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Dental open bite occurs in patients where the anterior teeth fail to touch. However, this is not accompanied by the skeletal tendency of having an open bite. Thus this type of open bite may happen in patients who have horizontal or hypodivergent growth pattern. These patients have normal jaw growth and do not have the long face syndrome. The anterior open bite in these patients may be caused by Macroglossia, Tongue thrusting habit or digit sucking habits. Some of the characteristics of a dental open bite include:
- Normal lower anterior facial height
- Horizontal/Hypodivergent growth pattern
- Occlusal plane diverges after the premolar contact
- Under-eruption of the anterior incisors
- Over-eruption of the posterior incisors
- Proclined upper and lower incisors
- No vertical maxillary excess or gummy smile
- Presence of habits such as thumb sucking, tongue thrusting
- Spacing between anterior incisors due to their proclination
Patient with skeletal open bites that accompany dental open bites may have Adenoid faces or Long face syndrome. They are said to have what is known as "Hyperdivergent Growth Pattern" which includes characteristics such as:
- Increased Lower Anterior Facial Height
- Occlusal plane diverges after the 1st molar contact
- May accompany dental open bite
- Narrow nostrils with upturned nose
- Dolicofacial or Leptoprosopic face pattern
- Constricted maxillary arch
- Bilateral Posterior Crossbite
- High and narrow palatal vault
- Presence of crowding in teeth
- Mentalis muscle strain upon forcibly closing of lips
- Possible gummy smile with increased interlabial gap
Cephalometric analysis features of skeletal open bite may include:
- Increased Frankfurt-Mandibular Plane angle
- Steep Occlusal Plane Angle
- Increased SN-MP Angle
- Short Mandibular ramus
- Increased mandibular body length
- Downward and backward position of mandible
- Increased gonial angle
- Proclined upper incisors, retroclined or upright lower incisors
- Posterior part of maxilla is tipped downwards
- Posterior facial height equals 1/2 of anterior facial height
- Increased hard tissue Lower Anterior Facial Height
- Increased total anterior facial height
- Short mandibular ramus
Viken Sassouni developed Sassouni analysis which indicates that patient's with long face syndrome have 4 of their bony planes (mandibular plane, occlusal plane, palatal plane, SN plane) steep to each other.
Unilateral crossbite involves one side of the arch. The most common cause of unilateral crossbite is a narrow maxillary dental arch. This can happen due to habits such as digit sucking, prolonged use of pacifier or upper airway obstruction. Due to the discrepancy between the maxillary and mandibular arch, neuromuscular guidance of the mandible causes mandible to shift towards the side of the crossbite. This is also known as Functional mandibular shift. This shift can become structural if left untreated for a long time during growth, leading to skeletal asymmetries. Unilateral crossbites can present with following features in a child
- Lower midline deviation to the crossbite side
- Class 2 Subdivision relationships
- Temporomandibular disorders
Overbite medically refers to the extent of vertical (superior-inferior) overlap of the maxillary central incisors over the mandibular central incisors, measured relative to the incisal ridges.
The term overbite does not refer to a specific condition, nor is it a form of malocclusion. Rather an absent or excess overbite would be a malocclusion. Normal overbite is not measured in exact terms, but as a proportion (approximately 30–50% of the height of the mandibular incisors) and is commonly expressed as a percentage.
An anterior crossbite in a child with baby teeth or mixed dentition may happen due to either dental misalignment or skeletal misalignment. Dental causes may be due to displacement of one or two teeth, where skeletal causes involve either mandibular hyperplasia, maxillary hypoplasia or combination of both.
Other kinds of malocclusions can be due to tooth size or horizontal, vertical, or transverse skeletal discrepancies, including skeletal asymmetries. Long faces may lead to "open bite malocclusion", while short faces can be coupled to a "Deep bite malocclusion". However, there are many other more common causes for open bites (such as tongue thrusting and thumb sucking), and likewise for deep bites. Upper or lower jaw can be overgrown or undergrown, leading to Class II or Class III malocclusions that may need corrective jaw surgery or orthognathic surgery as a part of overall treatment, which can be seen in about 5% of the general population.
