The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
2. Practice should always be based upon a sound
knowledge of theory.
• Is there a problem?
• What is the problem?
• How is the problem typified?
• What treatments are available for this problem?
• Which of the treatments is/are more appropriate for
us to use?
• How is successful treatment defined?
• How will the treatment be stabilized?
www.indiandentalacademy.com
3. • Ideal - Set Values
• Normal - Range
• Abnormal – Deviation further from the range
www.indiandentalacademy.com
8. • Specific Vector
• This mandible exhibits
‘clockwise’ rotation in
‘growth’
www.indiandentalacademy.com
9. • Increase in rate of
general growth
• He ‘grew’ rapidly during
adolescence
www.indiandentalacademy.com
10. • Predicting specific
increase in timing of rate
of growth
• We expect to see a spurt
in the ‘growth’ in the
next few weeks
www.indiandentalacademy.com
11. • Assumption of group
vectors
• This is a typical class III
‘growth’ pattern
www.indiandentalacademy.com
12. • Estimate of future
amount of growth
change
• This patient has very
little ‘growth’ left
www.indiandentalacademy.com
14. • Expecting growth which
will aid therapy
• We will wait for some
‘growth’ before starting
treatment
www.indiandentalacademy.com
15. • “Growth is said to be the raw material for
Orthodontic Treatment”
www.indiandentalacademy.com
16. • Growth leads to Biologic alterations
1. Short term – Response to pain
2. Long term – Mutations, Evolutionary changes
www.indiandentalacademy.com
17. • Principles of developmental events
• All changes from conception to death
• Major themes of importance
› Changing complexity
› Shift from competent to fixation
› Shift from dependent to independent
› Ubiquity of genetic control modulated by
environment
www.indiandentalacademy.com
19. • Gross and microscopic anatomy
• Biochemistry
• Physiology
• Genetics
• Anthropology
Knowledge of the following subjects
www.indiandentalacademy.com
20. • Molecular biology
• Developmental biology
• Physical growth
• Behavioral development
Study of Growth and Development is
done in various divisions
www.indiandentalacademy.com
21. • Molecular biology
• Study of physical and chemical
phenomenon in living processes
› Molecular genetics
› Biophysics
› Genetic engineering
Study of Growth and Development is
done in various divisions
www.indiandentalacademy.com
22. • Developmental biology
• Study from a single cell egg to adult
comprising millions of cells
› Cellular biology
› Embryology
› Teratology
www.indiandentalacademy.com
23. • Physical growth
• Study of organ and body growth of analyzing –
› morphogenesis,
› height &weight,
› growth rates,
› retarded growth,
› developmental physical fitness,
› pubescence and
› morphometrics.
www.indiandentalacademy.com
24. • Team – Pediatrician, Anthropologist,
Endocrinologist, Nutritionist and Dentist
• Research Orthodontists have contributed
extensively to the knowledge of postnatal
growth of head and face
• Clinical Orthodontics has been associated with
study of physical growth of head and face –
“Dentofacial Orthopedics”
Physical growth
www.indiandentalacademy.com
25. • Behavioral development
• Study of patterns of interaction with the
environment
› Embryologist, Psychologist, Psychiatrist,
Physiologist, Physiologic psychologist and
Geneticists
› Striving to provide us answers to how we think,
reason, remember and forget
www.indiandentalacademy.com
26. • Types of growth data
› Opinion
› Observation
› Ratings and rankings
› Quantitative measurements
Methods of studying Growth and
Development
www.indiandentalacademy.com
27. Direct data
Indirect growth measurements
Derived data – comparison/assumption
Methods of studying Growth and
Development
www.indiandentalacademy.com
28. • Longitudinal
• Cross sectional
• Overlapping / Semi longitudinal Method
Methods of gathering growth data
www.indiandentalacademy.com
29. • Statistics is a necessity for research or clinical
Orthodontist
› Decipher growth studies
› Quantify morphology
Evaluation of growth data
www.indiandentalacademy.com
30. › Assess progress of treatment
› Cephalometric analysis
› Judiciously interpreting the significance of
published findings in clinical and research
journals
Evaluation of growth data
www.indiandentalacademy.com
32. • Adult physique
• Socioeconomic factors
• Exercise
• Family size and birth order
• Secular trends
• Psychological disturbances
Variables affecting physical growth
www.indiandentalacademy.com
33. • A set of constraints operating to preserve the
integration of parts under varying conditions or
through time
• Interactions throughout life between heredity
and environment determines the expression
of pattern, quantifying them is the difficulty
Pattern
www.indiandentalacademy.com
34. › ‘That child has a class II facial pattern’ -
Morphologic pattern
› ‘This child has a vertical growth pattern’ –
Developmental pattern
Pattern
www.indiandentalacademy.com
35. • What is normal?
