Etiology of malocclusion- /fixed orthodontic courses by IDA

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INDIAN DENTAL ACADEMY Leader in continuing dental education

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The various classification proposed are: White and Gardiner Salzmann’s classification Moyer’s classification Graber’s classification

Graber’s classification General factors:

Graber’s classification General factors 1. Heredity 2. Congenital 3. Environment prenatal postnatal 4. Predisposing metabolic climatic and infectious disease 5. Abnormal pressure habits and functional aberrations—Thumb sucking, Tongue thrust, speech defects etc 6. Dietary problems 7. Posture 8. Trauma and accidents

Local factors:

Local factors 1. Anomalies in number of teeth 2. Anomalies of tooth size 3. Anomalies of tooth shape 4. Abnormal labial frenum 5 Premature loss of deciduous teeth 6. Prolonged retention of deciduous teeth 7. Delayed eruption 8. Abnormal eruptive pathway 9. Ankylosis 10.Dental caries 11.Improper dental restorations

General factors:

General factors Heredity : It includes factors that result in malocclusion and are inherited from the parents by the off springs. These factors can influence- Neuromuscular system Dentition Skeletal structures Soft tissues

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Neuromuscular system- There is deformity in neuromuscular co ordination pattern of facial,oral and tongue musculature Dentition- size and shape of the tooth number of teeth primary position of tooth germ shedding of deciduous teeth and sequence of eruption mineralization of teeth

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Skeletal structures- underlying basal bone and other associated cranial bone structures are partially inherited Class III skeletal pattern most commonly show familial tendency Soft tisuues (other than neuro muscular) Size and shape of frenum Microstomia Ankyloglossia

Congenital factors:

Congenital factors These malformations are seen at the time of birth Mal development of 1 st and 2 nd brachial arches Common conditions are: Micrognathism Oligodontia Anodontia Cleft lip and palate congenital syphillis Maternal rubella infections Cleidocranial dystosis Cerebral palsy


Micrognathism ( small jaw) congenital variety is usually seen with congenital heart disease and Pierre Robin syndrome. Micrognathia of maxilla is due to deficiency in the pre maxilla Mandibular retrognathism is characterized by severe retrusion of the chin

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Oligodontia : different teeth seem to be affected by different degree with the third molar being most affected Anodontia absence of teeth very rare condition Cleft lip & palate : generally associated with under developed maxilla and related dental disturbances

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Congenital syphills- syphills of congenital origin is transmitted from the infected mother to the child: Hutchinson’s molar Mulberry molar Enamel deficiency Extensive dental decay Small maxilla Ant cross bite

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Maternal rubella infections : dental hypoplasia retarded eruption of teeth extensive caries Cleidocranial dystosis - unilateral/bilateral partial/ complete absence of the clavicle - max retrusion and mandibular protrusion -over retained deciduous teeth and retarded eruption of permanent teeth -presence of supernumerary teeth

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Cerebral palsy aberrant muscle activity resulting in malocclusion


Environment Prenatal factors Abnormal fetal posture : - -Interferes with symmetric development of face -Not directly associated with malocclusion but may be associated with abnormal pressure or imbalance. -Most of the deformities are temporary and disappears with time

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Maternal infections such as German measles and use of certain drugs during pregnancy like thalidomide can cause congenital deformities like cleft Post natal factors - Trauma - Forceps delivery can result in injury to the TMJ area which can undergo ankylosis retarded mandibular growth

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Predisposing metabolic climate and disease:

Predisposing metabolic climate and disease Endocrinal imbalance: Diseases Features hypopitutarism - delayed tooth eruption - incomplete root formation Hyperpitutarism -large mandible -enlarged tongue - accelerated dental development

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Hypothyroidism - Growth retardation - Delayed eruption of the teeth - Maxillary protrusion - Spacing Hyperthyroidism - Accelerated skeletal growth - Irregular eruption of the teeth -Mild prognathism

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Hypoparathyroidism - retarded eruption -early exfoliation -enamel defects Hyperparathyroidism - demineralization -disappearance of lamina dura -mobility of teeth

Metabolic disturbances:

Metabolic disturbances Acute febrile diseases may also affect the dentition and its surrounding hard and soft tissue. If severity and duration is not prolonged the child is able to recoup and catch up growth is possible

Infectious diesease:

Infectious diesease Bacterial infection Osteomyelitis - Bone response to force is altered Congenital syphillis –under developed maxilla - narrow maxillary arch - enamel hypoplasia -Defect in shape of teeth

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Viral infection Mumps -dental hypoplasia -retarded eruption -extensive caries -Inflammation/ congestion of gingiva Measles -airway obstruction Rubella -retarded eruption of teeth -congenital malformations including cleft lip and palate

Dietary problems:

Dietary problems Protein deficiency - delayed eruption Vitamin A deficiency -calcification of teeth is affected - retarded eruption Vitamin B complex - cheilosis - retarded growth - pernicious anaemia

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Vitamin C deficiency - disturbed collagen fibre formation - bleeding gums - loosening of teeth Vitamin D -disturbed calcification of teeth -poor quality of teeth - narrow maxillary arch - High palatal vault -Under developed mandible