In dentistry, a furcation defect is bone loss, usually a result of periodontal disease, affecting the base of the root trunk of a tooth where two or more roots meet ("bifurcation" or "trifurcation"). The extent and configuration of the defect are factors in both diagnosis and treatment planning.
A tooth with a furcation defect typically possessed a more diminished prognosis owing to the difficulty of rendering the furcation area free from periodontal pathogens. For this reason, surgical periodontal treatment may be considered to either close the furcation defect with grafting procedures or allow greater access to the furcation defect for improved oral hygiene.
Malocclusion is a common finding, although it is not usually serious enough to require treatment. Those who have more severe malocclusions, which present as a part of Craniofacial Anomalies, may require orthodontic and sometimes surgical treatment (orthognathic surgery) to correct the problem. Correction of malocclusion may reduce risk of tooth decay and help relieve excessive pressure on the temporomandibular joint. Orthodontic treatment is also used to align for aesthetic reasons.
Malocclusions may be coupled with skeletal disharmony of the face, where the relations between the upper and lower jaws are not appropriate. Such skeletal disharmonies often distort sufferer's face shape, severely affect aesthetics of the face, and may be coupled with mastication or speech problems. Most skeletal malocclusions can only be treated by orthognathic surgery.
Overjet is the extent of horizontal (anterior-posterior) overlap of the maxillary central incisors over the mandibular central incisors. In class II (division I) malocclusion the overjet is increased as the maxillary central incisors are protruded.
Overbite is often confused with overjet, which is the distance between the maxillary anterior teeth and the mandibular anterior teeth in the anterior-posterior axis.
"Overbite" may also be used commonly to refer to Class II malocclusion or retrognathia, though this usage can be considered incorrect. This is where the mesiobuccal cusp of the maxillary first molar is situated anterior to the buccal groove of the mandibular first molar; in other words, the mandible (lower jaw) appears too far behind the maxilla. A person presenting with Class II malocclusion may exhibit excessive overbite as well, or may have the opposite problem, which is referred to as openbite (or apertognathia). In the case of apertognathia, the teeth do not overlap enough or at all. The upper teeth protrude past the lower teeth.
Prognathism in humans can be due to normal variation among phenotypes. In human populations where prognathism is not the norm, it may be a malformation, the result of injury, a disease state or a hereditary condition. Prognathism is considered a disorder only if it affects mastication, speech or social function as a byproduct of severely affected aesthetics of the face.
Clinical determinants include soft tissue analysis where the clinician assesses nasolabial angle, the relationship of the soft tissue portion of the chin to the nose, and the relationship between the upper and lower lips; also used is dental arch relationship assessment such as Angle's classification.
Cephalometric analysis is the most accurate way of determining all types of prognathism, as it includes assessments of skeletal base, occlusal plane angulation, facial height, soft tissue assessment and anterior dental angulation. Various calculations and assessments of the information in a cephalometric radiograph allow the clinician to objectively determine dental and skeletal relationships and determine a treatment plan.
Prognathism is less prevalent in East Asians and Caucasians. It is not to be confused with micrognathism, although combinations of both may be found. It affects the middle third of the face, causing it to jut out, thereby increasing the facial area, similar in phenotype of archaic hominids and apes. Mandibular prognathism is a protrusion of the mandible, affecting the lower third of the face. Alveolar prognathism is a protrusion of that portion of the maxilla where the teeth are located, in the dental lining of the upper jaw. Prognathism can also be used to describe ways that the maxillary and mandibular dental arches relate to one another, including malocclusion (where the upper and lower teeth do not align). When there is maxillary and/or alveolar prognathism which causes an alignment of the maxillary incisors significantly anterior to the lower teeth, the condition is called an overjet. When the reverse is the case, and the lower jaw extends forward beyond the upper, the condition is referred to as retrognathia (reverse overjet).
