditions where long-term
retention is required and intra-arch instability is
anticipated.
Various fixed retainers are as follows:
a. Banded canine-to-canine retainer:
• Commonly used in lower anterior region, for
maintenance of lower incisor position during
growth.
• The canines/premolars are banded and a thick
wire is contoured over the lingual aspect and
soldered to the bands.
• Disadvantages:
Predisposition to poor oral hygiene and are
unaesthetic
b. Bonded canine-to-canine lingual retainers:
• Various prefabricated lingual retainers are
available that can be bonded directly on
lingual aspect of canines.
• They are made from heavier wire to resist.
c. Band and spur retainer:
• It is used in cases of orthodontic correction of
single-tooth rotation or labiolingual
displacement.
• It holds the tooth in its corrected position and
prevents it from returning to its original
position.
d. Antirotation band:
• It is used to maintain corrected single-tooth
rotation.
• The band on the rotated tooth has two spurs
welded one each on labial and lingual sides, so
that they rest on adjacent teeth and prevents
relapse.
Q.4. Define retention and relapse in orthodontics.

What are the causes of relapse and how would you
prevent them?
Ans.
[Same as LE Q.1]
Q.5. Discuss the role of periodontium and growth in

causing relapse. Write in brief four other causes of
relapse?
Ans.
[Same as LE Q.1]
Q.6. Define retention and discuss various theories of

retention.
Ans.
[Same as LE Q.2]
Q.7. Write the theories of retention and types of

retention.
Ans.
[Same as LE Q.2]
Q.8. Classify retention appliances and describe in

detail the Hawley retainer.
Ans.
[Same as LE Q.3]
Q.9. Explain in detail retention after treatment of

malocclusion.
Ans.
[Same as LE Q.3]
Short essays:
Q.1. Retention in orthodontics.

Ans.
{SN Q.3, Q.5 and Q.13}
--- ..... -\.... .. _ ..... ..:..J .:_ ...... + .... 1.....:1.:_.: __ ... 1....._.:_ ------ ... .:--,
Q.1. Retention in orthodontics.
Ans.
{SN Q.3, Q.5 and Q.13}
• Retention can be of three types
i. Natural or no retention
ii. Limited or short-term retention
iii. Prolonged or permanent retention
i. Natural or no retention:

Some conditions that do not require any
retention include
{SN Q.11}
a. Anterior crossbite
b. Serial extraction procedures
c. Blocked out/highly placed canines in class I
extraction cases
Posterior crossbite in patients having steep cusps
ii. Limited or short-term retention:
Most cases treated routinely in the orthodontic
clinic fall into this category. Retention is
recommended to allow the bone and other
periodontal tissues to readapt to their new
location.
For example: class I nonextraction with dental
arches
a. Showing proclination and spacing
b. Deep bites
c. Class I, class II division 1 and
division 2 cases treated by
extraction.
iii. Prolonged or permanent retention:
{SN Q.3}
Cases that require prolonged or indefinite retention
include
For example:
a. Midline diastema
b. Severe rotations
c. Arch expansion achieved without
ensuring good occlusion
c. Certain class II division 2 deep bite
cases
d. Patients exhibiting abnormal
musculature or tongue habits
e. Expanded arches in cleft palate
patients
Q.2. What is relapse? What are the causes of relapse?

Ans.
[Ref LE Q.1]
Q.3. Fixed retainer.

Ans.
• Retainers are passive orthodontic appliances that
help in maintaining and stabilizing the position of
teeth long enough to permit reorganization of the
supporting structures after the active phase of
• Retainers can be classified as: (i) removable and (ii)
fixed retainers.
• Fixed retainers are fixed or fitted onto teeth, and
cannot be removal and reinserted by the patient.
• Various fixed retainers are as fallows:
i. Banded canine-to-canine retainer
ii. Bonded canine-to-canine lingual retainers
iii. Band and spur retainer
iv. Antirotation band
i. Banded canine-to-canine retainer
• Commonly used in lower anterior region for
maintenance of lower incisor position
during growth.
• The canines/premolars are banded and a
thick wire is contoured over the lingual
aspect and soldered to the bands.
ii. Bonded canine-to-canine lingual retainers:
Various prefabricated lingual retainers are
available that can be bonded directly on lingual
aspect of canines.
iii. Band and spur retainer: It is used in cases of
orthodontic correction of single-tooth rotation
or labiolingual displacement.
iv. Antirotation band
• It is used to maintain corrected single-tooth
rotation.
• The band on the rotated tooth has two spurs
welded one on each on labial and lingual
sides, so that they rest on adjacent teeth and
prevent relapse.
Q.4. Theories of retention.

Ans.
[Ref LE Q.2]
Q.5. Define retention. Explain the schools of

retention.
Ans.
Retention has been defined by Moyer as 'maintaining
newly moved teeth in position, long enough to aid in
stabilizing their correction'.
There are four schools of thought related to retention
in orthodontics:
i. Kingsley's occlusion school of thought: According to
this, proper occlusion of teeth, i.e. a good cusp to
fossa relationship between maxillary and mandibular
teeth is a potent factor in maintaining stability of
achieved orthodontic results.
ii. Axel Lundstrom apical base school of thought: Apical
base is one of the most important factors in
orthodontic correction as well as its post-treatment
maintenance.
iii. Mandibular incisor school of thought by Grieve and
Tweed: According to this, mandibular incisors should
be placed upright and over the basal bone.
iv. Roger's musculature school of thought: According to
this, to achieve stable occlusion and prevent relapse,
it is essential to establish proper functional muscle
balance.
Q.6. Permanent retention.