› Concepts of normality
› Age equivalence
› Significance of variability
Variability – Law of nature
www.indiandentalacademy.com
36. › Concepts of normality
Statistical
Evolutionary
Functional
Esthetic
Clinical – Ideal / Normal
Variability – Law of nature
www.indiandentalacademy.com
37. › Age equivalence
Chronological age
Developmental age
Skeletal age
Dental age
Mental age
Variability – Law of nature
www.indiandentalacademy.com
38. › Significance of variability
Norm of a group/area/race
Individual goal
Group goal
Familial variation
Pathologic variation
Variability – Law of nature
www.indiandentalacademy.com
39. • Predominated by genetic control
• Minimal alterations by environment
› Timing of growth phenomenon
Sex related
Environment related
Critical in the fusion of facial parts in prenatal growth
Synchronous facial and dental growth
Timing
www.indiandentalacademy.com
40. Prenatal Facial Growth
• The fundamental
plan of the individual
face unfolds during
the first four weeks in
prenatal life
www.indiandentalacademy.com
44. • The minute proportional differences that occur
in each human, make us a distinctly
recognizable individual
• The events leading to the organization of the
face in its normal form is critical in
understanding of various factors responsible for
development
Prenatal Facial Growth
www.indiandentalacademy.com
45. • Genetically determined growth leads to
formation of various –
› Body type
› Cephalic type
› Jaw types
• Migration of precursor cells to specific areas
• Environmental factors in each region
Physiologic factors of importance in
prenatal growth
www.indiandentalacademy.com
46. • Disappearance of branchial arches
• Elevation of palatal shelves & depression of the
tongue
• Shift of blood supply ICA to ECA
Physiologic factors of importance in
prenatal growth
www.indiandentalacademy.com
47. • Medially – cartilaginous growth,
• Laterally – intra membranous growth
• Muscles of mastication – confined growth within the
mandibular arch
• Muscles of facial expression – migration of the hyoid
arch over the face
Physiologic factors of importance in
prenatal growth
www.indiandentalacademy.com
48. • Period of organization of the face
• Development of oral structures
• Differentiation of supporting structures
• The fetal period
General outline of crucial growth events
www.indiandentalacademy.com
49. General outline of crucial growth events
• Period of organization of the face
› The branchial arches
› Development of the perioral region
› Changes in the facial proportions
www.indiandentalacademy.com
50. › The branchial arches
Initially its difficult to distinguish the primary
craniofacial features of the human embryo from
those of other mammals
www.indiandentalacademy.com
51. 4th
week IUL
Invagination of the surface ectoderm Oral
pit – surrounding area differentiates into face
Ectodermal oral plate meeting the endodermal
lining of the gut membrane disintegration
continuity between oral cavity and GIT gained
www.indiandentalacademy.com
52. Heart begins to beat
The growth pattern of
the face is downward
and forward between the
forebrain prominence
and cardiac bulge
www.indiandentalacademy.com
53. This growth pattern is
facilitated by the flexion
of the Brain ventrally
and then dorsally
resulting in the erect
head posture
Differentiation of human
face begins 5th
and 7th
week IUL
www.indiandentalacademy.com
54. › Development of the perioral region
5th
week IUL
Face is 1 ½ mm wide and as thick as of a sheet
of paper
Nasal pits – MNP, LNP – elongation – fusion
Tissue underlying each nostril represents the
first separation of the nasal cavity from the oral
cavity – Primary palate
www.indiandentalacademy.com
55. Mode of formation of these pits:
Contact between the epithelium covering the
medial border of the maxillary process and the
lateral border of the MNP
These epithelium together form a lamina –
nasal fin – fuse to form a single sheath
www.indiandentalacademy.com
56. Degeneration of nasal fin – connective tissue
penetration – rapid expansion leaves the nasal
fin at the anterior and posterior limits
Unification of the lip anteriorly and separation
of the floor of the pits in the form of cleft is
prevented
www.indiandentalacademy.com
57. The tissues underlying and between the two pits
is – primary palate – forms separation between
the Primitive nasal cavity and oral cavity
The posterior opening of the nasal pit is termed
as the internal nares and is the posterior limit of
the primary palate
Palatal shelves separate the oral and nasal
cavities – also called secondary palate
www.indiandentalacademy.com
58. • 6th
week IUL
• Face is flat and broad
• Inter nasal pit distance occupies 90% of the
breadth of face
• Mandibular arch starts differentiating along with
the auricle of the ear
• The first branchial slit later forms the external
auditory canal
www.indiandentalacademy.com
59. › Changes in the facial proportions
• Tremendous changes are observed every 3-4 days