Although it may be asymptomatic, symptoms usually are more likely to be present and more severe with larger tongue enlargements. Signs and symptoms include:
- Dyspnea - difficult, noisy breathing, obstructive sleep apnea or airway obstruction
- Dysphagia - difficulty swallowing and eating
- Dysphonia - disrupted speech, possibly manifest as lisping
- Sialorrhea - drooling
- Angular cheilitis - sores at the corners of the mouth
- Crenated tongue - indentations on the lateral borders of the tongue caused by pressure from teeth ("pie crust tongue")
- Open bite malocclusion - a type of malocclusion of the teeth
- Mandibular prognathism - enlarged mandible
- Mouth breathing
- Orthodontic abnormalities - including diastema and tooth spacing
A tongue that constantly protrudes from the mouth is vulnerable to drying out, ulceration, infection or even necrosis.
Not all alveolar prognathism is anomalous, and significant differences can be observed among different ethnic groups.
Harmful habits such as thumb sucking or tongue thrusting can result in or exaggerate an alveolar prognathism, causing teeth to misalign. Functional appliances can be used in growing children to help modify bad habits and neuro-muscular function, with the aim of correcting this condition.
Alveolar prognathism can also easily be corrected with fixed orthodontic therapy. However, relapse is quite common, unless the cause is removed or a long-term retention is used.
Nabers probe is used to check for furcation involvement clinically. Recently, cone beam computerised technology (CBCT) has also be used to detect furcation. Periapical and interproximal intraoral radiographs can help diagnosing and locating the furcation. The location and severity of furcation should be recorded in patient’s notes.
Only multirooted teeth have furcation. Therefore, upper first premolar, maxillary and mandibular molars may be involved.
Upper premolars have one buccal and one palatal root. Furcation involvement should be checked from the mesial and the distal aspects of the tooth.
Maxillary molars have three roots, a mesio-buccal root, disto-buccal root and a palatal root. Thus, check for furcation from buccal, mesio-palatal and disto-palatal aspects.
Mandibular molars have one mesial and one distal root, and so, check for involvement from buccal and lingual aspects.
Retrognathia (or retrognathism) is a type of malocclusion which refers to an abnormal posterior positioning of the maxilla or mandible, particularly the mandible, relative to the facial skeleton and soft tissues.
A retrognathic mandible is commonly referred to as an overbite, though this terminology is not used medically.
OMD refers to abnormal resting posture of the orofacial musculature, atypical chewing, and swallowing patterns, dental malocclusions, blocked nasal airways, and speech problems. OMD are patterns involving oral and/orofacial musculature that interferes with normal growth, development, or function of structures, or calls attention to itself. OMD are found in both children and adults. OMD that are commonly seen in children include tongue thrust that is also known as swallowing with an anterior tongue posture. OMD also refers to factors such as nonnutritive sucking behaviors, such as thumb sucking, clenching, bruxing, etc. that led to abnormal development of dentition and oral cavity. OMD in adult and geriatric population are due to various neurological impairments, oral hygiene, altered functioning of muscles due to aging, systemic diseases, etc.
Tongue thrusting is a type of orofacial myofunctional disorder, which is defined as habitual resting or thrusting the tongue forward and/or sideways against or between the teeth while swallowing, chewing, resting, or speaking. Abnormal swallowing patterns push the upper teeth forward and away from the upper alveolar processes and cause open bites. In children, tongue thrusting is common due to immature oral behavior, narrow dental arch, prolonged upper respiratory tract infections, spaces between the teeth (diastema), muscle weakness, malocclusion, abnormal sucking habits, and open mouth posture due to structural abnormalities of genetic origin. Large tonsils and adenoids also contribute to tongue thrust swallowing.
