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Growth modulation /certified fixed orthodontic courses by Indian dental academy


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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.

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Growth modulation /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Growth modulation versus Orthognathic surgeries  Dr. Yusuf ahammed  B. D. C. H. DAVANGERE
  3. 3. contents  Introduction  Basic definitions  Normal growth in 3 dimensions  Envelope of discrepancy  Developmental problems in three dimension.  Growth modulation - Different treatment modalities for skeletal discrepancy  Fourth dimension- timing for growth modulation  Growth modulation a) Functional appliance. b) Orthopedic appliance Limitations of growth modulation procedures.
  4. 4. Day-2  Orthognathic surgeries – definition  Indications of surgeries  Aims of the orthognathic surgeries  Compensation and Decompensation  Extraction pattern in different skeletal malocclusion  Skeletal class -3 and class -2 malocclusion  Comparison Growth modulation Orthognathic surgeries  Conclusion  References
  5. 5. Introduction  The concept of beauty is central to all human cultures regardless of race , age and sex and it is deeply rooted in the nature of man . In various ways ,human esthetics has been woven into the tradition of human civilization. Physical appearance has always played a significant role in the development of self-conceptualization and self esteem, in the establishment of inter personal relationship, in employment of opportunities and in quality of life.
  6. 6.  The human facial form is determined largely by the relative positioning of the maxilla and the mandible before , during and after the pubertal growth spurt .  The harmonious positioning of the maxilla and the mandible relative to the cranium not only facilitates the ultimate function of the jaw and teeth to break up food , but also forms the anatomical basis of pleasing facial esthetics .
  7. 7. 7 The area of the body which maximally determines physical attractiveness is the face. It is a primary means of identification , expression and non-verbal communication. There is a high value of cosmetic characteristics in the current society and severe cranio-facial deformity may cause significant psychosocial problems.
  8. 8. For better or worse facial esthetics can influence many aspects of our life. ,
  9. 9. 9 Soft tissues Dentition skeletal
  10. 10. Goals of orthodontics 10 • Achieve good occlusion Class -1 • Hormonise the skeletal bases Balance
  11. 11.  To find out the abnormal, one should know what is normal. Further, a knowledge of the feasible treatment modalities is also essential.  A correct diagnosis and an ideal treatment decision are the cornerstones of a successful treatment. They form the proper beginning.
  12. 12. Normal Growth  When the horizontal, vertical and transverse growth components of maxilla and mandible match that of each other, normal growth results.
  13. 13. Growth  Stewart 1982 : Growth may be defined as a developmental increase in mass. In other words it is a process that leads to increase in the physical size of cells, tissues, organs or organisms as a whole
  14. 14.  Profitt 1986 Growth usually refers to an increase in size and the number  Moyers 1988 Growth may be defined as the normal changes in the amount of living substance.
  15. 15. Development  Moyers  “Development refers to all naturally occurring progressive, unidirectional, sequential changes in the life of an individual from it’s existence as a single cell to it’s elaboration as a multifunctional unit terminating in death”  Enlow  “Development connotes a maturational process involving progressive differentiation at the cellular and tissue levels”
  16. 16. Maxilla Body –Large and pyramidal in shape . Four processes FRONTAL ZYGOMATIC ALVEOLAR PALATINE
  17. 17. Maxilla The growth mechanism is produced by  Displacement  Growth at sutures  Surface remodelling
  18. 18. Displacement  Primary Displacement  displacement of a bone in conjunction with its own growth.  Initiated by the sum of the expansive forces of the soft tissue. 18 As a bone enlarges , it simultaneously Carried away from other bones in direct Articulation with it.
  19. 19. Secondary displacement -Movement of bone is not directly related to its own enlargement but by the growth of the other bones and their soft tissues.
  20. 20. Frontozygomatic suture Frontomaxillary suture Nasomaxillary suture Zygomaticomaxillary suture Growth – Sutures  Greatest until the age of 4 years
  21. 21. zygomaticoTemporal suture Midpalatine suture Growth – Sutures
  22. 22. Surface remodeling  Deposition occurs on side facing the direction of growth  Resorption on surface facing away from direction of bone growth.  Cortical drift
  23. 23. Drift and displacement occur together and complement each other (that is, they move in the same direction) or they may take place in contrasting directions. 23 As a bone enlarges , it simultaneously Carried away from other bones in direct Articulation with it. Displacement.