• Expansion of anterior region of the brain
• 90° rotation of the eyes and cheeks from side to the
front of the face
• Median nasal tissue - between the maxillary wedges –
site of future philtrum of the upper lip
• 7th
week IUL
• Face is recognizable as a human
www.indiandentalacademy.com
60. • Three important stages where malformations
occur
› Epithelial contact
› Fusion of the sheath
› Invasion of connective sheath
• Due to the complexity of the events congenital
defects are quite common to this area
www.indiandentalacademy.com
61. • Development of oral structures
› Development of the tongue
› Palatal development
› Tooth development
› Salivary gland development
General outline of crucial growth events
www.indiandentalacademy.com
62. › Development of the tongue
› Tongue musculature develops from occipital
myotomes
› Body – 1st
branchial arch – 3 primordia
Paired lingual swellings
Tuberculum impar
› Base – 2nd
,3rd
& 4th
arches – median elevation
The copula
www.indiandentalacademy.com
63. › Lateral lingual swellings enlarge – furrow
appears along the labial borders of the tongue,
separating from the developing alveolar ridges
› 8-9 weeks Clear differentiation of the muscles
of tongue
www.indiandentalacademy.com
64. › Palatal development
Formation of the palatal shelves
Normal palatal development
Fusion of the palatal shelves
www.indiandentalacademy.com
65. › Tooth development
7th
week IUL
Epithelial labial lamina becomes apparent along
the perimeter of the maxillary and mandibular
processes
www.indiandentalacademy.com
66. › Tooth development
Separation of the alveolar ridge from lip
2nd
lamina appears lingually – dental lamina –
epithelial enamel organs
The elongation of the developing crowns and
roots later leads to the growth of alveolar
process
www.indiandentalacademy.com
67. › Salivary gland development
6th
week IUL – Begins in the connective tissue
of the developing cheek – Parotid and
submandibular
8th
week IUL – Sublingual
Epithelial cells – grow to form solid cords and
branch repeatedly
www.indiandentalacademy.com
68. Site of origin of the gland – initial epithelial
growth – orifice of main duct opening nto the
oral cavity
3rd
month – Subdivision and organization is
complete
6th
month – Acini of mucous glands are
functional
Birth – Acini of serous glands become
functional
www.indiandentalacademy.com
69. • Differentiation of supporting structures
Development of the :
› Chondrocranium
› Maxillary complex
› Bony palate
› Mandible and temperomandibular joint
› Facial muscles
› Muscles of mastication
General outline of crucial growth events
www.indiandentalacademy.com
70. › Chondrocranium
(Skeletal elements of
the skull)
Develop to support the brain
Neurocranial elements
surround the brain
Bar of cartilage – Anterior
nasal region to foramen
magnum
This cartilage provides
support, anterior facial
growth, early fibrous
attachment to premaxilla
www.indiandentalacademy.com
71. 10th
– 14th
week
Doubles in length
17th
week Trebles
36th
week Six times
www.indiandentalacademy.com
72. › Related to - olfactory nerve anteriorly
- pitutary medially
- otic capsule laterally
- occipital cartilages posteriorly
› Crucial in cranial base synchondroses
www.indiandentalacademy.com
73. › Nasomaxillary complex
Nasal capsule - only skeletal
support of the upper face
until bone formation occurs
All bones of this region
expand until they appear as
bones separated by sutures
www.indiandentalacademy.com
74. › Bony palate
8th
week – bilateral ossification centers in
anterior palate
14th
week – established bony palate with a
midline suture extending its length between the
premaxilla, maxilla and palatine bones
www.indiandentalacademy.com
75. › Mandible and temperomandibular joint
Meckels cartilage Rod shaped extends from
midline to otic capsule functions to carry
mandibular growth forward 2 posterior elements
become malleus and incus
Malleus and incus Articular and quadrate in lower
animals
Evidence that they function to provide movable joint
until the mandibular condyle develops in relation to
glenoid fossa - i.e btw 8th
to 18th
week
www.indiandentalacademy.com
76. 16th
week - condyle – carrot shaped cartilage
The cartilagenous head functions as a growth
center until about 25 years of age
Rapid bone formation along superior surface
between developing teeth
Symphyseal cartilage unites by 1st
year of life
Angle of mandible - 130° - coronoid process
projects above the head of condyle
www.indiandentalacademy.com
77. • The fetal period 3rd
to 9th
month
3rd
month – human appearance
Until 5th
month increase in height is maximum
where width and length are proportional
Apparently visible
3rd
month – nasal bones
- cranial base
General outline of crucial growth events
www.indiandentalacademy.com
78. 4th
month – sella turica
6th
month – sphenoethmoidal and
sphenooccipital synchondroses
Birth – mandibular midline suture
disappears
6 to 7 years – Maxillary midpalatal sutures