Ans.
[Same as SE Q.1]
Q.7. Relapse in orthodontics.

Ans.
[Same as SE Q.2]
Q.8. Define relapse. Add a note on the role of third

molars in causing relapse.
Ans.
[Same as SE Q.2]
Short notes:
Q.1. Relapse in orthodontics.

Ans.
[Ref LE Q.1]
Q.2. Hawley's retainer.

Ans.
[Ref LE Q.3]
Q.3. Permanent retention.

Ans.
[Ref SE Q.1]
Q.4. Retention appliance.

Ans.
[Ref LE Q.3]
Q.5. 'Relapse' and 'retention'.

Ans.
[Ref SE Q.1]
Q.6. Name different schools of thought for retention.

Ans.
• Retention has been defined by Moyer as 'maintaining
newly moved teeth in position, long enough to aid in
stabilizing their correction'.
• There are four schools of thought related to retention
in orthodontics:
i. Occlusion school of thought by Kingsley
ii. Apical base school of thought by Axel
Lundstrom
iii. Mandibular incisor school of thought by Grieve
and Tweed
iv. Musculature school of thought by Roger
Q.7. What is the role of third molar in causing the

relapse?
Ans.
• Relapse can be defined as 'the loss of any correction
achieved by orthodontic treatment'. In simple terms,
it is the tendency of teeth to return back to original
position post-treatment.
• Role of third molars
i. Most patients would have completed their
orthodontic treatment by the time third molars
start erupting, i.e. around 18-21 years of age.
ii. The pressure exerted by erupting third molars
is believed to cause late anterior crowding,
predisposing to relapse.
Q.8. Adjunctive periodontal surgeries to minimize

relapse.
Ans.
Certain minor surgical procedures performed as
adjunctive periodontal surgeries to minimize relapse
following orthodontic treatment are
i. Frenectomy: It is a surgical procedure to remove
entire frenum, sometimes even along with fibrous
tissue present between the roots of central incisors.
ii. Pericision: It is also known as 'supracrestal
fibrotomy', involves severing the fibres connecting
tooth to gingival soft tissues by passing a no.15 BP
blade around circumference of the tooth.
iii. Papilla-dividing procedure: This procedure is usually
undertaken a few weeks before removal of active
orthodontic appliance.
It is nothing but making a vertical incision in the
centre of each gingival papilla 1-2 mm away from the
gingival margin.
Q.9. Riedel's theorems of retention and relapse.

Ans.
[Ref LE Q.2]
Q.10. Define retention period.

Ans.
Retention period can be defined as time required after
orthodontic therapy for holding teeth in optimal
aesthetic and functional position for long enough to aid
in their stabilization with the help of retention
appliances.
Q.11. Give an example of natural or self-retention.

Ans.
[Ref SE Q.1]
Q.12. What is relapse? How to prevent relapse?

Ans.
• Relapse can be defined as 'the loss of any correction
achieved by orthodontic treatment'. In simple terms,
it is the tendency of teeth to return back to original
position post-treatment.
• Relapse can be prevented by:
i. Achieving proper occlusal stability, e.g.
corrected crossbite cases
ii. Using retention appliances - either fixed or
removable
iii. Adjunctive procedures like frenectomy,
pericision or papilla-dividing procedures.
Q.13. Define and classify retention giving examples.

Ans.
[Ref SE Q.1]
Q.14. Upper Hawley's appliance.

Ans.
[Same as SN Q.2]
Q.15. Retainers.
Ans.
[Same as SN Q.4]
Q.16. Define retention.

Ans.
[Same as SN Q.S]
Q.17. Types of retention.

Ans.
[Same as SN Q.13]
Topic 33 Genetics in orthodontics
Short essays:
1. Importance of genetics in orthodontics.
2. Methods of genetic studies.
3. Twin studies. [Same as SE Q.2]

Short notes:
1. Genetics in orthodontics. [Ref SE Q.1]
2. Teratogens.
3. Dentofacial disturbances of genetic origin. [Ref SE
Q.1]
4. Mutation.
5. Chromosomes.
6. Pedigree studies. [Ref SE Q.2]
7. Role of genetics in aetiology of malocclusion.
[Same as SN Q.1]
8. Importance of genetics in malocclusion. [Same as
SN Q.1]
9. Genetic disorders. [Same as SN Q.3]
Solved answers
Short essays:
Q.1. Importance of genetics in orthodontics.