  24. 24. 24 Growth Of The Mandible Primarily Involve  Bone remodelling- remodels differentially in direction that are predominantly posterior and superior.  Cortical drift Growth movement ( relocation or shifting) of an enlarging portion of a bone by the remodeling action of its osteogenic tissues.  Displacement Movement of whole bone as a unit  Primary displacement  Secondary
  25. 25. Main sites of post natal growth in the Mandible  Condylar cartilage  Posterior border of the Ramus.  Alveolar ridges
  26. 26. Condylar cartilage  Condyle plays significant role , it is directly involved as a unique , regional growth site ; it provides site for adaptive growth, it provides movable articulation , it is pressure tolerant and provides a means for bone growth (endochondral) in a situation in which ordinary periosteal (intramembranous ) growth would not be possible .
  27. 27.  Condylar cartilage - major growth site , having considerable clinical significance.  Is a secondary cartilage, which means that it does not develop by differentiation from the established primary cartilages of the fetal skull  (the cartilages of the pharyngeal arches , such as Meckel’s cartilage, and the definitive cartilages of the basicranium) .
  28. 28. 28  Secondary type of cartilage  Secondary in evolution  Secondary in embryonic origin  Secondary in adaptive responses to changing developmental conditions  Secondary in histological structure
  29. 29. 29 Type of bone formation  Intramembranous ossification  Whole body of mandible except the anterior part  Ramus of mandible as far as mandibular foramen  Endochondral ossification  Anterior portion of the mandible (symphysis)  Part of ramus above the mandibular foramen  Coronoid process  Condylar process
  30. 30. Post natal development of Mandible  Ramus Superior part of ramus below sigmoid notch Lingual -Deposition Buccal - Resorption Lower part of ramus below Coronoid process Buccal – Deposition Lingual - Resorption
  31. 31. Ramus Moves progressively posterior by:- deposition of bone in the posterior region and resorption in the anterior region. 
  32. 32. Coronoid process  Follows enlarging “V” principle  Deposition occurs medial surfaces and also vertical dimensions also increases  Briefly – propellar- like twist, so that its lingual side surface three general directions all at once: posterio-superio- medially
  33. 33. 33 Lingual Tuberosity Direct anatomic eqivalent of maxillary tuberosity Major growth and remodeling site Effective boundary between ramus and corpus
  34. 34. WIDTH OF MANDIBLE  Growth in width is completed before adolescent growth spurt  Both molar and bicondylar width shows small increase until growth in length ends GROWTH IN LENGTH Growth in length continues through puberty  Girls—14-15 years  boys---18-19 years
  35. 35. Homeostasis and adaptability.  The adaptability of the condyle to various functional relationships during the growth period , which is one of the basic principles of the functional jaw orthopedics .  Function is indeed the common denominator joining the individual parts of the orofacial system into a dynamic , integrated and purposive system Petrovic and Rakosi.
  36. 36.  Disturbances in one part of this system not only remain isolated but affect the equilibrium of the whole system .  This unique quality is important in not only etiologic considerations but also in the assessment of the effectiveness and various side effects of different orthodontic appliances.
  37. 37. 37 DIFFERENT APPROACHES IN ORTHODONTICS  Envelope of discrepancy shows how much change can be produced by various treatment modalities.
  38. 38. 38 The envelope of discrepancy for the maxillary and mandibular arches in three planes of space •This envelope of discrepancy is not symmetric. In general greater discrepancies can be corrected by orthodontic-functional treatment in the sagittal planes than in the vertical or transverse planes.
  39. 39. Envelope of discrepancy 39 4 6 10 2 2 7 12 15510 5 15
  40. 40. 40 4 6 10 51012 2 5 15 3 5 25
  41. 41. Maxilla- in transverse plane 41 Palatal Buccal2 2 33 3 4 4 3 4 10 10 7
  42. 42. 42 1 2 2 3 2 4 4 4 10 10 35 BuccalLingual
  43. 43. Dentofacial deformity  Refers to deviations from the normal facial proportions and dental relationships that are severe to be handicapping .  The affected individuals are handicapped in two ways A) Jaw function is compromised . B) Dental and facial appearance often leads to discrimination in social interaction
  44. 44. 44  Class I malocclusion could be a result of normal growth of all structures, or  It could be a product of various diverse growth of the dentofacial complex, compensating each other to create a balanced face.
  45. 45. Development problems  Sagittal plane class -2; Prognathic maxilla, Retrognathic mandible Combination . class-3 ; Retrognathic maxilla Prognathic mandible Combination.  Vertical problem Vertical excess (maxilla) (vertical deficiency) undecscended maxilla  Transverse problem .
  46. 46. 1.Saggital problem; retrognathic mandible
  47. 47.