begin to close
General outline of crucial growth events
www.indiandentalacademy.com
79. • Face and associated roof of the mouth most
common areas of congenital defects
• Anterior brain deficiency results in facial
defects
• Supporting structures
cartilage develops in the midline
intramembranous development laterally
www.indiandentalacademy.com
80. • Genetic
• Genetic influences
• Intrauterine and neonatal environment
Etiology of malformations
www.indiandentalacademy.com
82. Formation of
germ layers
Day 17
Fetal alcohol
syndrome
[mid face
deficiency]
Migration and
proliferation
of cell
population
Day 19-28
Treacher Collin
syndrome
www.indiandentalacademy.com
83. Pre natal growth
Primary palate
formation
28-38
days
Cleft lip /cleft palate
other facial clefts
Secondary
palate
formation
42-55
days
Cleft palate/synostosi
CROUZON syndrome
Epithelial pearls
Torus palatinus
high arched palatewww.indiandentalacademy.com
87. • Ectomorph
› Tissues predominantly derived from ectoderm
› Linearity and fragility – preponderence
› Large surface area
› Thin muscles and subcutaneous tissue
› Heavily developed viscera
Normal body somatoypes
www.indiandentalacademy.com
88. • Mesomorph
› Tissues predominantly derived from mesoderm
› Muscle, bone and connective tissue
preponderence
› Heavy physique of rectangular outline
Normal body somatoypes
www.indiandentalacademy.com
89. • Endomorph
› Tissues predominantly derived from endoderm
› Soft roundness of body
› Large digestive viscera
› Accmulations of fat
› Large trunk and thighs
› Tapering extermities
Normal body somatoypes
www.indiandentalacademy.com
90. • Brachycephaly
• Short and wide head
• Cephalic index of 80 – 85.4
• Americans, Indians, Malayans and Burmese
• Euryprosopic jaws
• Wide jaws
www.indiandentalacademy.com
91. • Dolichocephalic
› Long headed
› Cephalic index < 75.9
• Leptoprosopic jaws
› Narrowness of jaws
› Slender features
› Long nose, narrow nostrils and small mouth
www.indiandentalacademy.com
92. • Mesocephalic
› Average skull length and breadth
› Cephalic index 75 – 79.9
• Mesoprosopic
› Face of moderate width
www.indiandentalacademy.com
96. • Genetic theory initially first four weeks
• Sicher’s sutural dominance theory –
nasomaxillary complex
• Scott’s cartilagenous theory –nasal
septum, mandible and cranial base
• Moss’s functional matrix theory -
Functional matrices
• Petrovic’s cybernetics or servosystem –
Action of functional appliances
Hypothesis of craniofacial growth
www.indiandentalacademy.com
97. • Natural factors
› Genetics
› Function
› General body growth
› Neurotrophism
Controlling factors in craniofacial
growth
www.indiandentalacademy.com
101. • Growth status
• Problems during Deciduous dentition
• Early mixed dentition
• Late mixed/early perm dentition/preadolescent
• Adolescent
• Adult – Surgical orthodontics
• Naso alveolar molding
www.indiandentalacademy.com
102. • Using the quantitative measurements of height
and weight percentile charts are referred
• Average child should be in the 50th
percentile of
growth
• Anything lesser than 30th
percentile suggests a
physical or psychological problem
Growth Percentiles
www.indiandentalacademy.com
103. Growth spurts
• Birth to 1st
year of life
• 6 to 7 years
• Pubertal growth spurt
www.indiandentalacademy.com
104. Pubertal growth spurts
• ♀
• Pubertal growth spurt usually
precedes 1 year before
menarche
• Menarche is basically used to
decide whether growth
modification is still feasible
• 10 – 12 yrs
• Lasts for 3 ½ yrs
• ♂
• There is no single indicator
to judge the exact
developmental status
• Facial hair appears usually
near or following peak
sutural growth
• 12- 14 yrs
• Lasts for 5 years
www.indiandentalacademy.com
105. Primary dentition 3 - 6 years
• Alignment problems
› Hollywood smile
› Loss of teeth
Incisor
Canine
Molar
www.indiandentalacademy.com
107. Primary dentition 3 - 6 years
• Anteroposterior discrepancies
• Flush terminal plane
• Mesial step
• Distal step – Definite class II permanent
relationship
• Vertical problems
• Open bite
• Deep bite
www.indiandentalacademy.com
108. Early mixed dentition
Moderate Severe
• Space problems < 3mm >5mm
• Skeletal “ no treatment Grth Mod
www.indiandentalacademy.com
109. Early mixed dentition
• Serial extraction
• No skeletal disproportions
• Class I molar relationship
• Normal overbite
• Large arch perimeter deficiency 10mm>
• Primary lateral incisors Primary canines
Primary 1st
molars 1st
Premolar
www.indiandentalacademy.com
110. Late mixed dentition/Early permanent
dentition
• Depending on the severity all orthodontic
treatment procedures are carried in this period
of development
• Growth modification
www.indiandentalacademy.com
111. • Growth modification appliances change size of
one or both the jaws
• Work by accelerating the desired growth but
not changing the ultimate size or shape of the
jaw
• Changing the spatial relationship of the jaws
Reorientation
Growth modification – how it works?
