1. INCIPIENT MALOCCLUSION
BY: Dr. Richa Khanna

2. Types.... Definition.... An incipient malocclusion is defined as a
condition which shows a tendency
to develop into a deviation from the normal
dentofacial or occlusal relationship
Types....
DENTAL
SKELETAL
DENTO-SKELETAL

3. Why diagnose while INCIPIENT??
To prevent their establishment
To refer at appropriate time.
To minimize corrective treatment and its duration.

4. DIAGNOSING INCIPIENT MALOCCLUSIONS
The modern concept is......
stressing on
prevention – oriented early detection of problems

5. DIAGNOSING INCIPIENT MALOCCLUSIONS
Incipient malocclusions are result of developmental processes.....and not pathologic
Objective signs and symptoms measured by the dentist are morphologic characteristics of malocclusion and NOT physiologic measurements of function that help to treat any illness

6. DIAGNOSING INCIPIENT MALOCCLUSIONS
ALSO..... While diagnosing Parents must be made to understand that a normal occlusion may not develop always..... AND.... How future problems could be prevented and intercepted at INCIPIENT STAGE.

7. ESSENTIALS OF DIAGNOSIS
GENERAL EVALUATION:
Initial patient interaction
Chief complaint-
Find out what is important for the patient,
that is the major concerns.
Medical history
Very important to elicit as orthodontic
problems are mostly developmental
Dental History-
May additionally help to elicit parents attitude, awareness and any hereditary component

8. ESSENTIALS OF DIAGNOSIS
Genetic history-
any history of orthodontic treatment in siblings, close relatives or parents themselves.
Sociobehavioural history
Difficult to elicit
Parents generally do not tell about child’s emotional problems.
You may ask about school progress rather.
Questions related to Quality of life being affected may be put up.

9. ESSENTIALS OF DIAGNOSIS
It has three major areas:
-the patient's motivation for treatment,
-what he or she expects as a result of treatment, and
-how cooperative or uncooperative the patient is likely to be.
AGE
GENDER
PRENATAL HISTORY
Includes drugs, any illness, type of delivery.

10. ESSENTIALS OF DIAGNOSIS
2. STRUCTURAL ASSESSMENT
EXTRAORAL:
General
i. Physical growth status: Ht&Wt
To know present status and future potential.
ii. Body type
b. Facial features
i. Facial type
ii. Shape of Head
iii. Facial Profile
iv. Lip posture
v. Relative symmetry of facial structures.
c. TMJ
d. Speech difficulties if any.

11. ESSENTIALS OF DIAGNOSIS
INTRAORAL EXAMINATIONS:
Jaw relationship( ant-post, vertical,lateral)
Open mouth examination:
no. of teeth, any abnormality of size and shape, restorations, oral hygiene, molar relation, overjet, overbite, midline.
c. Soft tissues:
Gingiva, frenums,tongue, palate, tonsils, oral mucosa in general,lips.

12. ESSENTIALS OF DIAGNOSIS
Tooth-Lip Relationships: Mini-Esthetics:
Tooth-Lip Relationships
This includes:
- Relationship of the dental midline of each arch to the skeletal midline of that jaw (i.e., the lower incisor midline related to the midline of the mandible, and the upper incisor midline related to the midline of the maxilla
- vertical relationship of the teeth to the lips, at rest and on smile( incisor display)

13. ESSENTIALS OF DIAGNOSIS
b. Smile analysis:
Amount of Incisor and Gingival Display.
Smile arc , golden proportions etc.

14. ESSENTIALS OF DIAGNOSIS
3. FUNCTIONAL ASSESSMENT
RESPIRATION
Tests for checking respiration mode are:
Observation without informing the patient
Observation while asking the patient to breathe.
Mirror test
Cotton/Butterfly test
Water test
OCCLUSAL INTERFERENCE
Such interferences may lead to deviated paths of closure, and hence imbalance of musculature. May affect TMJ.

15. POTENTIAL PROBLEMS OF INCIPIENT MALOCCLUSION
PREDENTATE PERIOD
Type of delivery:
Crossbite incidence is high in children born with forceps delivery.
Also, abnormal arch dimensions, increased height of maxilla and increased length of mandible is seen
Narrow arches are more common.
b. Preterm birth:
Gestational age less than 37 weeks
Such children are under variety of metabolic stresses.