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Hypervitaminosis D - poorly calcified teeth -decalcification of bones -Increased osteoclastic activity

Abnormal pressure habits and functional aberrations:

Abnormal pressure habits and functional aberrations Thumb sucking Tongue thrust Lip and nail biting Abnormal swallowing habits Speech defects Respiratory abnormalities Tonsils and adenoids Pshychogenic habits and bruxism

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All these habits are functional aberrations which produces forces that are abnormal and these forces are capable of bringing about a permanent deformity in the developing musculo skeletal unit Deformity depends upon the- - Intensity - Duration - Frequency

Posture :

Posture Poor postural habit It may be associated with maloclusion though not proved

Accidents and Traumas:

Accidents and Traumas Injuries of the dento alveolar region may get unnoticed during the early years of life Responsible for - Non vital teeth - Ankylosed teeth - Injuries at condylar region

Local factors—anomalies in number:

Local factors—anomalies in number Supernumerary teeth –Teeth extra to normal complement -Most common mesiodens -may closely resemble the teeth of the group they belong or bear no resemble supplemental teeth- teeth that bear close resemble to a particular group of teeth and erupt close to original site of these teeth Most common are-premolar region or the lat region

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supplemental teeth- -Teeth bear close resemble to a particular group of teeth - Erupt close to original site of these teeth -Most common are-premolar region or the lateral incisor region

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Supernumerary teeth can cause- -Non eruption of adjacent teeth -Delay the eruption of adjacent teeth -Deflect the erupting tooth into abnormal locations -Crowding

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Missing teeth –more common condition than supernumerary teeth Oligodontia- absence of many teeth Anodontia-absence of all the teeth Hypodontia-presence of few teeth eg-hypo hydrotic ectodermal dysplasia

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This condition can lead to - Spacing between the teeth - Aberrant swallowing patterns -Abnormal axial inclination of adjacent teeth

Anomalies of tooth size:

Anomalies of tooth size Microdontia - True generalized form of microdontia is rare Usually seen in cases of pitutary dwarfism Most common form of localized microdontia is- max lat incisors called-peg lateral

Anomalies of tooth shape-:

Anomalies of tooth shape- Fusion - tooth arises through the union of two normally seperated tooth bud -may lead to spacing Gemination Twinning Concrescence Dilaceration

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Abnormal of labial frenum:

Abnormal of labial frenum - Often associated with maxillary mid line spacing A heavy fibrous frenum is found attached to inter dental papilla Can prevent the two max central incisors from approximating each other

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Blanch test- is used to determine the role of frenum as a casuative factor for mid line test Step 1. The lip is pulled superiorly and anteriorly Step 2. Any blanching indicates fibres of the frenum crossing the alveolar ridge An IOPA will show notching in the inter dental alveolar ridge region

Premature loss of deciduous teeth-:

Premature loss of deciduous teeth- - -Decrease in total arch length as the posterior teeth move mesially -Ectopic eruption of teeth -Shift in the midline

Prolonged retention of deciduous teeth:

Prolonged retention of deciduous teeth Reasons for prolonged retention of tooth are- - Absence of any underlying permanent teeth - Endocrinal disturbances- Hypothyroidism - Ankylosed deciduous teeth - Non vital teeth that do not resorb

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Prolonged retention of deciduous teeth result in lingual or palatal eruption of their successors.

Delayed eruption of permanent teeth:

Delayed eruption of permanent teeth May result in ectopic eruption of permanent teeth The reasons for delayed eruption are- -Congenital absence of the permanent tooth -Presence of supernumerary teeth

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-Presence of heavy mucosal barrier can prevent the permanent tooth from emerging into the oral cavity - Presence of deciduous root fragments - Endocrinal disturbances - Ankylosed teeth

Abnormal eruptive path:

Abnormal eruptive path Causes for this are: - Tooth bud displaced from its ideal position Presence of supernumerary teeth , odontomas, retained tooth may divert a tooth from its eruptive path

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Retained deciduous teeth might force a tooth to erupt along a path of least resistance rather than in place of deciduous teeth Arch length deficiency or excess of tooth material may cause one or more teeth to deviate from their eruptive path - Most common is max canine

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Various reasons for this behavior are- -Travels the longest distance, from near the floor of the orbit to cover the arch - It is the last anterior tooth to erupt and loss in arch length- anterior or posterior teeth may impinge on the space required for it to erupt - Abnormal position of the tooth bud


Ankylosis -Union of the root or part of a root directly to the bone without the intervening periodontal ligament -Associated with certain infections, endocrine disorders, and congenital diseases

Dental caries:

Dental caries -Proximal caries may result in reduction of arch length -Loss of E space -Migration/ tilting of teeth in the space available -Supra eruption of the teeth in opposing arch

Malocclusions caused due to caries:

Malocclusions caused due to caries

Improper dental restoration:

Improper dental restoration -Under contoured proximal restoration- decrease in arch length -Over contoured restoration- may bulge into the space to be occupied by the succadenous tooth -Overhang or poor proximal contact- periodontal breakdown -Occlusal prematurities due to over contoured occlusal restoration can cause a functional shift of the mandible

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