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Growth Rotations

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INDIAN DENTAL ACADEMY
Leader in continuing dental education
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 Introduction
 Maxillary rotations
 Prediction of growth rotation
 Growth rotations- facial development,
tooth eruptio...
Introduction
 Facial growth in terms of rotations is
important in the understanding of the
development of the craniofacia...
MAXILLARY ROTATIONS
 Less easy to divide maxilla into a core of bone
and a series of functional processes.
 There are no...
ENLOW’S CONCEPT

Maxillary Rotations

Displacement

Remodeling

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Displacement
 Primary displacement occurs-antroinferior
direction.
 Sutures are tension adapted-cannot grow by
pushing-a...
 Secondary displacement-

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Growth of the brainSpinal cord aligns
vertically.
Orbits rotate and align so
that they point forward.
This plane determine...
The maxillary
tuberosity located just
below the floor of the
orbit.
The tuberosity is
aligned perpendicular
to neutral geo...
 The hard palate
conforms to the
alignment of maxillary
nerve before it enters
the orbit.

 The plane projects to
inferi...
Remodeling
 Lacrimal suture: key
growth mediator.
 Sutural system of
lacrimal bone –slippage
for multiple bones.
 The m...
Drift of the teeth
 As the maxilla and mandible enlarge,
dentition drifts-horizontally and vertically.
 The whole tooth ...
Nasal and palatal
remodeling

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 The balance between greater and lesser amounts
of remodeling in the posterior & anterior parts of
the maxilla is the res...
1-2-direct relocation.
2-3- primary displacement

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BJORK’S CONCEPT
 Longitudinal study done by implant method.
Lateral implants:4yrs of age
-inserted laterally in the zygo...
Anterior implants:10-11yrs of age
-inserted below the anterior nasal spine.
-one on each side of the median suture at lev...
 Implant line-Tip of 1 anterior implant to midpoint of 2
lateral implants.
-Change in the inclination of implant line to
...
Maxillary growth-Lateral
implants.
 Height

(4 yrs)

-growth at frontal and zygomatic process.
-apposition at lower alveo...
 Lateral implants-vertical
component calculated at
right angles to S-N.
 Sutural lowering -11.2mm
 Apposition at the fl...
 Width
-growth in the median suture.
-appositional remodeling in the outer
aspects.
-Enlow-widening of hard palate mainly...
 Implants study show
-median suture growth-6.7mm
-outer aspect of maxilla-9.5mm
-growth in the median suture follow the s...
Growth of maxilla in 3-d anterior and lateral implants(10-11
yrs)
 Length-sutural growth towards palatine bone by
apposit...
Sagittal growth studied in relation to
infrazygomatic crest.

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ROTATIONS
 Transverse plane
 Vertical plane.

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Transverse mutual rotation
of the two maxillae: Joining anterior and lateral implants on each
side a triangle is construc...
 Lateral implants increased 3mm against 0.9mm
of the anterior implants.
 Thus, the lateral implants separate more.
 Thi...
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VERTICAL ROTATIONS
 Superimposition shows parallel lowering
of nasal floor.

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 Implant studies-maxilla undergoes vertical rotation.
-inclination of anterior cranial base to nasal floor
is maintained ...
 Backward rotation-Rotates down anteriorly.

-posterior resorption more
than anterior.

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Prediction of growth
rotation

 Rotational prediction has been done in various
ways:
-Bjork’s method
-Logarithmic spiral ...
BJORK’S METHOD
 LONGITUDINAL
 METRIC
 STRUCTURAL

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LOGITUDINAL
 Longitudinal method-annual cephalograms.
-natural reference structures.
-rotation can be read from angle for...
1.

Tip of the chin.

2.Inner cortical structure at the
inferior border of the
symphysis.
3. Mandibular canal.
4. Lower co...
Limitations :
 The pattern of growth is not constant and
changes by adolescence.

 It permits the observation of changes...
Metric
 It aims at a prediction of facial development
on the basis of the facial morphology, determined
from single x-ray...
Structural
 Based on information concerning the remodeling
process gained from implants.
 If implants are not used, sing...
Structural signs of growth
rotation
 Seven signs-extreme growth rotation.