Ans.
{SN Q.1}
• Genetics plays a major role in aetiology of
malocclusion.
• Genetic disorders are caused due to disturbance in
germ plasm or chromosomes or genes. They are
classified as:
i. Hereditary
ii. Mutational
{SN Q.3}
• Genetic disorders seen at the time of birth are called
congenital defects. Heredity plays a role in the
following conditions:
i. Congenital deformities
ii. Facial asymmetry
iii. Mandibular prognathism and retrognathism
iv. Macrognathia and micrognathia
v. Deep bite
vi. Macrodontia and microdontia
vii. Anodontia, oligodontia and hypodontia
viii. Cleft lip and palate
ix. Variations of tooth shape
x. Abnormalfrenal attachments (resulting in
diastema)
• Hereditary disorders are transmitted from one
generation to another
• The modes of inheritance of genetic disorders are as
follows:
a. Autosomal dominant
b. Autosomal recessive
c. X-linked
d. Chromosomal
e. Polygenic
• Mutational disorders occur de novo in a previously
unaffected individual as result of damage to germ
plasm. If they get transmitted to next generation it
becomes hereditary.
• The two major possible ways in which malocclusion
could be produced by heredity are as follows:
Inherited disproportion between:
i. Size of teeth and jaws
ii. Size or shape of upper and lower jaws
• Examples of some of the malocclusions caused due to
heredity or genetic cause are as follows:
{SN Q.1}
i. Dental problems:
a. Crowding - Hereditary and environmental
reasons
b. Individual tooth malalignments and crossbites
- Pressure environment
ii. Skeletal problems:
a. Retrognathic mandible and retrognathic
maxilla (achondroplasia)
b. Prognathic mandible (Hapsburg jaw)
c. Skeletal deep bite
Q.2. Methods of genetic studies.

Ans.
Genetic studies are basically of two types:
A. Twin study
B. Family study or pedigree study
A. Twin study:
i. Twins are compared in this study.
ii. The heritability of malocclusion can be
determined by comparing the monozygotic
twins, dizygotic twins and normal siblings.
iii. The best way to determine the genetic effect on
malocclusion is to compare monozygotic
(identical) twins with dizygotic (fraternal)
twins.
iv. In monozygotic twins as both have same DNA
any change in occlusion or features could be
attributed to environmental factors.
v. In dizygotic (fraternal) twins, interplay of
genetic and environmental factors is studied.
vi. Disadvantages of twin study are
• Difficulty in identifying the identical twins
• Difficult to establish same environment for
both the twins
{SN Q.6}
B. Family study or pedigree study:
i. Pedigree study is a type of genetic study. It is
also known as family study where occlusal
features and differences between mother-child,
father-child and siblings are analysed.
ii. It helps to differentiate between dominant and
recessive traits.
iii. Dominant traits will be expressed in all the
subsequent generations, while recessive traits
will be expressed in children born of
consanguineous marriage.
Q.3. Twin studies.

Ans.
[Same as SE Q.2]
Short notes:
Q.1. Genetics in orthodontics.

Ans.
[Ref SE Q.1]
Q.2. Teratogens.
Ans.
• The various chemicals or agents which crosses the
placental barrier and produce embryologic defects
are called teratogens.
• The various teratogens and their effects are as
follows:
For example:
Name of the teratogens Effect seen

i. Aspirin, valium, dilantin Cleft lip and palate and
cigarette smoke
ii. Aminopterin Anencephaly
iii. X-ray radiation Microcephaly
iv. Toxoplasma and Microcephaly and
cytomegalovirus hydrocephaly
v. Thalidomide Hemifacial microsomia-like
features
vi. Ethyl alcohol Central midface deficiency
Q.3. Dentofacial disturbances of genetic origin.

Ans.
[Ref SE Q.1]
Q.4. Mutation.
Ans.
• The term mutation refers to permanent change in the
DNA.The genetic disorders arising from
chromosomal aberrations includes disorders that are
consequence of numeric or structural abnormalities
in the chromosomes.
• Some of the general features of chromosomal
disorders and some specific examples of diseases
involving changes in the karyotype are as follows:
i. Chromosomal disorders resulting from
mutations may be associated with absence, i.e.
deletion or monosomy, excess, i.e. trisomy or
abnormal rearrangements, i.e. translocation of
chromosomes.
ii. In general the loss of chromosomal material
produces more severe defects than does the
gain of chromosomal material.
iii. The excess chromosomal material may result
from a complete chromosome as in trisomy or
from part of a chromosome as in Robertsonian
translocation.
iv. Most of the times chromosomal disorders
result from de novo changes. An uncommon
but important exception to this principle is
exhibited by the translocation form of Down
syndrome.
Q.5. Chromosomes.
Ans.
i. A typical chromosome is made up of two rod-shaped
structures or chromatids placed more or less parallel
to each other and are united by a centromere or
kinetochore.
~-- Satellite
• Secondary
Short arm of--1 constriction
chromatid
Long arm of--,

chromatid
Typical chromosome
ii. Each chromosome has a very large number of

structures called genes on it, which guide the
performance of particular cellular functions, and in
turn lead to the development of particular features of
a species or an individual.
iii. Chromosomes control the development and
functioning of cells, by determining what types of
proteins will be synthesized in them.
iv. Chromosomal aberrations result in various
syndromes which exhibit different types of
malocclusion as follows:
For example:
• Class II malocclusion is seen in Pierre Robin
syndrome, mandibulofacial dysostosis,
Goldenhar syndrome, etc.
• Class III malocclusion is observed in Down
syndrome, Marfan syndrome, Gorlin syndrome,
etc.
Q.6. Pedigree studies.

