MALOCCLUSION AND DENTOFACIAL
DEFORMITY IN CONTEMPORARY SOCIETY
By William R. Proffit
OUTLINE
■ THE CHANGING GOALS OF ORTHODONTIC TREATMENT
Early Orthodontic Treatment
Modern Treatment Goals The Soft Tissue Paradigm
■ THE USUAL ORTHODONTIC PROBLEMS: EPIDEMIOLOGY OF
MALOCCLUSION
■ WHY IS MALOCCLUSION SO PREVALENT?
■ WHO NEEDS TREATMENT?
Psychosocial Problems
Oral Function
Relationship to Injury and Dental Disease
■ TYPE OF TREATMENT: EVDENCE-BASED SELECTION
Randomized Clinical Trials' The Best Evidence
Retrospective Studies: Control Group Required
■ DEMAND FOR TREATMENT
Epidemiologic Estimates of Orthodontic Treatment Need
Who Seeks Treatment?
THE CHANGING GOALS OF ORTHODONTIC
TREATMENT
Early Orthodontic Treatment
■ Crowded, irregular, and protruding teeth have been a
problem for some individuals since antiquity, and
attempts to correct this disorder go back at least to
1000 BC. Primitive (and surprisingly well-designed)
orthodontic appliances have been found in both Greek
and Etruscan materials.
■ As dentistry developed in the eighteenth and
nineteenth centuries, a number of devices for the
"regulation" of the teeth were described by various
authors. After...1850, the first texts that systematically
described orthodontics appeared, the most notable
being Norman Kingsley’s ‘Oral Deformities.’
■ Kingsley, who had a tremendous influence on American
dentistry in the latter half of the nineteenth century, was
among the first to use extraoral force to correct
protruding teeth. He was also a pioneer in the treatment
of cleft palate and related problems.
■ It was necessary to develop a concept of occlusion, and
this occurred in the late 1800s. Edward H. Angle whose
influence began to be felt about 1890, can be credited
with much of the development of a concept of occlusion
in the natural dentition. Angle's original interest was in
prosthodontics, and he taught in that department in the
dental schools at Pennsylvania and Minnesota in the
1880s. His increasing interest in dental occlusion and in
the treatment necessary to obtain normal occlusion led
directly to his development of orthodontics as a
specialty, with himself as the "father of modern
orthodontics:'
■ Angle's classification of
malocclusion in the 1890s was an
important step in the development of
orthodontics because it not only
subdivided major types of
malocclusion but also included the
first clear and simple definition of
normal occlusion in the natural
dentition. Angle's postulate was that
the upper first molars were the key to
occlusion and that the upper and
lower molars should be related so
that the mesio-buccal cusp of the
upper molar occludes in the buccal
groove of the lower molar.
■ Angle then described three classes of malocclusion,
based on the occlusal relationships of the first
molars:
Class I: Normal relationship of the molars, but
line of occlusion incorrect because of malposed teeth,
rotations, or other causes
Class II: Lower molar distally positioned
relative to upper molar, line of occlusion not specified
Class III: Lower molar mesially positioned
relative to upper molar, line of occlusion not specified
The line of occlusion is a smooth
(catenary) curve passing through
the central fossa of each upper
molar and across the cingulum of
the upper canine and incisor teeth,
The same line runs along the
buccal cusps and incisal edges of
the lower teeth, thus specifying
the occlusal as well as inter arch
relationships once the molar
position is established.
■ Angle and his followers strongly opposed extraction for
orthodontic purposes. With the emphasis on dental occlusion that
followed, however, less attention came to be paid to facial
proportions and esthetics.
■ Under the leadership of Charles Tweed in the United States and
Raymond Begg in Australia (both of whom had studied with
Angle), extraction of teeth was reintroduced into orthodontics in
the 1940s and 1950s to enhance facial esthetics better stability of
the occlusal relationships.
■ Cephalometric radiography, which enabled orthodontists to
measure the changes in tooth and jaw positions produced by
growth and treatment, came into widespread use after World War
II.
■ In Europe, the method of "functional jaw orthopedics" was
developed to enhance growth changes, while in the United States,
extraoral force came to be used for this purpose. At present, both
functional and extraoral appliances are used internationally to
control and modify growth and form.
