Tag Archives: Diagnosis

Management of congenitally missing lateral incisors

Summarized by : Dr Hani Alhebshi .

Three treatment options for replacing missing lateral incisors :

1.Canine substitution. ( Space Closure ).

2.A tooth supported restoration ( Space Opening ).

3.A single tooth implant ( Space Opening ).


The primary consideration to choose one option is to choose the most conservative one or the least invasive according to each case. 

congenitally missing lateral

Canine substitution :

Select the appropriate patient for canine substitution according to several criteria :

A. Malocclusion :

Two types of malocclusion can accept canine substitution according to

  1. Class II with no crowding in mandibular arch.In this pattern molars remain in class II and premolars are located in traditional canine position.
  2. Class I with crowding in lower arch that necessitate extraction.

Diagnostic wax up will greatly help the orthodontist and the dentist to evaluate the final occlusion and how much canine reduction is necessary.

B.Profile :

  • The ideal profile to accept canine substitution is straight profile or mildly convex. 
  • Moderately convex or retrusive mandible or chin are not appropriate patients.

Continue reading Management of congenitally missing lateral incisors

General Guidelines to Management of Class II Malocclusion

Prepared by : Dr. Hani Alhebshi. , Dr, Saleh Alkhathami and Dr.Shehab Kaaki.

This is  a thorough overview on the management of  Calss II malocclusion.

Signs of Class II malocclusion :

  • Convex Profile
  • Increased overjet
  • Skeletal pattern can be due to retrognathic mandible or prognathic maxilla or combination or both.That can be figured out by checking SNA and SNB angles.
  • Lips are commonly incompetent.
  • Nasiolabial angle is acute espaecially in Class II division I.
  • Class II molars , Canines and Incisors.
    British school classify malocclusions according to the incisors relation mainly , while american school mainly depends on the molar and canine relation.
    Therefore the British consider an increased overjet due to thumb sucking as Class II even if molars and canines are in Class I relation.

In Class II division 1 :

Treatment of class  II division  I is done sometimes to prevent trauma to maxillary anterior teeth because they are too proclined.

In Class II division 2 :
Upper central incisors are retroclined while laterals are in average or proclined inclination.
Overbite is commonly increased. The retroclined incisors might mask an increased overjet.Canine classification might then be a good parameter to check to confirm the Class II occlusion.

First step in managment : Determine the cause of Class II malocclusion. Is it skeletal or dental ?
If it is a skeletal then it can be due to a prognathic maxilla or a deficient mandible or combination of both.
On Cephalometric radiograph , ANB is oftenly increased ( above 4° ).

Skeletal Age : is the first important parameter that determines the path of treatment.In growing patients , growth modification can be used by the use of functional appliances or headgear while non-growing (adults) patients a camouflage or orthognathic surgery are chosen.

Growth Modification :
When patient is in preadolescence then a growth modification strategy can be considered.
CVM ( Cervical Vertebral Maturation) or hand wrist evaluation will show whether growth is still active or not.
Menarche ( The 1st menstruation cycle in girls )  indicates that growth has passed the peak in females. Ideal time to start growth modification is when CVM at stage 3 meaning that the peak in mandibular growth has occured within one year before this stage.
Therefore , correction of class II  can be carried out in this time by inducing mandibular advancement by functional appliances like herbst or twin block appliance. especially when the problem is mainly due to the mandibular retrognathism; or by restraining maxilla by means of headgear to allow mandible to grow and catch up maxillary growth especially when the problem is maxillary prognathism.
The choice between a high pull or cervical headgear depends on the vertical growth pattern of the patient.
If the lower facial height is high (with or without an open bite ) and mandibular plane angle is increased (hyperdivergent) then a high pull or combined headgear should be chosen to prevent extrusion of molars or any increase in the vertical dimension.
On the contrary, low facial height and (hypodivergent mandibular plane) necessate the use of cervical headgear type to allow some extrusion of molars and subsequent overbite correction owed to backward rotation of the mandible.