Ans.
[Ref SE Q.2]
Q.7. Role of genetics in aetiology of malocclusion.

Ans.
[Same as SN Q.1]
Q.8. Importance of genetics in malocclusion.

Ans.
[Same as SN Q.1]
Q.9. Genetic disorders.

Ans.
[Same as SN Q.3]
Topic 34 Lab procedures
Short essays:
1. Soldering and welding.
2. Solder and flux.
3. Soldering and spot welding. [Same as SE Q.1]

Short notes:
1. Soldering. [Ref SE Q.1]
2. Spot welding. [Ref SE Q.1]
3. Flux and antiflux.
4. Dental spot welder.
5. Heat treatment of orthodontic wire.
6. Sensitization and stabilization.
7. Soldering and welding. [Same as SN Q.1]
8. Welding in orthodontics. [Same as SN Q.1]
9. Soldering welding and brazing. [Same as SN Q.1]
10. Antiflux. [Same as SN Q.3]
Solved answers
Short essays:
Q.1. Soldering and welding.

Ans.
{SN Q.1}
Soldering is defined as a process of joining metals by
the use of a filler metal which has substantially lower
fusion temperature than that of the metals being joined.
If fusion temperature of filler metal is
<450°( Procedure is known as Soldering

>450°C Procedure is known as Brazing
Solders are the alloys that are used as intermediary or

a filler metal to join two or more metallic parts. They
are composed of gold, silver, copper, zinc, tin and nickel.
{SN Q.1}
Applications of soldering in orthodontics:
Used to joins parts of orthodontic appliances
Used to fasten attachments to bands
Types of soldering:
a. Inve trnent Embedding~ the metallic

soldering part in an invest leaving
a gap ofO.l} mm between
Two metal ends.
methods
b. Free-band Used when the area of

oldering contact between metallic
parts to be joined
is large.
Most of the orthodontic

soldering procedures fall
in this category.
Involves oldcrins~ of two

metallic parts together after
adequate tabilization without
use of investment to precisely
hold the parts together.
Practical considerations in soldering:

i. Use the reducing flame of the soldering torch
ii. Use wet cotton and asbestos to limit the spread
of heat
iii. Soldered joint should not be polished as it
weakens the joint.
iv. Antiflux should be used to prevent excessive
spread of soldering.
Steps in soldering:
i. Cleaning the surfaces to be joined
ii. Assembling the parts to be joined
iii. Selecting the right solder and flux
iv. Selection of proper joint
v. Application of flux
vi. Heating and introduction of solder
vii. Quenching
i. Cleaning the surfaces to be joined: In order to
remove dirt and other surface contaminants
which result in poor solder flow and therefore
failure of the procedure.
ii. Assembling the parts to be joined: The part to
be joined is stabilization in desired fashion
using plaster or orthophosphate cement. A gap
of about 0.5 mm is considered adequate
between parts to be joined.
iii. Selection of right solders and flux: Based on
metallic parts to be joined solder should be
compatible with metals in aspects of strength
and colour and they should exhibit lower
fusion temperature. A good flux is also selected.
iv. Selection of proper joint: Between metals being
joined greatly enhances the strength of the
joint. Point of contact - Do not offer adequate
strength when two wires are being joined
together. It would be beneficial to wrap one of
the wires around the other.
v. Application of flux: The flux applied in the gap
between the parts also covers a portion of the
parts being joined. The flow of the solder can
be limited by using antiflux.
vi. Heating and introduction of solder: The area to
be joined is heated using a soldering torch. As
soon as the flux begins to fuse, the solder is
introduced. The solder melts and encases the
joint. The flame should be maintained until the
filler metal has flowed completely into the joint.
vii. Quenching: The assembly is immediately
quenched in water to limit the spread of heat.
Welding
{SN Q.2}
Welding involves the joining to two or more metal
pieces directly under pressure without the introduction
of an intermediary or filter material.
a. Cold welding -. Done by hammering or pressure
b. Hot welding -. Uses heat of sufficient intensity to melt
the metals being joined
The type of welding used to join orthodontic
components is called spot welding. Orthodontic spot
welders employ the electrode technique and are used
instead of soldering in cases where the heating cycle
must be very short, in order to prevent changes in the
physical properties of the components being joined.
Application of welding in orthodontics:
Joining of metal strips during bending.
Fixing attachments such as brackets and molar tubes
onto bands.
Principle of spot welding:
i. Heat and pressure are the two basic principles
involved in spot welding.
ii. Electric current (AC) is made to pass through a
stepdown transformer to obtain a low voltage
and high amperage current that is conducted
through two copper electrodes on either side of
the metals being joined.
iii. The resistance offered by stainless steel to
current of high amperage generates very high
temperature at the electrodes. Thus the area of
metal under the electrodes becomes plastic.
iv. The copper electrodes simultaneously apply
pressure on the metals and therefore squeeze
the metals into each other.
v. It is very important that the passage of current
at the weld spot be of very short duration, i.e.
not more than one-tenth of a second.
In case the current is passed for a long duration of
time, it results in weld decay due to precipitation
of carbides from the metal. Thus most of the
modern welders have an electronic timer that
helps in discharging current of very short
duration.
vi. Welding of stainless steel depends on proper
use of following three variables:
a. The current flowing through the circuit.
b. Time during which the current is allowed
of flow.
c. The mechanical press is applied at the
weld heads.
Procedure of spot welding:
i. Select proper electrode in the thickness or
shape of the material to be welded.
A broad electrode should be used for thin
material.
A narrow electrode should be used for thick
material.
ii. The electrodes of welder are cleaned so
as to remove any carbide precipitates.
iii. The surface of each electrode must be
smooth, flat and perpendicular to its long
axis.
iv. When the electrodes are together, they
should be in total contact.
v. The welder has a timer that is set to the
iv. When the electrodes are together, they
should be in total contact.
v. The welder has a timer that is set to the
required reading. The metals to be joined
are placed between the two electrodes
and the switch is turned on. The electrode
pressure can be maintained for a few
seconds to help obtain a good joint.
Q.2. Solder and flux.