Modern Treatment Goats: The Soft tissue paradigm
■ A paradigm can be defined as "a set of shared beliefs and
assumptions that represent the conceptual foundation of an
area of science or clinical practice”.
USUAL ORTHODONTIC PROBLEMS:
EPIDEMIOLOGY OF MALOCCLUSION
Epidemiology of Malocclusion Angle’s
“normal occlusion” more properly
should be considered the ideal.
■ In fact, perfectly interdigitating
teeth arranged along a perfectly
regular line of occlusion are quite
rare.
■ The characteristics of malocclusion
evaluated in NHANES III included
the irregularity index
1.Incisor alignment
2.the prevalence of midline
diastema larger than 2 mm.
3.The prevalence of posterior
crossbite
4. overjet overbite or open bite
The percentage with excellent
alignment decreases in the age 12
to 17 group as the remaining
permanent teeth erupt, then
remains essentially stable in the
upper arch but worsens in the lower
arch for adults. Only 34% of adults
have well-aligned lower incisors.
Nearly 15% of adolescents and
adults have severely or extremely
irregular incisors, so that major
arch expansion or extraction of
some teeth would be necessary to
alignment
■ Overjet or reverse overjet
indicates anteroposterior
deviations in the Class II or
Class III direction,
respectively, with Class III
being much less prevalent .
■ Normal overjet is 2 mm.
Overjet of 5 mm or more,
suggesting Angle’s Class II
malocclusion.
■ Severe Class II problems are
less prevalent and severe
Class III problems are more
prevalent in the Mexican-
American than the white or
black groups.
■ Vertical deviations from the
ideal overbite of 0 to 2 mm
are less frequent in adults
than children but occur in
half the adult population,
with excessive overbite
occurring much more
frequently
Why Is Malocclusion So
Prevalent
■ The number of teeth in the dentition of higher
primates has been reduced from the usual mammalian
pattern .
■ The third incisor and third premolar have
disappeared, as has the fourth molar.
■ At present, the human third molar, second premolar,
and second incisor often fail to develop, which
indicates that these teeth may be on their way out.
Compared with other primates, modern humans have
quite underdeveloped jaws.
■ The number of teeth in the dentition of higher
primates has been reduced from the usual mammalian
pattern
■ Malocclusion is another condition made
worse by changing condition of modern
life, perhaps resulting in part from less
use of the masticatory apparatus with
softer food now.
■ A capable masticatory apparatus was
essential to deal with uncooked or
partially cooked meat and plant foods.
Watching an Australian aboriginal man
using every muscle of his upper body to
tear off a piece of kangaroo flesh from
the barely cooked animal, for instance,
makes one appreciate the decrease in
demand on the masticatory apparatus
that has accompanied civilization.
Who Needs Treatment?
■ Protruding, irregular, or maloccluded teeth can cause
three types of problems for the patient:
(1) social discrimination because of facial
appearance;
(2) problems with oral function, including difficulties
in jaw movement
temporomandibular dysfunction and problems
with mastication,
swallowing, or speech.
(3) greater susceptibility to trauma, periodontal
disease, or tooth decay.
PSYCHOSOCIAL PROBLEMS
■ Children anticipating orthodontic treatment typically
expect an improvement in their social and
psychologic well-being and see an improvement in
function as a secondary advantage of treatment
ORAL FUNCTION
■ Malocclusion usually affects function not by making
it impossible but by making it difficult, so the extra
effort is required to compensate for the anatomic
deformity.
■ The relationship of malocclusion and adaptive
function to TMD, manifested as pain in and around
the TM joint.
RELATIONSHIP TO INJURY
AND DENTAL DISEASE
■ Malocclusion, particularly
protruding maxillary incisors, can
increase the likelihood of an injury
to the teeth (Figure 1-18). There is
about one chance in three that a
child with an untreated Class II
malocclusion will experience
trauma to the upper incisors, but
most of the time, the result is only
minor chips in the enamel.