Orthognathic Surgery:

  • In late adolescence or adults (i.e non-growing): Usually a bilateral sagittal split osteotomy is performed to advance the mandible.
  • Maxillary setback with impaction can be beneficial too especially if the malocclusion is accompanied by a gummy smile.
  • Double jaw surgery can be done in both jaws if the problem is related to a combination of prognathic maxilla and retrognathic mandible.

The decision is better made by the surgeon and the orthodontist after making a visual treatment objective plan (VTO). This will predict the required movements needed to correct the skeletal discrepancy.


Camuoflage :
Camouflage options are useful if patient has mild to moderate skeletal discrepancy or refuses surgical option.That will depend on the severity of Class II.
The soft tissue profile is a critical factor in the treatment plan.Nose and lips position are also other important parameters.

  • Camouflage treatment is most often done by extraction of upper 4s with maximum or absolute anchorage finishing molars in Class II while correcting canines into Class I relation.
  • Other options include extraction of upper 4s and lower 5s if crowding is severe in lower arch.
  • In severely flat profile or very prominent nose , extraction of upper premolars will ruin the profile and dish the face so that it appears uglier than before the treatment. Therefore , surgical approach should be presented to the patient as best option.
  • Using Class II correctors like Forsus is a good option unless patient has a severely proclined lower anterior teeth where it is contraindicated.
  • Class II elastics are also used to correct Class II molars and canines to class I relationship.It should be used cautiously especially when lower anteriors are proclined or vertical dimension is already high before treatment. Thats owing to the effect of class II elastics namely the protrusion of lower incisors , extrusion of lower molars that would increase the vertical dimension.Class II elastics is also contraindicated in gummy smile cases because of their effect in rotating the occlusal plane in a clockwise direction ending up with an increased gingival display.
  • Genioplasty ( to advance the chin )  is needed sometimes to correct the retrusive chin usually accompanied with extraction of upper 4s. this option is offered to the patient after the treatment of orthodontics is completed.

Effect of types of treatment on the soft tissue :

  • Lips should go back and become competent.
  • Nasiolabial angle should increase. ( i.e change from acute to obtuse angle. )



Borderline Class III cases : Surgery vs. Camouflage.

Written by : Dr. Rania Alraddadi ..

Dear all,

I just wante d to summarize what we discussed today regarding the treatment decision in borderline Class III cases:

Surgery vs. Camouflage:

Factors to consider:

1- Extra oral exam including both profile and frontal views (is the mandible big? In AP? In transverse including the symmetry and In vertical?).

2- Family history. Continue reading Borderline Class III cases : Surgery vs. Camouflage.

TIPS : Condylar Hypertrophy and Mandibular asymmetry

Tip by Prof.Fahad Alsolaimani :

Asymetric manibular appearnce can be caused by unilateral overgrowth of one condyle.The overgrowth can be due to Rheumatic Artheritis , Trauma or inflammation of the condyle (s).

Mandibular condylar hyperplasia ( CH ) is a condition that causes excessive growth of the condylar head and neck , as well as the mandible , creating functional and cosmetic deformities of the face and jaw .

Signs of unilateral Condylar hyperplasia (most common):

1. Deviation of the mandible to the opposite side of the condyle that has overgrowth. ( I.e if overgrowth on left condyle , deviation will be toward the right ). Continue reading TIPS : Condylar Hypertrophy and Mandibular asymmetry

Assessment of Lip Position

Written By : Dr. Rania AlRaddadi .

Dear all,

Here is a quick reminder & an illustration + some old but nonetheless classic references.

In ceph and photographic analysis there are many lines that have been introduced to assess lip position: Ricketts E line, Steiner’s S line, Holdaway’s H line, Burstone’s B line to name a few.. But actually the ones that are mostly used are the E line and the S line.
Continue reading Assessment of Lip Position