From the dental perspective, teeth move in relation to the balance of the soft tissue; the normal relationship of teeth lies in occlusion; and any deviation from the normal occlusion can lead to dental distress. Tongue posture plays an important role in swallowing and dentofacial growth. In case of tongue thrust swallowing, the tip of the tongue can come against or between the dentition; the midpoint may be collapsed or extended unilaterally or bilaterally; or the posterior part of the hard palate. In these conditions, there are chances of abnormal dentofacial growth and other concerns regarding development of the craniofacial complex.
There are pertinent symptomatic questions that can be considered for the diagnosis of tongue thrust swallow. Some of these questions are geared toward tongue protrusion and an opening of lips when the client is in repose; habitual mouth breathing; digit sucking; existence of high and narrow palatal arch; ankyloglossia (tongue-tie); malocclusions, (Class II, III); weak chewing muscles (masseter); weak lip muscles (orbicularis oris); overdeveloped chin muscles (mentalis); muscular imbalance; abnormal dentition.
Tongue thrusting and speech problems may co-occur. Due to unconventional postures of the tongue and other articulators, interdental and frontal lisping are very common. The alveolar sounds /s/ and /z/ are produced more anteriorly thus leading to interdental fricative like sounds, /th/.
In dentistry, anodontia, also called anodontia vera, is a rare genetic disorder characterized by the congenital absence of all primary or permanent teeth. It is associated with the group of skin and nerve syndromes called the ectodermal dysplasias. Anodontia is usually part of a syndrome and seldom occurs as an isolated entity.
Congenital absence of permanent teeth can present as hypodontia, usually missing 1 or 2 permanent teeth, or oligodontia that is the congenital absence of 6 or more teeth. Congenital absence of all wisdom teeth, or third molars, is relatively common. Anodontia is the congenital absence of teeth and can occur in some or all teeth (partial anodontia or hypodontia), involve two dentitions or only teeth of the permanent dentition (Dorland's 1998). Approximately 1% of the population suffers from oligodontia. Many denominations are attributed to this anomaly: partial anodontia, hypodontia, oligodontia, the congenital absence, anodontia, bilateral aplasia. Anodontia being the term used in controlled vocabulary Medical Subject Headings (MeSH) from MEDLINE which was developed by the United States National Library of Medicine. The congenital absence of at least one permanent tooth is the most common dental anomaly and may contribute to masticator dysfunction, speech impairment, aesthetic problems, and malocclusion (Shapiro and Farrington 1983). Absence of lateral incisors represents a major stereotype. Individuals with this condition are perceived as socially most aggressive compared with people without anodontia (Shaw 1981).
Orofacial myofunctional disorders (OMD) (sometimes called “oral myofunctional disorder", and “tongue thrust”) are muscle disorders of the face, mouth, lips, or jaw.
Recent studies on incidence and prevalence of tongue thrust behaviors are not available. However, according to the previous research, 38% of various populations have OMD. The incidence is as high as 81% in children exhibiting speech/articulation problems (Kellum, 1992).
A jaw abnormality is disorder in the formation or shape of the jaw. It can involve malocclusion.
Types include:
- Micrognathism
- Prognathism
- Retrognathism
- Pierre Robin syndrome
Repair with cementum or dentin occurs after partial root resorption, fusing the tooth with the bone. It may occur following dental trauma, especially occlusal trauma, or after periapical periodontitis caused by pulp necrosis. Ankylosis itself is not a reason to remove a permanent tooth, however teeth which must be removed for other reasons are made significantly more difficult to remove if they are ankylosed.
Lefort I - Slight swelling of the upper lip, ecchymosis is present in the buccal sulcus beneath each zygomatic arch, malocclusion, mobility of teeth. Impacted type of fractures may be almost immobile and it is only by grasping the maxillary teeth and applying a little firm pressure that a characteristic grate can be felt which is diagnostic of the fracture. Percussion of upper teeth results in cracked pot sound. Guérin's sign is present characterised by ecchymosis in the region of greater palatine vessels.
Lefort II and Lefort III (common) - Gross edema of soft tissue over the middle third of the face, bilateral circumorbital ecchymosis, bilateral subconjunctival hemorrhage, epistaxis, CSF rhinorrhoea, dish face deformity, diplopia, enophthalmos, cracked pot sound.