Ans.
Solder

• Solders are the filler metals used in process of
soldering; they have substantially lower fusion
temperature than the metal parts being joined.
• Orthodontic silver solders are alloys of silver,
copper and zinc to which tin and indium are added
to lower the fusion temperature.
• Properties of a solder are as follows:
i. It should have ability to wet the substrate metal.
ii. It should have sufficient fluidity at the flow
temperatures.
iii. Solder alloy should have a small liquidus-
solidus range, which means that it should
harden instantly.
iv. It should have adequate strength and hardness
and as . well good resistance to tarnish and
corrosion.
v. Should also have colour compatibility.
Flux
• 'Flux' is a Latin word which means 'flow'.
• Flux is defined as compound applied to metal
surfaces that dissolves or prevents the formation
of oxides and other undesirable substances that
may reduce the quality or strength of a soldered or
brazed area.
• Composition:
Flux is made up of borax, boric acid and potassium
fluoride.
• Types:
i. Type 1 - Surface protection:
Coats the metal surface and prevents entry of
oxygen
ii. Type 2 - Reducing agent:
Reduces any oxide present and exposes clean
metal surface
iii. Type 3 - Solvent:
Dissolves oxides present on the surface and
carries them away
Used for orthodontic purpose
Q.3. Soldering and spot welding.

Ans.
[Same as SE Q.1]
Short notes:
Q.1. Soldering.
Ans.
[Ref SE Q.1]
Q.2. Spot welding.

Ans.
[Ref SE Q.1]
Q.3. Flux and antiflux.

Ans.
Flux:
• Flux is a Latin word meaning 'flow'.
• Flux is defined as compound applied to metal
surfaces that dissolves or prevents the formation
of oxides and other undesirable substances that
may reduce the quality or strength of a soldered or
brazed area.
• Functions of a flux:
i. To remove any oxide coating on the parent
metal and increase the flow of molten solder.
ii. To protect the metal surface from oxidation
during soldering procedures.
iii. Significantly decreases melting point of the
dental solder.
• Composition of flux used in dentistry:
Borax glass - 55°/o
Boric acid - 35°/o
Silica - 10°10
Fluoride fluxes containing boric acid and
potassium fluoride in a 1:1 ratio also produce
excellent soldered joints.
Antiflux:
• Antiflux is a material that is used to confine the
flow of the molten solder over the metals
being joined.
• The commonly used antifluxes are
a. Lead pencil markings
b. Graphite lines
c. Iron rouge
Q.4. Dental spot welder.

Ans.
• Dental spot welder is used to perform spot welding of
bands, attachments to bands and fine springs to
heavy wire in orthodontic appliances.
• It welds by a process of fusing two or more metal
parts through the application of heat, pressure or
both without using a filler metal.
• The parts of a welder are electric transformer, copper
electrodes, pressure mechanism and timer switch.
• The electric transformer reduces voltage of the main
supply to a low value, which is safe to handle and the
copper electrodes convey the current to the work
pieces.
• Main heating takes place between the work pieces
which soften and get welded together by the
pressure of the electrodes.
Q.5. Heat treatment of orthodontic wire.

Ans.
• Heat treatment or annealing is a controlled heating
and cooling process designed to produce desired
properties in a metal.
• The unwanted effects of cold working a cast metal
like strain hardening, reduced ductility and distorted
grains can be eliminated by annealing. The
annealing process includes simply heating the metal
to a temperature that is approximately half the
melting point of the metal or fusion temperature of
the alloy.
• Annealing takes place in three successive stages:
Recovery, recrystallization and grain growth.
• Clinical applications of annealing: Altering the
properties of wires; softening a metal (e.g. steel); and
increasing their plastic deformation potential to
stabilize shape and to increase machinability.
Q.6. Sensitization and stabilization.