  48. 48. 2.Saggital problem; prognathic maxilla
  49. 49. 3.Sagittal problem; combination
  50. 50.
  51. 51. 4.Sagittal problem; prognathic mandible
  52. 52. 52 Name- master Ajay. S age- 10 years Sex- male .
  53. 53. Vertical problem  Orthodontists must consider, understand ,and appreciate the value of vertical growth as it relates to antero- posterior growth.  These two factors should be considered as opposing forces, each weighing for the control of pogonion. Vertical growth tries to carry pogonion downwards and anteroposterior growth tries to carry it forward.  The interplay of growth in these two directions is responsible for various retrognathic and prognathic profiles. Vertical growth versus anteroposterior growth as related to function and treatment. F. F. Schudy- angle 1964; vol-34
  54. 54. Vertical descent of the maxilla.  Vertical maxillary excess- clock wise rotation of the mandible.  Decrease in the condylar growth and decrease in the ramal height – swings mandible backward.
  55. 55. Vertical descent of maxilla 55 Increase in the Lower 1/3 rd of the face
  56. 56. Prognathic maxilla
  57. 57. compensating mandible for vertical descent of maxilla
  58. 58. Vertical problem; retrognathic maxilla; class -3 . 58 Decrease in the lower facial height
  59. 59.
  60. 60. Transverse dimension problem  In contrast to the aggressive approaches often taken in treating skeletally based anteroposterior and vertical problems , orthodontists traditionally have been reluctant to change the arch dimensions transversly .  Yet it appears that the Transverse dimension of the maxilla may be the most adaptable of all the regions of the craniofacial complex.
  61. 61.  The key to such adaptations in the transverse dimension is the use of rapid maxillary expansion as routine treatment procedure .  Most orthodontists cite crossbite as the primary reason to alter the transverse dimension clinically
  62. 62. It is very common for one or more of the maxillary posteriors to be in a lingual orientation relative to the mandibular teeth Through the widening of the midpalatal suture , the correction of a posterior crossbite is accomplished quite readily in a patient in whom the maxillary sutural system is still patent.
  63. 63. 63 Kumari - Kavitha 12 year old female patient Complains of forwardly placed upper front teeth
  64. 64.
  65. 65. Maxillary expansion
  66. 66.
  67. 67.
  68. 68. Rotation of the jaw bases.  Bjork – in 1969(AJO) differentiates the two types involved in rotional growth of the mandible. 68 Forward rotation Forward rotation –centers in the joints- type1 Forward rotation –center located at the incisal edges of the lower incisors. Type 2 Type 3 . Center of rotation lies at the premolar region . Backward rotation- less frequent Type-1 center of the rotation lies at the joint Type 2 –backword rotation occurs about the center situated at the most dital occluding molar.
  69. 69. Rotation can be differentiated as shown by Lavergne and Gasson – 1982 in human implant studies.  Convergent rotation of the jaw bases-  Divergent rotation of the jaw bases.  Cranial rotation of the jaw bases.  Caudal rotation of the jaw bases.
  70. 70. Converging jaw bases
  71. 71. Rotation of the jaw bases; Diverging jaw bases
  72. 72. 72 Master abhishek 9 years male complains of forwrdly placed upper Front teeth
  73. 73.
  74. 74. Caudal Rotation of the jaw bases
  75. 75. Cranial Rotation of the jaw bases
  76. 76. Fourth dimension  To use functional appliance growth is essential .  Success can be achieved in some cases in the pre pubertal or post-pubertal growth period , the optimum time should include the period of maximum growth velocity.
  77. 77. 77 TIMING OF TREATMENT  Growth modulation is possible only in patients who are growing actively  Girls before boys- as they mature earlier.  Severe cases should begin earlier than mild cases  Retention must continue until active growth is essentially complete
  78. 78. 78  Where prominent upper incisors are vulnerable to trauma - early treatment is indicted.  Class III malocclusion also responds to early intervention  Abnormal perioral musculature must be eliminated at the earliest. Ideally, treatment would be provided when it is most effective and most efficient.
  79. 79. GROWTH MODULATON  A variety of different functional appliances are available. The appliance selected for the treatment can be adapted to the type of anomaly and to the growth pattern.  The growth direction, the growth amount, and the timing are relevant to the ultimate success of the treatment.  Consequently, diagnosis and case selection are critical for functional treatment.
  80. 80.  Functional treatment in general is the principle that a "new pattern of function," dictated by the appliance, leads to the development of a correspondingly "new morphologic pattern."  The "new pattern of function" can refer to different functional components of the orofacial system— for example, the tongue, the lips, the facial and masticatory muscles, the ligaments, and the periosteum.