Lefort II - Step deformity at infraorbital margin, mobile mid face, anesthesia or paresthesia of cheek.
Lefort III - Tenderness and separation at frontozygomatic suture, lengthening of face, depression of ocular levels (enophthalmos), hooding of eyes, and tilting of occlusal plane, an imaginary curved plane between the edges of the incisors and the tips of the posterior teeth. As a result, there is gagging on the side of injury.
The ICD-10 lists macroglossia under "other congenital malformations of the digestive system". Definitions of macroglossia have been proposed, including "a tongue that protrudes beyond the teeth during [the] resting posture" and "if there is an impression of a tooth on the lingual border when the patients slightly open their mouths". Others have suggested there is no objective definition of what constitutes macroglossia. Some propose a distinction between "true macroglossia", when histologic abnormalities correlate with the clinical findings of tongue enlargement, and "relative macroglossia", where histology does not provide a pathologic explanation for the enlargement. Common examples of true macroglossia are vascular malformations, muscular enlargement and tumors; whilst Down syndrome is an example of relative macroglossia. "Pseudomacryglossia" refers to a tongue that is of normal size but gives a false impression of being too large in relation to adjacent anatomical structures. The Myer classification subdivides macroglossia into generalized or localized.
Diagnosis is suspected by physical exam and history, in which, classically, the hard and soft palate of the midface are mobile with respect to the remainder of facial structures. This finding can be inconsistent due to the midfacial bleeding and swelling that typically accompany such injuries, and so confirmation is usually needed by radiograph or CT.
Ankylosis of deciduous teeth ("submerged teeth") may rarely occur. The most commonly affected tooth is the mandibular (lower) second deciduous molar. Partial root resorption first occurs and then the tooth fuses to the bone. This prevents normal exfoliation of the deciduous tooth and typically causes impaction of the permanent successor tooth. As growth of the alveolar bone continues and the adjacent permanent teeth erupt, the ankylosed deciduous tooth appears to submerge into the bone, although in reality it has not changed position. Treatment is by extraction of the involved tooth, to prevent malocclusion, periodontal disturbance or dental caries.
By far, the two most common symptoms described are pain and the feeling that teeth no longer correctly meet (traumatic malocclusion, or disocclusion). The teeth are very sensitive to pressure (proprioception), so even a small change in the location of the teeth will generate this sensation. People will also be very sensitive to touching the area of the jaw that is broken, or in the case of condylar fracture the area just in front of the tragus of the ear.
Other symptoms may include loose teeth (teeth on either side of the fracture will feel loose because the fracture is mobile), numbness (because the inferior alveolar nerve runs along the jaw and can be compressed by a fracture) and trismus (difficulty opening the mouth).
Outside the mouth, signs of swelling, bruising and deformity can all be seen. Condylar fractures are deep, so it is rare to see significant swelling although, the trauma can cause fracture of the bone on the anterior aspect of the external auditory meatus so bruising or bleeding can sometimes be seen in the ear canal. Mouth opening can be diminished (less than 3 cm). There can be numbness or altered sensation (anesthesia/paraesthesia in the chin and lower lip (the distribution of the mental nerve).
Intraorally, if the fracture occurs in the tooth bearing area, a step may seen between the teeth on either side of the fracture or a space can be seen (often mistaken for a lost tooth) and bleeding from the gingiva in the area. There can be an open bite where the lower teeth, no longer meet the upper teeth. In the case of a unilateral condylar fracture the back teeth on the side of the fracture will meet and the open bite will get progressively greater towards the other side of the mouth.
Sometimes bruising will develop in the floor of the mouth (sublingual eccymosis) and the fracture can be moved by moving either side of the fracture segment up and down. For fractures that occur in the non-tooth bearing area (condyle, ramus, and sometimes the angle) an open bite is an important clinical feature since little else, other than swelling, may be apparent.