Ans.
Sensitization:
• Heating of stainless steel between 400°C and 900°C
leads to reaction between chromium and carbon
resulting in the formation of chromium carbide at
the grain boundaries.
• Depletion of chromium content near grain
boundaries to less than 12°/o causes stainless steel
to become susceptible to corrosion.
• This effect of losing resistance to corrosion by
forming chromium carbide at the grain boundaries
is called 'sensitization'.
Stabilization:
• Introduction of some other elements like titanium
which prevents chromium carbide formation at
the grain boundaries of stainless steel is known as
stabilization.
• Addition of titanium usually six times that of
carbon is the most successful method employed to
eliminate chromium carbide precipitation.
Stainless steel that is modified in this manner is
said to be 'stabilized'.
Q.7. Soldering and welding.

Ans.
[Same as SN Q.1]
Q.8. Welding in orthodontics.

Ans.
[Same as SN Q.1]
Q.9. Soldering welding and brazing.

Ans.
[Same as SN Q.1]
Q.10. Antiflux.
Ans.
[Same as SN Q.3]
Topic 35 Materials used in
orthodontics
Short essays:
1. Properties of an ideal orthodontic wire.
2. 18-8 stainless steel.

3. Direct bonding.
4. Elgiloy wires.
Short notes:
1. Irreversible hydrocolloids.
2. Properties of ideal orthodontic wires. [Same as SE
Q.1]
3. Stainless steel in orthodontic practice. [Same as SE
Q.2]
4. Name various light sources used in curing
composite.
5. Direct bonding. [Ref SE Q.3]
6. Shape memory alloys.
7. Glass ionomer cements.
8. Uses of NiTi alloys in orthodontics.
9. Braided and twisted wires.
10. Super elasticity.
11. Wires used in orthodontics.
12. Elgiloy wires. [Ref SE Q.4]
13. Molar tubes.
14. Tensile strength.
15. Cold-cure acrylic resins.
16. Composition of wrought cobalt-chromium-nickel
alloys.
1 7. Nitinol wires/NiTi wires.
18. Stainless steel. [Same as SN Q.3]
19. Nickel-titanium wires. [Same as SN Q.17]
20. Nickel-titanium alloy. [Same as SN Q.17]
Solved answers
Short essays:
Q.1. Properties of an ideal orthodontic wire.

Ans.
{SN Q.2}
Desirable properties or ideal requirements of
orthodontic wire are as follows:
i. The wire should deliver low constant force.
ii. It should have high strength and range.
iii. It should have low stiffness or good spring back.
iv. It should be easy to manipulate.
v. It should exhibit ease of joining, i.e. solderable and
weldable.
vi. It should offer less frictional resistance between wire
and bracket base.
vii. It should be biocompatible.
viii. It should be stable in the oral environment, i.e.
resistant to tarnish and corrosion.
ix. It should be economical.
Q.2. 18-8 stainless steel.

Ans.
{SN Q.3}
• Steel is an alloy of iron containing less than 1.2°/o
carbon. The alloy is referred stainless steel when the
chromium content of the steel exceeds 11 °/o.
• Based on crystal structure arrangement, stainless
steel is of three types, namely ferritic, martensitic
and austenitic.
• Austenitic type of stainless steel is most corrosion
resistant and is widely used in dentistry.
• Type 302 and 304 austenitic types of stainless steel are
called 18-8 stainless steel.
Type 302 austenite is the basic alloy containing 17°/o-
200/o chromium, 8°/o-12°/onickel and 0.15°/o carbon,
while type 304 has similar content but carbon
content is 0.08°/o.

Ans.
{SN Q.5}
i. The direct bonding is a technique, sensitive procedure,
where brackets can be directly attached on to the
teeth. The development of resins by Newman in 1960s
replaced banding with bonding.
ii. The introduction of acid-etching technique and
composites has revolutionized direct bonding of
brackets.
Two types of bonding materials like self-cure and
light-cure bonding materials are available.
iii. The most important requirements of orthodontic
bonding agents are that it should be biologically safe
in oral cavity and should generate minimum bond
strength of 7-15 MP a.
Currently available bonding agents offer bond
strength of 12-20 MPa which exceeds the
minimum required bond strength.
{SN Q.5}
iv. Successful direct bonding includes:
• Optimum etching
• Maintenance of moisture-free environment of
bonding site
• A thin and uniform layer of primer
• Optimum quantity of bonding agent on brackets
• Correct placement of brackets,
• A slight but firm, vibration-free pressure on bracket
to ensure good flow of bond material into enamel
micropores and bracket base mesh
Q.4. Elgiloy wires.

Ans.
{SN Q.12)
• Elgiloy, i.e. cobalt-chromium-nickel alloy was
developed during 1950s by Eligin Watch Company
(USA). This belongs to group of alloys called satellite
alloys.
{SN Q.16}
• The typical composition of Co-Cr alloy is
Cobalt - 40°/o
Chromium - 20°/o
Nickel-15°/o
Iron - 15.8°/o
Molybdenum - 7°/o
Manganese - 2°/o
Carbon - 0.160/o
Beryllium - 0.04°/o
• Co-Cr alloys are available commercially as Elgiloy
(Rocky Mountain Orthodontics), Azura (Ormco
Corporation) and Multiphase (American
Orthodontics Corporation).
{SN Q.12}
• Elgiloy wires by Rocky Mountain Orthodontics are
supplied in four tempers (level of resilience) which
are colour coded.
a. Blue (soft)
b. Yellow (ductile)
c. Green (semiresilient)
d. Red (resilient)
• Co-Cr-Ni alloys have:
a. Best formability among all the wires.
b. Greater resistance to fatigue and distortion
than SS.
c. High yield strength on heat treatment.
d. Good biocompatibility and high corrosion
resistance.
e. Good join ability and can be easily soldered or
welded.
f. Low coefficient of friction like SS.
g. Stiffness is a bit higher than SS after heat
treatment.
h. Cost is slightly higher than SS.
Short notes:
Q.1. Irreversible hydrocolloids.