■ Extreme overbite, so that the
lower incisors contact the palate,
can cause significant tissue
damage leading to early loss, of
the upper incisors and also can
result in extreme wear of incisors
Demand for Treatment
■ Epidemiologic Estimates of Orthodontic Treatment Need
Index of Treatment Needs (IOTN) Treatment Grades
Grade 5 (Extreme/Need Treatment)
■ 5.i Impeded eruption of teeth (except third molars) due to
crowding, displacement, the presence of supernumerary teeth,
retained deciduous teeth, and any pathologic cause.
■ 5.h Extensive hypodontia with restorative implications (more
than one tooth per quadrant) requiring pre-prosthetic
orthodontics.
■ 5.a Increased overjet greater than 9 mm.
■ 5.m Reverse overjet greater than 3.5 mm with reported
masticatory and speech difficulties.
■ 5.p Defects of cleft lip and palate and other craniofacial
anomalies.
■ 5.s Submerged deciduous teeth.
■ Grade 4 (Severe/Need Treatment)
■ 4.h Less extensive hypodontia requiring pre-
restorative orthodontics or orthodontic space closure (one
tooth per quadrant).
■ 4.a Increased overjet greater than 6 mm but less than or
equal to 9 mm.
■ 4.b Reverse overjet greater than 3.5 mm with no
masticatory or speech difficulties.
■ 4.m Reverse overjet greater than 1 mm but less than
3.5 mm with
■ 4.c Anterior or posterior crossbites with greater than 2
mm discrepancy between retruded contact position and
intercuspal position.
■ 4.l Posterior lingual crossbite with no functional
occlusal contact in one or both buccal segments.
■ 4.d Severe contact point displacements greater
than 4 mm.
■ 4.e Extreme lateral or anterior open bites greater than
4 mm.
■ 4.f Increased and complete overbite with gingival or
palatal trauma.
■ 4.t Partially erupted teeth, tipped, and impacted
against adjacent teeth.
■ 4.x Presence of supernumerary teeth.
■ Grade 3 (Moderate/Borderline Need)
■ 3.a Increased overjet greater than 3.5 mm but less
than or equal to 6 mm with incompetent lips.
■ 3.b Reverse overjet greater than 1 mm but less
than or equal to 3.5 mm.
■ 3.c Anterior or posterior crossbites with greater than
1 mm but less than or equal to 2 mm discrepancy
between retruded contact position and intercuspal
position.
■ 3.d Contact point displacements greater than 2
mm but less than or equal to 4 mm.
■ 3.e Lateral or anterior open bite greater than 2 mm
but less than or equal to 4 mm.
■ 3.f Deep overbite complete on gingival or palatal
tissues but no trauma
Grade 2 (Mild/Little Need)
■ 2.a Increased overjet greater than 3.5 mm but less than or equal
to 6 mm with competent lips.
■ 2.b Reverse overjet greater than 0 mm but less than or equal to
1 mm.
■ 2.c Anterior or posterior crossbite with less than or equal to 1
mm discrepancy between retruded contact position and
intercuspal position.
■ 2.d Contact point displacements greater than 1 mm but less than
or equal to 2 mm.
■ 2.e Anterior or posterior open bite greater than 1 mm but less
than or equal to 2 mm.
■ 2.f Increased overbite greater than or equal to 3.5 mm without
gingival contact.
■ 2.g Prenormal or postnormal occlusions with no other
anomalies
■ Grade 1 (No Need)
■ 1.Extremely minor malocclusions, including contact
point displacements less than 1 mm.
Who seeks treatment?
■ Demand for treatment is indicated by the patients who actually make
appointments and seek care
■ Both the perceived need and demand vary with social and cultural
conditions
■ Family income is the major determinant of how many children receive
treatment.
■ The higher the aspirations for a child, the more likely the parents are to
seek orthodontic treatment for him or her.
■ Today medical aid and dental interventions that are intended to make the
individual either “better than well” or “beyond normal” are called
enhancements
■ Orthodontics often can be considered an enhancement technology .
■ It is increasingly accepted that appropriate care for individuals should
often include enhancements to maximize their quality of life.
■ Orthodontics has become a more prominent part of dentistry .
■ The vast majority of individuals who had orthodontic treatment feel that
they benefited from the treatment and are pleased with the result.
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