 Considered in relation to direction of
condy...
 Inclination of condylar head
 Curvature of the mandibular canal
 The shape of the lower border of the mandible
 Incli...
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Condylar Inclination

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Mandibular Canal

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Lower Border & Inclination of
Symphysis

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Inter Incisal Inclination

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Inter Molar Relation

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Condylar Inclination

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Mandibular Canal

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Lower Border & Inclination of
Symphysis

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Inter Incisal Inclination

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Inter Molar Relation

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Mandibular morphologic
characteristics in relation to
various facial types and jaw
rotations.- Dr. Violet Barbosa
 Had di...
 Index I = S-tgo/ N-Gn x 100
 Lower gonial angle
 Inclination of condylar head
 Shape of lower border of mandible
 In...
 Results:
Index I,
Lower gonial angle ,
Inclination of condylar head and
Inclination of symphysis
could be relied upon, t...
Facial pattern and Tooth
eruption

 There is considerable difference in development
and facial form.
 Forward rotation-n...
www.indiandentalacademy.com

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Tooth eruption
 The rotational pattern influences the magnitude
and direction of tooth eruption.

 Superimposition on lo...
 Implants-forward directed path of eruption in
case of forward rotation.
 Forward migration of the entire dentition.
 M...
Average values:
 Maxillary arch
-Mesial migration I molars-5mm
-central incisors-2.5mm
Shortening of arch-1mm+1.5mm

www....
Average values:
Mandibular arch
Mean forward migration of mandibular molars 5.2mm.
Lower central incisors-3.2mm.
Shortenin...
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 Backward rotation-lower anterior teeth-tipped
backward.
 Reduced alveolar prognathism.
 Molar eruption-diminished.

ww...
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 Proffit
-The lower mandibular teeth erupt in upward and
forward direction.
-Forward rotation –alters the path of eruptio...
Clinical implications
Extreme forward rotation







Short face type
“Square jaw” type
Low mandibular plane
angle
...
Backward rotation Long face type
 “Round jaw” type
 Steep mandibular plane
angle
 Skeletal anterior open
bite
 Dental...
 Can have various combinations of rotations of
maxilla and mandible.

 Convergence or divergence of jaw bases leads to
v...
TREATMENT OF SKELETAL PROBLEMS
IN PREADOLESCENT CHILDREN
GROWTH MODIFICATION
Before the adolescent growth spurt ends

www....
FUNCTIONAL JAW ORTHOPEDIC APPLIANCES:
MANDIBULAR DEFICIENCY
REMOVABLE:

Activator, Bionator, Frankel 1&2,Bimler’s
applianc...
MANDIBULAR EXCESS:
FUNCTIONAL JAW ORTHOPEDICS
Frankel 3 appliance
Reverse activator

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MANDIBULAR EXCESS
 extra oral force
 orthopedic
chin cup
 occipital pull chin cup
vertical pull chin cup
Steep mandib...
ADULTS
BILATERAL SAGITTAL SPLIT OSTEOTOMY

SET BACK

ADVANCEMENT

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Maxillary excess:For restriction of maxillary growth in growing
individuals appliances like
1.Headgear
2.Functional appli...
Cervical head gear:
used in patients with horizontal growth
pattern with reduced lower facial height.

www.indiandentalaca...
Occipital pull Head gear:Used in long face patients with high mandibular
plane angle.

www.indiandentalacademy.com

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 Maxillary Deficiency: Growth modulation in
sagittal plane can be done :
1.face mask

Delaire facemask

2.reverse functi...
Combination of maxillary excess and
mandibular deficiency

High pull headgear with functional appliance
www.indiandentalac...
References
 Contemporary orthodontics
- William.R.Proffit(2nd &3rd ed.)
 Essentials of of facial growth
- Donald.H.Enlow...
 Facial growth and facial orthopedics.
-van der Linden.
 Determinants of mandibular form & growth
(CFGS) Monograph-4
 F...
 Prediction of growth rotation - A.Bjork-AJODO-1969,jun 39-53.

 Facial development and tooth eruption :an
implant study...
 The puzzle of growth rotation. J.M.H.Dibbets –
AJO-DO June 1985 ,87,6;473-480.
 Mandibular rotations – concepts & termi...
Thank you
www.indiandentalacademy.com
Leader in continuing dental education

www.indiandentalacademy.com

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Growth rotations /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.


Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
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Growth rotations /certified fixed orthodontic courses by Indian dental academy

  1. 1. Growth Rotations www.indiandentalacademy.com 1
  2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com 2
  3. 3.  Introduction  Maxillary rotations  Prediction of growth rotation  Growth rotations- facial development, tooth eruption  Clinical implications www.indiandentalacademy.com 3
  4. 4. Introduction  Facial growth in terms of rotations is important in the understanding of the development of the craniofacial complex.  The introduction of the implant method by Bjork (1955)made it possible to study the rotations of the maxilla and mandible. www.indiandentalacademy.com 4
  5. 5. MAXILLARY ROTATIONS  Less easy to divide maxilla into a core of bone and a series of functional processes.  There are no areas of muscle attachment analogous to those of the mandible.  Implants placed above the maxillary alveolar process show that the core of the maxilla undergoes a small degree of rotation www.indiandentalacademy.com 5
  6. 6. ENLOW’S CONCEPT Maxillary Rotations Displacement Remodeling www.indiandentalacademy.com 6
  7. 7. Displacement  Primary displacement occurs-antroinferior direction.  Sutures are tension adapted-cannot grow by pushing-apart.  Stimulus for sutural remodeling is due to the displacement. www.indiandentalacademy.com 7
  8. 8.  Secondary displacement- www.indiandentalacademy.com 8
  9. 9. Growth of the brainSpinal cord aligns vertically. Orbits rotate and align so that they point forward. This plane determines the direction of nasomaxillary development. www.indiandentalacademy.com 9
  10. 10. The maxillary tuberosity located just below the floor of the orbit. The tuberosity is aligned perpendicular to neutral geometric axis of the orbit. www.indiandentalacademy.com 10
  11. 11.  The hard palate conforms to the alignment of maxillary nerve before it enters the orbit.  The plane projects to inferior most point in the occipital fossa. www.indiandentalacademy.com 11
  12. 12. Remodeling  Lacrimal suture: key growth mediator.  Sutural system of lacrimal bone –slippage for multiple bones.  The maxilla slides down along its orbital contacts.  Lacrimal bone – remodeling rotation. www.indiandentalacademy.com 12
  13. 13. Drift of the teeth  As the maxilla and mandible enlarge, dentition drifts-horizontally and vertically.  The whole tooth and its socket move. www.indiandentalacademy.com 13
  14. 14. Nasal and palatal remodeling www.indiandentalacademy.com 14
  15. 15.  The balance between greater and lesser amounts of remodeling in the posterior & anterior parts of the maxilla is the response to clockwise/ counterclockwise rotatory displacement of middle cranial fossa.  Compensatory remodeling rotation of the nasomaxillary complex-sustains its proper position relative to the neutral orbital axis.  Remodeling also occurs as bones assume new positions with expansion of the soft tissue matrix. www.indiandentalacademy.com 15
  16. 16. 1-2-direct relocation. 2-3- primary displacement www.indiandentalacademy.com 16
  17. 17. BJORK’S CONCEPT  Longitudinal study done by implant method. Lateral implants:4yrs of age -inserted laterally in the zygomatic process of the maxilla (2 on each side). -increase in distance between the implants on the frontal film - increase in the width in the median suture at the level of the 1st molars. www.indiandentalacademy.com 17
  18. 18. Anterior implants:10-11yrs of age -inserted below the anterior nasal spine. -one on each side of the median suture at level with the apices of the central incisors. - increased distance bw the implants measured on frontal film - growth in the width in the median suture at the level of the incisors. www.indiandentalacademy.com 18
  19. 19.  Implant line-Tip of 1 anterior implant to midpoint of 2 lateral implants. -Change in the inclination of implant line to the S-N line-vertical rotation of maxilla in relation to cranial base. www.indiandentalacademy.com 19
  20. 20. Maxillary growth-Lateral implants.  Height (4 yrs) -growth at frontal and zygomatic process. -apposition at lower alveolar process and eruption of teeth. -apposition at floor of the orbit. -nasal floor lowered down. www.indiandentalacademy.com 20