Ans.
• Irreversible hydrocolloid or alginate is available as a
powder.
• Composition of alginate is as follows:
i. Sodium or potassium or triethanolamine
alginate -15°/o
ii. Calcium sulphate (reactor) - 16°/o
iii. Zinc oxide - 4°/o
iv. Diatomaceous earth - 60°/o
v. Potassium titanium fluoride - 3°/o
vi. Sodium phosphate (retarder) - 2°/o
vii. Colouring and flavouring agents - traces
• When alginate powder is mixed with water a sol is
formed which later sets to a gel by a chemical
reaction.
• The calcium sulphate reacts with sodium alginate to
form insoluble calcium alginate which forms a gel
with water.
• Applications of alginate hydrocolloid are as follows:
i. It is used for impression making when there are
undercuts and also in mouths with excessive
~::i li"tr::itinn
• Applications of alginate hydrocolloid are as follows:
i. It is used for impression making when there are
undercuts and also in mouths with excessive
salivation
ii. For making preliminary impressions for
complete dentures.
iii. For impressions to make study models and
working casts.
iv. For duplicating models.
Q.2. Properties of ideal orthodontic wires.

Ans.

[Ref SE Q.1]
Q.3. Stainless steel in orthodontic practice.

Ans.
[Ref SE Q.2]
Q.4. Name various light sources used in curing

composite.
Ans.
Various light sources used in curing composites are as
follows:
i. Conventional and fast halogen lights
ii. Argon lasers
iii. Plasma arc lights (xenon)
iv. Light-emitting diodes

Ans.
[Ref SE Q.5]
Q.6. Shape memory alloys.

Ans.
i. Shape memory was defined by Andreasen as 'Ability
of wire to return to a previously manufactured shape
when it is heated through a transition temperature
range (TTR)'.
ii. Shape memory is also known as 'thermoelasticity'
and is one of the distinctive properties of Nitinol,
where in the material has ability to remember its
'original shape'.
iii. It is because of temperature induced crystallographic
transformation. It is associated with reversible
martensitic-austenitic transformation.
Q.7. Glass ionomer cements.

Ans.
• Glass ionomer cements (GIC) are adhesive tooth-
coloured anticariogenic restorative materials and is
one of the cements widely used in orthodontics for
cementation of orthodontic bands.
• Composition:
Powder: an acid-soluble calcium
fluoroaluminosilicate glass.
Liquid: in most current cements, the liquid contains
polyacrylic acid, tartaric acid and water.
• It is available in four forms:
a. Conventional luting glass ionomer
b. Light-cured resin modified GIC
c. Chemically cured resin modified GIC
d. Glass ionomer for orthodontics
• Glass ionomer-resin combination materials are
relatively new materials having various names like
compomer, resin-ionomers, RMGI, light-cured GIC,
dual-cure GIC and tri-cure GIC.
They are preferable as adhesives for orthodontic
brackets.
Q.8. Uses of Ni Ti alloys in orthodontics.

Ans.
Japanese Ni Ti.
• Clinical uses of Ni Ti alloy in orthodontics are as
follows:
They are used as
i. Initial alignment and levelling archwires
iv. Devices for distalization of molars
Q.9. Braided and twisted wires.

Ans.
i. The wires used in orthodontics may be:
• Single stranded
• Multi-stranded
• Twisted or braided
ii. Very thin small diameter stainless steel wires can be
twisted or braided together to form wires in clinical
orthodontics which may be round or rectangular in
shape.
iii. They apply low forces for a given deflection when
compared to similar size solid wire and are able to
sustain large elastic deflections in bending.
iv. Coaxial/braided wires with greater working range
offer a good choice of wire for initial alignment and
levelling of untreated malocclusion.
v. Many researchers have found that the properties of
these wires are comparable with nickel-titanium
.
wires.
Q.10. Super elasticity.

Ans.
• Super elasticity is one of the distinct properties of
Nitinol.
• It is the ability of wire to sustain or deliver a near
constant force over a wide range of activation.
Instead of temperature, stress is used to bring about
changes in crystalline structure, i.e. from austenite to
martensite and back to austenite.
• The elasticity of the wire increases during activation;
this is called super elasticity, which is associate with
very large reversible strain and nonelastic force
deflection curves.
For example: Chinese NiTi and Japanese NiTi
Q.11. Wires used in orthodontics.