www.indiandentalacademy.com
112. Growth modification
• Patient must be growing, preferably 6-12 yrs
• Accurate diagnosis of source of discrepancy and
application of appropriate amount and
direction of force to correct
• Growth modification is only one portion of a
treatment plan
www.indiandentalacademy.com
113. Growth modification
• Psychological and functional benefits
• Child prone to trauma as in extreme severity
X Prolonged treatment
X Patient cooperation
X Cost
X Variable stability
• ‘GOLD STANDARD’
www.indiandentalacademy.com
114. • Skeletal problems
› Growth modifications
› Camouflage- when soft tissue profile is
acceptable and when tooth movement will not
change or compromise the profile
› Orthognathic surgery
Adolescent
Early – 12 to 14 yrs Late – 16 to 19/21yrs
www.indiandentalacademy.com
115. • Important trends to remember
• Camouflage of class II skeletal problems is
more acceptable in women
• Convex profile better accepted
• Camouflage of class III problems is more
acceptable in males
• Straight profile better accepted
Adolescent
www.indiandentalacademy.com
116. • For the 3 planes of space in both maxilla &
mandible
• Definite sequence of growth completion
– WIDTH
– LENGTH
– HEIGHT
www.indiandentalacademy.com
117. Transverse relationship
• Usually completed at the
time of adolescent
growth spurt.
• Narrow skeletal width
Narrow palatal vault
Narrow dental arch
Cross bite
• Maxillary constriction
www.indiandentalacademy.com
119. • Ideal patients for RME treatment.
– Full cusp cross bite with a skeletal
component
– Some degree of dental as well as skeletal
constriction initially
– No pre-existing dental expansion.
www.indiandentalacademy.com
120. Transverse relationship
• Rapid Maxillary Expansion (Haas 1965)
› More skeletal changes
› Less dental changes
› Not used in preschool children
› 0.5mm/day
› 10-20 pounds
› Occlusal radiographs
› Clinical examination
› 3-4 months of retention
www.indiandentalacademy.com
122. • Activation of RME.
Upto 15yrs of age 180 (2 turns daily)
15-20yrs. of age 180 (4 turns daily)
Over 20yrs 90 (2 turns daily)
www.indiandentalacademy.com
123. • Effects of RME:-
-Midpalatal suture opens
anteroinferiorly.
-Midline diastema.
-Buccal flaring of
posteriors.
www.indiandentalacademy.com
124. • Nasal hump & paranasal
swelling.
• Pain.
• Buccal tipping of
posteriors.
• Root resorption.