  81. 81. 81 The "new morphologic pattern" includes a different arrangement of the teeth within the jaws, an improvement of the occlusion, and an altered relation of the jaws. It also includes changes in the amount and direction of growth of the jaws, and differences in the facial size and proportions.
  82. 82. Depending on the type of appliance, its proponent puts more emphasis on one of these different functional components. Eg – Frankel emphasis on perioral musculature.
  83. 83. Skeletal malocclusions Skeletal Class II or Skeletal Class III Treated by ---- a) Functional appliances b) Headgear c) Combination d) Camouflage e) Surgical intervention Growth Modulation
  84. 84. Growth modification  Headgears  Face mask  Chin cup  Functional appliances 1 Activator 2. Bionator 3 . Frankel appliance 4. Twin block appliance
  85. 85. Goals and benefits of growth modulation  Superior facial esthetics  Greater ability to modify the growth process  Fewer extractions  Reduction in the duration and difficulty of subsequent therapy  Improvement in patients self concept
  86. 86.  Reduction potential of in fracture protruding incisors  Greater patient compliance  Eliminate , if not reduce the need for future jaw surgery  Greater stability.
  87. 87. Functional appliance therapy 87 In the last 40 years, functional appliance therapy has become a generally accepted method to treat severe and moderate discrepancies of sagittal jaw relations in children. Until now, functional appliance therapy had its greatest application and success in Class II malocclusion
  88. 88. 88 The success of functional appliance therapy depends on the neuromuscular response. Mandibular orthopedics must modify growth signals targeted at both the ramus and condyle to be maximally effective
  89. 89. 89 PRINCIPLES AND MODE OF ACTION OF FUNCTIONAL APPLIANCES A primary objective of functional appliances is to take advantage of natural forces and transmit them to selected areas to produce the desired change.
  90. 90. 90 FORCES  The duration of force in most functional appliance treatment is interrupted  The direction of force for the movement of teeth should be consistent  The magnitude of force is small in functional appliance therapy
  91. 91. 91 Applied force may be compressive or tensile. Depending on the type applied, two treatment principles can be differentiated: force application and force elimination  In force application, compressive stress and strain act on the structures involved, resulting in a primary alteration in form with a secondary adaptation in function  In force elimination, abnormal and restrictive environmental influences are eliminated, allowing optimal development
  92. 92. 92 Classification of functional appliances  Group I – Transmit muscle force directly to the teeth  Group II - All reposition the mandible downward and forward  Group III - Major operating area is in the vestibule Also been classified as ‘Myotonic’ and ‘Myodynamic’
  93. 93. 93 Increased contractile activity of LPM Intensification of the repetitive activity of the Retrodiscal pad Increase in growth-stimulating factors Enhancement of local mediators. Reduction in factors having negative feedback effects on cell multiplication rate Change in condylar trabecular orientation Additional growth of condylar cartilage Additional subperiosteal ossification of the posterior border of the mandible. Supplementary lengthening of the mandible. MODE OF ACTION OF FUNCTIONAL APPLIANCES
  94. 94. 94 The Pterygoid Response  Within a few days of the fitting of functional appliances, the position of muscle balance is altered so greatly that the patient experiences pain when retracting the mandible  Due to the formation of a “tension zone” distal to the condyle
  95. 95. 95 MUSCULAR ADAPTATION  Within the central nervous system  At the muscle/bone interface  Within muscle tissue 1. Geometric rearrangement of fibers 2. Changes in Sarcomere number. 3. Changes in Sarcomere length. 4. Changes in muscle physiology
  96. 96. 96 Although it has been generally accepted that the orofacial musculature has a profound influence on the development of the face and dentition, it may be very difficult to evaluate and quantify this effect as it relates to the morphology, to the relative position, and to the functional behavior of the muscular components. The importance of the lateral pterygoid muscle has conclusively been demonstrated in the experiments of McNamara, Petrovic, and their respective colleagues. Volume Aug (162 - 168):AJO DO 1998
  97. 97. 97 One of the earliest functional appliances was called the Activator because it was supposed to activate the masticatory, facial, lip, and tongue musculature. Andresen believed that the protractor muscles of the mandible especially were stimulated by the use of the activator.
  98. 98. 98 Master Pavan 14 yrs male c/o – forwardly placed upper front teeth
  99. 99. 99 Activator 6mm advancement and 4 mm vertical opening
  100. 100.
  101. 101.
  102. 102.