16. Following problems in preterm infants may be index for developing probable malocclusion problems:
i. Palatal grooves and cleft formation
ii. Primary incisor defects.
iii. Delayed eruption of primary teeth

17. c. Neonatal jaw relationship:
No precise relationship exists.
Anterior openbite seen in gumpads is very common...and is usually transient.
Oral habits may influence duration of anterior openbite.
d. Retained Infantile swallowing:
In the infantile swallowing reflex tongue lies between gumpads and, mandible is stabilised by
an obvious contraction of facial muscles. The buccinator is especially very strong

18. Infantile swallow disappears with eruption of primary incisors normally.
Sometimes, a transitional state between an infantile and mature swallowing can be seen with an open bite.
When infantile swallow persists even after eruption of permanent incisors, it leads to:
Very strong contraction of lips
And Facial muscles, particulary noticeable are buccinator contractions.

19. e. Inadequate breast feeding OR early weaning:
Lead to low impact muscle activity
Problems in normal development of alveolar ridges, palate.
And, hence crossbites are frequent in primary dentition.
Early introduction of bottle may also lead to such consequences.

20. II. DECIDUOUS DENTITION:
DENTAL ARCHES:
What to look for:
Spacing
Crowding
Isolated teeth crowding
Relationship of crowding with any oral habit

21. B. TRANSVERSE RELATIONSHIP:
What to look for:
Midline discrepancies
--- large midline shifts are usually rare in primary dentition
--- if present... Mandibular shift should be suspected. It usually manifests as unilateral crossbite
--- True cause should be looked for - Whether developmental size discrepancy of jaws is present
Crossbite
---- Should be treated immediately
Overjet

22. C. Vertical Dimension:
What to look for:
Openbite
Deepbite
D. Eruption problems
Delayed eruption
Missing tooth

23. E. Habits:
What to look for:
Associated features
F. Primary dentition terminus
Second primary molar relationship in non spaced dentition

24. Second primary molar relationship in non spaced mandibular and spaced maxillary dentition.
If present with a flush terminal relationship
If present with a distal step
Leads to development of disto-occlusion immediately after eruption of permanent first molars
Leads to development of disto-occlusion if maxillary first permanent molar erupts before mandibular

25. G. Impacted primary teeth:
Very rare—usually due to trauma...mostly re-erupt
Can cause delay in eruption of permanent teeth
H. Congenital absence of primary teeth
What to look for:
Agenesis of permanent successors

26. I. Infected primary teeth:
These may cause Ankylosis or Enamel defects in permanent successors.
Infected teeth also may lead to single side chewing and hence, hygiene and malocclusion problems.
J. Retained primary teeth
What to look for:
Lead to crossbites, ectopic eruption, malocclusion.

27. K. Ankylosis of primary teeth:
Very common in primary molars
Can delay eruption of permanent teeth
Inhibit growth of alveolar process, leading to development of a bony step.
Supraeruption of opposite teeth can also occur

28. L. Loss of primary teeth:
Can accelerate permanent successor eruption if crown completion is complete and root formation has started.
Can delay permanent successor eruption if crown completion is not complete
M. Premature loss of primary teeth
Lead to:
Loss of arch length
Tipping of adjacent teeth
Supraeruption of opposing teeth

29. N. Supernumery teeth M. Abnormal TMJ relationship -- Leads to development of functional malocclusions N. Gingival Or Periodontal conditions leading to premature loss of Primary teeth

30. Space Loss & SPACE ANALYSIS
BY: Dr. Richa Khanna

31. RATE AND TIME OF SPACE LOSS
Earlier the tooth is lost greater the initial space loss
Studies have reported 1.5mm per year in the maxilla and 1 mm per year in mandible
Studies have also found that greatest space loss occurs in first four months.(Many controversial results are reported)

32. AMOUNT OF SPACE closure
Studies have found the total space loss upto 2.5 mm

33. DIRECTION OF SPACE closure
Kronfeld’s theory states that there are neutral areas located:
between the bicuspids in maxilla and
just mesial to the first molar in mandible.
According to this theory :
Teeth anterior to neutral zone have a tendency to drift distally
Teeth posterior to neutral zone have a tendency to drift mesially

34. Variables affecting space control interventions
-- Given by Wright and Kennedy
Oral musculature and habits
Time elapsed since extraction
Dental age, eruption pattern and bony covering
Available space
Interdigitation
Anamolies
Sequence of eruption

35. Space discrepancy analysis in mixed dentition
Two most imporatant variables considered for calculating space discrepancy in mixed dentition
Space requirement = Space needed for permanent canines + premolars
(calculated from mixed dentition analysis, after taking into account incisor position, curve of spee, late mesial shift. )
Space available = distance between mesial contact point of permanent molar and distal contact point of deciduous canine is done.