• Fenestration of roots
Adverse effects of RME:-
www.indiandentalacademy.com
125. • Slow expansion (Hicks 1978)
› Less force
› 1mm/week
› 5mm expansion achieved
› Reduced tissue damage
› Reduced hemorrhage
› 2-4 pounds of force
› More physiologic response
› More stable results
www.indiandentalacademy.com
126. •Dental cross bites are corrected
by
› Quad helix
› W arch
› Arch wire
www.indiandentalacademy.com
127. Skeletal & Dental changes in Expansion
•Rapid •Slow
www.indiandentalacademy.com
128. Antero posterior/Vertical
• Head gear
› Cervical pull
› Occipital pull
› High pull head gear
• Functional
appliances
› Removable –
Activator, Bionator,
Twin block, Frankel
regulator
› Fixed – Herbst,
Jasper jumper,
Forsus, Eva,Churro
www.indiandentalacademy.com
129. • Timing of Functional appliance wear
• Growth has a circadian rhythm
• Most growth is during evening hours 8pm-1am
• Active tooth eruption takes place
• 12 hour wear per day
• 4 – 6mm movement seen in 6 – 12 months of
wear
www.indiandentalacademy.com
130. Antero posterior skeletal problems
• Maxillary excess Class II
› Cervical pull head gear
› Distal and occlusal force on the maxillary dentition
and maxilla – but not selectivily
› Very heavy forces tooth movement
› Heavy – light forces skeletal movement
› Functional appliances
› Stimulate mandibular growth
› Has secondary effects of restricting forward maxillary
movement
www.indiandentalacademy.com
132. Antero posterior skeletal problems
• Mandibular deficiency Class II
› Stimulate or accelerate mandibular growth
› 2 4mm/year
› Headgear is used in conjunction for restricting
maxillary growth
www.indiandentalacademy.com
134. Antero posterior skeletal problems
• Maxillary deficiency Class III
› Reverse pull Headgear or facemask
› Ideal between 6-8yrs
› Attached to removable splint or fixed appliance
• Functional appliance
› Not effective in stimulating maxilla
www.indiandentalacademy.com
137. Antero posterior skeletal problems
• Mandibular excess Class III
› Chin cup therapy
› Distal rotation of the mandible and lingual tipping of
the lower incisors
› Short to normal face height individuals
› Contraindicated in long face individuals
• Functional appliances
› Frankel regulator III
› Very minor changes
www.indiandentalacademy.com
141. • Short facial height
• Cervical pull headgear or functional appliance
depending on the antero-posterior relation
• Functional appliance designed to prevent
eruption of anterior teeth and facilitate eruption
of posterior teeth
Vertical skeletal problems
www.indiandentalacademy.com
143. Vertical skeletal problems
• Magnetic splints for
intrusion of
posterior teeth
• Rare earth magnets
• Treatment to be
continued as long as
the patient is
growing
www.indiandentalacademy.com
147. • Clinical features
• Occlusal wear or interferences
• Joint sounds
• Limitation of opening and mandibular
deviation on opening
TMJ disorders
www.indiandentalacademy.com
148. TMJ disorders
• Maximum opening 35 – 45 mm
• Lateral movements 8 – 12 mm
• Clicking In coordination between disk and condyle
on movement
• Treatment
› Avoid elastics as far as possible
› Splint
› Correction of malocclusion
› Muscle physiotherapy
www.indiandentalacademy.com
149. • Characteristic features
› Waning craniofacial growth
› Decision of the individual
› Malocclusion often complicated by periodontal
disease or loss of teeth
Adult Orthodontics >19 yrs
www.indiandentalacademy.com
150. • Three groups according to etiology
› Orthodontic treatment with good oral health
› Orthodontic treatment of malocclusions
complicated by periodontal disease and loss of
teeth
› Treatment of severe skeletal dysplasias
requiring both orthognathic surgery and
orthodontic correction
Adult Orthodontics
www.indiandentalacademy.com
153. Sagittal relationship
› Movement of maxilla
and mandible is
relatively easy
› Extreme movement
affects stability because
neuromusculature
adaptation and
stretch of investing
soft tissue
www.indiandentalacademy.com
154. • Maxillary excess/deficiency
• Leforte I fracture
• Posterior movement of maxilla
• Extreme posterior placement causes
› Speech alteration
› Nasopharyngeal incompetence
Sagittal relationship
www.indiandentalacademy.com
155. • Mandibular deficiency/excess
• BSSO
› Paresthesia
• TOVRO
› Less time consuming procedure
› No altered sensation
Sagittal relationship
www.indiandentalacademy.com
157. • Maxilla
› Moved superiorly - successfully
› Inferior positioning less predictable
• Mandible
• Difficulty in moving downwards at the gonial
angle Stability affected due to the muscular
sling
Vertical relationship
www.indiandentalacademy.com
158. Vertical relationship
• Long face
› Superior positioning of the maxilla
› Excellent stability
› Some vertical growth of maxilla should be expected
‹ Ramus surgery to decrease the MPA is highly
unstable
‹ Mandibular surgery preferred when there is excess of
incisor eruption
› Inferior border osteotomy
› Chin augmentation
www.indiandentalacademy.com
159. • Short face
› Sagittal split mandibular ramus surgery
› Facilitates forward and downward rotation of
the mandible
› Orthodontic levelling of COS to be done after
surgery
‹ Maxillary Leforte I down surgery
‹ Relapse
‹ Grafts used are of less help
Vertical relationship