Ans.
Various wires used in orthodontics are classified based
on composition, number of filaments, cross section and
diameter as follows:
Based on:
i. Compo ition
I
Metallic
i
Nonmetallic
For example: For example:
Stainles teel. Elgiloy. Compo ites and
p.-:ri and nickel-titanium optiflex
ii. Number of filaments
i
Monofilament
l
Polyfilament
i
Twisted or
braided
iii. Cross Section
i
Round
l
Square
i
Rectangular
iv. Diarnctcr/dimen ion of wire available in inche
i
Round wires
l
Square wires
i
Rectangular
~ wire
(0 .0 IO, 0 .0 l 2, (0.016 x O .0 l 6) (0.016 x 0.022;
0.014, 0.016, 0.017 x 0.025:
0.018, 0.020. 0.022) 0.018 x 0.025:
0 .o J 9 x O .025:
0.0215 x 0.0275)
Q.12. Elgiloy wires.

Ans.
[Ref SE Q.4]
Q.13. Molar tubes.

Ans.
• Molar tubes are both bondable and weldable.
Weldable tubes are more common in use.
• Buccal tubes are housed on first and second molars;
they are usually 0.75" long with internal dimensions
of 0.022" x 0.028".
• Maxillary molar tubes are often a combination of
rectangular edge-wise and round tube called double
tube. The rectangular tube is the main tube and
round tube is for headgear. The tube has built in
offset to compensate for molar rotation. They are
designed to enhance anchorage and produce
sufficient torque for normal buccolingual inclination
of molars.
• The triple buccal tubes or auxiliary edge-wise tubes
are used for two active archwires simultaneously.
Q.14. Tensile strength.

Ans.
• Tensile strength or ultimate tensile strength is tensile
stress at the point of fracture.
• It is the maximum load a wire can sustain.
• This determines the maximum force a spring can
deliver.
Q.15. Cold-cure acrylic resins.

Ans.
i. The chemically activated acrylic resins polymerize at
room temperature. They are also known as 'self-
curing' or cold-cure or autopolymerizing resins.
ii. In cold-cured acrylic resins, the chemical initiator
benzoyl peroxide is activated by another chemical
dimethyl-para toluidine which is present in the
monomer.
iii. Instead of heat as in heat-cure resins, the
polymerization is achieved at room temperature.
Q.16. Composition of wrought cobalt-chromium-

nickel alloys.
Ans.
• Cobalt-chromium-nickel alloy belongs to a group of
alloys called satellite alloys.
• Elgiloy wires by Rocky Mountain Orthodontics are
supplied in four tempers based on level of resilience
which are colour-coded.
[Refer SE Q.4]
Q.17. Nitinol wires/NiTi wires.

Ans.
Japanese Ni Ti.
• Clinical uses of Ni Ti alloy in orthodontics are as
follows:
They are used as
i. Initial alignment and levelling archwires
iv. Devices for distalization of molars.
Q.18. Stainless steel.

Ans.
[Same as SN Q.3]
Q.19. Nickel-titanium wires.

Ans.
[Same as SN Q.17]
Q.20. Nickel-titanium alloy.

Ans.
[Same as SN Q.17]

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Q.1. Define orthodontics. Describe aims and science

Functional efficiency Structural balance

(SN Q.2 and SE Q.1)

Q.2. What is orthodontia? Describe the various

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Q.3. Describe briefly the aims, objectives, scope and

Q.1. Objectives of orthodontics.

Q.1. Aims of orthodontics.

Q.2. Jackson's triad.

Q.3. Define interceptive and preventive

Q.4. Define orthodontics.

Q.5. Adult orthodontics.

Q.6. Contributions of E.H. Angle to orthodontics.

Q. 7. Aims and scope of orthodontics.

Q.8. Describe Andrew Jackson's triad.

Q.9. Give the BSSO definition of orthodontics.

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Q.1. Define growth and development. Mention the

Associated with one single

• It was demonstrated that the origin, growth and

Functional cranial component

Skeletal unit: Comprising bone, cartilage and tendinous

A.fbetkd~I ••If Mattod.:.rl.tr.-1 t1.1tlt

l M.nible "1s blowirglric...i..letal ..-: alveolar;

""'""'*· pw,I rd baui.

Periosteal matrix Capsular matrix

They act directly and They act indirectly and

Neurocranial capsule Orofacial capsule

N eurocranial capsule Orofacial capsule

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• Each of the neurocranial capsule and orofacial

Q.2. Define growth and enumerate various theories

• It was demonstrated that the origin growth and

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Q.3. Enumerate the various methods of measuring

B. Moyer's classification is of the following types:

i. Anthropometry i. Study casts i. Radiography

iv. Implant markers

Various methods of measuring growth in detail are

Maximum cranial breadth

• Maximum cranial breadth 'is the measured

• Facial height is the measured distance from

Q.4. Define growth. Discuss briefly clinical

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Q.5. Enumerate the various theories of growth.

Q.6. Enumerate various theories of growth. Describe

Q.7. Enumerate theories of bone growth.

Q.8. What are the methods of measuring growth?

Q.1. Growth spurts.

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Q.2. Methods of gathering growth data.

Q.3. Discuss drift and displacement with examples.

Functional cranial component

• It was demonstrated that the origin, growth

Periosteal matrix Capsular matrix

They act directly and They act indirectly and

Capsular matrix has neurocranial capsule and

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Q.6. Scammon's curve.