  103. 103. The Functional Regulator Prof -Rolf Frankel. He has been an outstanding contributor to functional appliance thought & the creator of the Function regulator (Frankel) system of appliances
  104. 104. 104  The treatment with this appliance is not primarily directed toward the teeth or the skeletal tissues themselves but rather to the functional disorders  The primary aim of treatment is to identify a faulty postural performance of the orofacial musculature and to correct it by a functional therapy.
  105. 105. 105  The reestablishment of adequate space conditions of the oral functioning space is primary aim of a functional treatment  However, we must not only correct the existing structural aberrations but also the functional performances of the muscles forming the circumoral capsule
  106. 106. 106 Smitha k.T 11 yrs c/o forwardly placed upper front teeth
  107. 107.
  108. 108.
  109. 109.
  110. 110. Twin block Theraphy ( William J.Clark )  Introduced in 1977 as a two-piece appliance resembling a Schwarz double plate and a split activator.  Further reviewed by clark ( 1982, 1988, 1995 )  Replacement of occlusal inclined planes by means of acrylic inclined planes on bite blocks  Guide mandible downward and forward  Favorable propioceptive contacts of inclined planes.  Adaptation of the muscles of mastication
  111. 111. Advantages over other Functional appliances;TWIN BLOCK 1. Functional mechanism similar to natural dentition. 2. Occlusal inclined planes give greater freedom of movement in anterior and lateral excursions. 3. Less interference with normal function. 4. Improved appearance and function due to absence of lip, cheek and tongue pads. 5. Esthetically acceptable. 6. Can be worn 24 hrs. 7. Indepedent control over upper and lower arch width.
  112. 112. 112 Seemashree 14 –female pretreatment c/o – forwardly placed upper front teeth
  113. 113.
  114. 114.
  115. 115. 115 Post functional photographs.
  116. 116.
  117. 117.
  118. 118. Orthopedic Appliances  These appliances are used in the growing stage to control or alter the growth of the maxillo-mandibular skeletal components in the anteroposterior, vertical and transverse directions.  Hence they are termed growth modulation appliances.
  119. 119. Patients with maxillary excess skeletal class II malocclusion with a component of excessive horizontal or vertical growth of the maxilla and some protrusion of maxillary teeth. Reasonably good mandibular dental and skeletal morphology as this will be minimally affected by extraoral forces. Potential for continued mandibular growth IDEAL PATIENTS FOR TREATMENT WITH HEADGEARS:
  120. 120. 3.  In these patients, restriction of vertical maxillary growth is needed along with an augmentation of mandibular growth that is left. Control of vertical eruption of teeth in both the arches is important.  high pull headgear for upper molars is given  Interocclusal bite blocks can also aid in prevention of eruption of posterior teeth. E.g. high pull HG with functional appliances. Ideal patients are long face patients skeletal open bite Patients with vertical maxillary excess:
  121. 121.
  122. 122.
  123. 123.
  124. 124.
  125. 125. Patients with horizontal maxillary deficiency: These patients are ideal candidates for treatment with extraoral forces using the reverse pull headgear. This causes reciprocal downward and backward rotation of the mandible. Ideal patients should have normally positioned or slightly retrusive but not protrusive maxillary teeth Normal or short but not long anterior facial height Ideal age of 8 yrs
  126. 126. REVERSE PULL HEADGEAR  Maxillary protraction is recommended for skeletal Class III patients with maxillary deficiency. Delaire and others used face mask for maxillary protraction. Petit later modified Delaire’s concept by increasing the amount of force generated and thus reducing the overall treatment time.  In 1987, McNamara introduced the use of bonded acrylic expansion appliance with acrylic occlusal coverage for maxillary protraction. Turley improved patient co-operation by fabricating customized facemasks.
  127. 127.  The current literature indicates that reverse pull head gear is an effective treatment for growing class 3 maloccusions with average to deep bite.  The correction occurs by combination of skeletal and dental movement in the anteroposterior and vertical planes of space.
  128. 128. 128 Pavan – 10 yr old male patient c/o forwardly growing lower jaw.
  129. 129.
  130. 130.
  131. 131.
  132. 132.
  133. 133. Limitations of growth modulation  Neuromuscular disorder – children with neuromuscular disorder such as poliomyelitis and cerebral palsy cannot be treated successfully with functional appliance therapy .  Unfavorable growth pattern – functional appliance are contraindicated.
  134. 134. 134 Name- master Ajay. S age- 10 years Sex- male .
  135. 135.  Age factor – McNamara in 1984 used five cases (adult) and treated with functional appliances and noted that the malocclusion present at the beginning of the treatment was still present to a large degree at the end of treatment.
  136. 136. 136 Thank you For more details please visit