www.indiandentalacademy.com
162. • Maxilla
• Expansion relatively more stable than
constriction
• Mandible
• Anterior constriction more stable than
expansion
• Constriction to a limited extent in the canine
region
Transverse relationship
www.indiandentalacademy.com
166. Timing
• After growth modulation
• Too severe to camouflage
• When surgery has little inhibitory effect or
further growth
• Delay in mandibular prognathism
• Rarely done before adolescent growth spurt
www.indiandentalacademy.com
168. • One phase
• Moderate discrepancies
• No choice of extn/non-
extn
• Major psychological
complex develops in the
individual
• Two phase
• Severity of malformation
• Growth changes can
avoid extraction
• Psychologically reasons
www.indiandentalacademy.com
169. Early v/s late surgery
• Early surgery
• Congenital/Genetic
defects
• Cleft lip and palate
• Ankylosis
• Progressive deficiency
‹ Vertical repositioning of
maxilla can cause
supraeruption of
posterior teeth
• Late surgery
• Vertical excess of
mandible
• Severe but stable
deficiencies
www.indiandentalacademy.com
170. Stability
• Class III Less stable
• Class II More stable
www.indiandentalacademy.com
171. Retention
• Class II
• Class III
• Open bite
• Deep bite
• Late incisor crowding
• Timing - Initially - 3 to 4 months, part time for
12 months or till growth completion
www.indiandentalacademy.com
172. • Nasoalveolar Molding
• Dr. Barry Grayson and Dr. Court Cutting
• Nasoalveolar molding is a nonsurgical method
of reshaping the gums, lip and nostrils before
cleft lip and palate surgery, lessening the
severity of the cleft
• Surgery is performed after the molding is
complete, approximately three to six months
after birth
Cleft lip and palate
www.indiandentalacademy.com
173. • Fixing a large cleft required multiple surgeries
between birth and age 18, putting the child at
risk for psychological and social adjustment
problems
• The first procedure pulled the lip together, a
second improved the position of the lip,
another two would be for the nose, then
another—often including a bone graft—would
close the palate, and so on
Conventional techinique
www.indiandentalacademy.com
174. Cleft lip & palate
• Infant orthopedics
• Late primary & early mixed dentition treatment
• Early permanent dentition treatment
• Orthognathic surgery
www.indiandentalacademy.com
176. Nasoalveolar molding
• With nasoalveolar
molding, the
orthodontist and
surgeon can improve a
large cleft in the months
before surgery
• This helps the surgeon
get a better shape of the
nose and a thinner scar
in only one surgery
www.indiandentalacademy.com
178. • After the baby has worn the molding plate for a
week, the orthodontist slowly adjusts the shape
by sculpturing the plastic
• Each adjustment is very small, but it starts to
guide the baby’s gums as they are growing
• Adjustment of the molding plate is done by the
orthodontist weekly or every other week
depending on progress.
www.indiandentalacademy.com
180. • Dr. Cutting Using a technique of dissecting
out missplaced muscles in the soft palate that
would otherwise interfere with complete closure
• The usual success rate in achieving a fully
closed palate is about 80%; ours is 96%
• A more complete closure has dramatically
improved the ability of children with cleft lip to
speak more clearly
www.indiandentalacademy.com
182. Key interventions in cleft lip and palate
1-4 months
• Check feeding and growth
• Repair cleft lip
• Check ears and hearing
5-15 months
• Check feeding, growth, development
• Check ears and hearing; consider ear
tubes
• Repair cleft palate
• Provide oral hygiene instructions
www.indiandentalacademy.com
183. 16-24
months
• Assess ears and hearing
• Assess speech and language
• Check development
2-5 years
• Assess speech and language; manage
Velopharyengeal Insufficiency
• Consider lip/nose revision before school
• Assess development and psychosocial adjustme
www.indiandentalacademy.com
185. References
• Contemporary Orthodontics 3rd
Edition
-William Proffit
• Handbook of Orthodontics 4th
Edition
-Robert E. Moyers
• Facial Growth and Facial Orthopedics
-Van der Linden
• Pediatric Dentistry 3rd
Edition
-Pinkham
Thank youwww.indiandentalacademy.com
Editor's Notes
DHEA dihydro epi androsterone weak androgen released when adrenal gland first appears
Relates – 1st perm molar eruption
Endochondral growth – 2 fold
Endo/ectomorph – urban/rural
girls – b4 final transition to perm dentition
Incisor no treatment/ esthetic only perm eruption delayed
Canine Lateral tends to tip rare
Dec 1st molar Mesial movt of post teeth in maxillary arch
Lateral and distal movt of anterior teeth in mand arch
Dec 2nd molar space maintainence with guidance for 1st perm molar eruption
Habits Self correcting if the habit is stopped
Ant Xbite Xpand until the mand buccal cusps lie on the buccal inclines of the buccal cusps of maxillary teeth
Treat class II and III only if too severe
B’cos they tend to recur
Missing teeth – space maintainence
Space loss – space regaining – 2nd dec molars, canine
Lat inc à when 11, 12 erupt
Canineà when 12, 22 erupt
Deci 1st molarsà 6 to 12 months b4 exfol à Pm roots ½, 2/3 formed
1st PM à Canine erupts
Modifications generally done`
When do we consider growth modification?