36. Space analysis is based on important assumptions:
(1) the anteroposterior position of the
incisors is correct (i.e., the incisors are neither excessively protrusive nor retrusive),
(2) the space available will not change because of growth; and
(3) all the teeth are present and reasonably normal in size.
None of these assumptions can be taken for granted. All of them must be kept in mind when space analysis is done.
Besides these , curve of spee and late mesial shift should also be taken into consideration

37. Crowding and protrusion are really different
aspects of the same phenomenon.
If there is not enough room to properly align the teeth, the result can be
crowding,
protrusion,
or (most likely) some combination of the two.
For this reason, information about how much the incisors protrude must be available from clinical examination to evaluate the results of space analysis.
This information comes from facial form analysis (or from cephalometric analysis if available).

38. The second assumption, that space available will not change during growth, is valid for most but not all children.
In a child with a well-proportioned face, there is little or no tendency for the dentition to be displaced relative to the jaw during growth, but the teeth often shift anteriorly or posteriorly in a child with a jaw discrepancy.
For this reason, space analysis is less accurate and less useful for children with skeletal problems (Class II, Class III, long face, short face

39. Radiographic method
It uses radiographic measurements for prediction of sizes of unerupted permanent canines and premolars.
The technique can be used in maxillary and mandibular arches for all ethnic groups

40. Radiographic method Disadvantages:
This requires an undistorted radiographic image
Even with individual radiographs, it is often difficult to obtain an undistorted view of the canines, and this inevitably reduces the accuracy.

41. Moyer’s analysis It is a correlational-statistical method
Utilises the correlation between the size of the erupted permanent incisors and the unerupted canines and premolars
The size of the lower incisors correlates better with the size of the upper canines and premolars than does the size of the upper incisors, because upper lateral incisors are extremely variable teeth.
The data has been tabulated for white American children by Moyers

42. Moyer’s analysis To utilize the Moyers prediction tables,
mesiodistal width of the lower incisors is measured
this number is used to predict the size of both the lower and upper unerupted canines and premolars.
No radiographs are required, and it can be used for the upper or lower arch.
Values at 75% Confidence Interval from the tables are found to be most accurate predictions.

43. Moyer’s analysis Disadvantages: tendency to overestimate
More accurate for Europeans from which the data is derived

44. Tanaka and johnston It is a correlational-statistical method
uses the width of the lower incisors to predict the size of unerupted canines and premolars
It requires neither radiographs nor reference tables
Very simple calculations

45. Tanaka and johnston
Disadvantages:
- the method has good accuracy in Europeans despite a small bias toward overestimating the unerupted tooth sizes.
- May not be accurate for all population groups

46. SUM OF WIDTHS OF CENTRAL AND LATERAL INCISORS IN ONE QUADRANT
Hixon and oldfather
It is actually a combination of radiographic and correlational-statsitical method
They found strongest correlation from:
SUM OF WIDTHS OF CENTRAL AND LATERAL INCISORS IN ONE QUADRANT +
SUM OF WIDTHS OF TWO PREMOLARS OF SAME QUADRANT AS MEASURED ON RADIOGRAPH
But these correlations were only for mandible
From these predictions they devised a prediction table

47. THANK YOU

48. QUES 1 Which is the most easy and practical Mixed dentition analysis
Radiographic method
Moyer’s
Tanaka – johnston
Hixon-Oldfather

49. Ques 2
Which Confidence interval of Moyer’s prediction tables are used for accurate predictions?
25th
50th
75th
100th

50. Ques 3 Neutral zone in the maxilla as given by Kronfeld lies in:
Incisor region
Canine refion
Bicuspid region
Molar region

51. Ques 4
Which of the following is an indication of Incipient malocclusion in Primary dentition?
Absence of spacing
Generalised spacing
Leeway spacing
Primate spacing

52. Ques 5
Which is the most important factor that needs consideration while calculating space discrepancy in a protruded well aligned mixed dentition?
Upper canine position
Lower molar position
Lower incisor position
Upper premolar position

53. Ques 6
Disadvantage of Radiographic method of mixed dentition analysis:
Distortion of radiographic image
Grayscale disturbances occur
Cannot be used in both the arches
Cannot be used in all ethnic groups

54. Ques 7
Consequences of forceps delivery on the developing jaws and occlusion can be:
Openbite development
Tongue thrust development
Increase in facial height
Decrease in mandibular length

55. Ques 8
Which of the following is considered to be an Incipient malocclusion warranting treatment in future?
Adequate breast feeding
Openbite in predentate period
Retained infantile swallow
Spacing in primary dentition