Growth hormone secretion
Cervical pull – Avoid in long face
High pull - Avoid in short face
Cervical pull – Avoid in long face
High pull - Avoid in short face
500 1000 gms – ½ that per side
Force direction slightly above the occlusal plane if force applied thru molar
12 hrs
Typical duration 12 18 months
Mostly insufficient
Amt of growth is not sufficient to overcome the discrepancy
All available growth needs to in Ant post direction but due to eruption of the posteriors – vert growth occurs
Mandible grows downward and forward but not straight forward
When used after 8yrs this appliance exerts a predominantly tooth moving force due to a integrated maxilla at the sutures
Distal and superior force through the chin that inhibits the growth of the condyle
Extraoral and intraoral force
Bite block to prevent eruption of maxillary and mandibular posterior teeth, Functional appliance designed to an increased vertical rest position, headgear attached to FA
20 – 35mm Muscular problem
&lt;20mm Prob in the joint (displaced disk)
Lat move &lt; disloc disk or muscle prob
&gt; damaged or loose ligament
Kinesiology, Thermography and jaw tracking
Trauner and Obwegeser 1959 – First sagittal split osteotomy
Brginning of modern era of orthognathic surgery
Bell,Epker and Wolford -1960 Leforte I fracture for repositioning the maxilla in all three planes of space
Posterior teeth act as fulcrum for rotation
Pterygomandibular sling is sterched
RELAPSE or WORSENING OF THE CONDITION
TMJ and Musculature cause problems in mandibular surgery
No one looks how long we took for the treatment
But everyone looks at how well we did it
Methods of assessing
Indirect methods
Serial cephalometric records
II --&gt; traditional fixed appliance/ HG to U molars/ Fun Appl 12 to 24 month
Better to prevent relapse from differential growth than to try and correct later
III - V difficult in severe cases but in mild cases fun appl are good to maintain occ relations
Open bite - high pull HG and a conv retainer/ Activator, Bionator with occ bite blocks to prevent eruption
Deep bite - Retainer with lower incisor bite plate for several years - night wear is required
Unlike some older techniques, the molding plate does not push or stretch the delicate tissues; it only helps gently direct the growth of the gums. The baby wears the molding plate 24 hours day, seven days a week, including when they are feeding. The parents change the tape and clean the molding plate daily as needed.
To start NAM, parents work with an orthodontist. Within the first couple of weeks after birth, babies are fitted with a custom-made molding plate that looks like an orthodontic retainer. The device is attached with a small orthodontic rubberband that is taped to the baby’s face.
The molding plate causes no pain and after the first few days the plate usually doesn’t bother babies at all; it’s an accepted part of their face.
Once the cleft gap in the gums is small enough (around one quarter-inch), a post is attached to the molding plate and is inserted in the nostril. This post is then slowly adjusted to lift up the nose and open the nostril.
By the time of the surgery, the nose has been lifted and narrowed, the gap in the gums is smaller and the lips are closer together
A smaller gap means less tension when the surgeon closes the cleft. In our experience this results in a better final result than if NAM had not been done.
&quot;After the molding, the gum pads are lined up instead of wide apart, so usually repair the gums is done without a bone graft. In children with bilateral clefts, the nose can be repaired at the same time. The net result is that in one operation, can repair the lip, gum, and nose.
Orthodontics and Surgery: Melding Two Traditions
The success of Drs. Cutting and Grayson&apos;s approach requires close collaboration between surgeon and orthodontist. &quot;Orthodontists are very patient,&quot; explains Dr. Cutting. &quot;It is interesting that Dr. Grayson&apos;s hobby is bonsai. He&apos;ll take a very young tree and hang a small weight on one branch and it will slowly bend; or he may use a wire to gently change the direction of growth of a branch. Little by little, with small forces, you can completely shape a miniature tree.
&quot;Orthodontists routinely do something very similar in correcting the teeth with braces. With a little bit of force applied over a long period of time, the braces manage to move a child&apos;s teeth through bone into a new pattern,&quot; says Dr. Cutting. &quot;Surgeons, in contrast, like to get in there and &apos;fix it now&apos;. We&apos;re bringing the best of these two different traditions together and getting wonderful results
McNeil introduced infantile orthopedics modified by Burstone