  21. 21.  Lateral implants-vertical component calculated at right angles to S-N.  Sutural lowering -11.2mm  Apposition at the floor of the orbit-6.4mm.  Lowering of nasal floor4.6mm  Appositional growth in height of alveolar processwww.indiandentalacademy.com 14.6.mm 21
  22. 22.  Width -growth in the median suture. -appositional remodeling in the outer aspects. -Enlow-widening of hard palate mainly result of remodeling. -Persson, Melsen-growth in median suture upto adolescence. www.indiandentalacademy.com 22
  23. 23.  Implants study show -median suture growth-6.7mm -outer aspect of maxilla-9.5mm -growth in the median suture follow the same curve as their growth in body height. www.indiandentalacademy.com 23
  24. 24. Growth of maxilla in 3-d anterior and lateral implants(10-11 yrs)  Length-sutural growth towards palatine bone by apposition on tuberosities. -anterior surface was thought to be resorptive; unchanged when studied using implants. www.indiandentalacademy.com 24
  25. 25. Sagittal growth studied in relation to infrazygomatic crest. www.indiandentalacademy.com 25
  26. 26. ROTATIONS  Transverse plane  Vertical plane. www.indiandentalacademy.com 26
  27. 27. Transverse mutual rotation of the two maxillae: Joining anterior and lateral implants on each side a triangle is constructed with sides of constant length. www.indiandentalacademy.com 27
  28. 28.  Lateral implants increased 3mm against 0.9mm of the anterior implants.  Thus, the lateral implants separate more.  This reduces length of maxilla in mid sagittal plane.  The distance between 1st molars increases more than canines www.indiandentalacademy.com 28
  29. 29. www.indiandentalacademy.com 29
  30. 30. VERTICAL ROTATIONS  Superimposition shows parallel lowering of nasal floor. www.indiandentalacademy.com 30
  31. 31.  Implant studies-maxilla undergoes vertical rotation. -inclination of anterior cranial base to nasal floor is maintained by compensatory remodeling. -forward rotation-anterior resorption & deposition posteriorly. www.indiandentalacademy.com 31
  32. 32.  Backward rotation-Rotates down anteriorly. -posterior resorption more than anterior. www.indiandentalacademy.com 32
  33. 33. Prediction of growth rotation  Rotational prediction has been done in various ways: -Bjork’s method -Logarithmic spiral (Moss) - Arcial growth prediction (Ricketts)mandible rotates in the form of an arc. www.indiandentalacademy.com 33
  34. 34. BJORK’S METHOD  LONGITUDINAL  METRIC  STRUCTURAL www.indiandentalacademy.com 34
  35. 35. LOGITUDINAL  Longitudinal method-annual cephalograms. -natural reference structures. -rotation can be read from angle formed between S-N lines of 2 ages. www.indiandentalacademy.com 35
  36. 36. 1. Tip of the chin. 2.Inner cortical structure at the inferior border of the symphysis. 3. Mandibular canal. 4. Lower contour of molar germ . www.indiandentalacademy.com 36
  37. 37. Limitations :  The pattern of growth is not constant and changes by adolescence.  It permits the observation of changes in the sagittal jaw relation, but changes in the vertical jaw relation are masked. Periosteal remodeling at the lower border masks the actual rotation. www.indiandentalacademy.com 37
  38. 38. Metric  It aims at a prediction of facial development on the basis of the facial morphology, determined from single x-ray film.  Statistical studies show –possibility of predicting intensity & direction of growth from size and shape on childhood is not feasible.  Very weak correlation found between inclination of mandible at 12years and rotation during adolescence. www.indiandentalacademy.com 38
  39. 39. Structural  Based on information concerning the remodeling process gained from implants.  If implants are not used, single radiograph is used to predict mandibular rotation.  Specific structural features develop as a result of remodeling in a particular type of rotation. www.indiandentalacademy.com 39
  40. 40. Structural signs of growth rotation  Seven signs-extreme growth rotation.  Considered in relation to direction of condylar growth.  Greater the number-more reliable the prediction. www.indiandentalacademy.com 40
  41. 41.  Inclination of condylar head  Curvature of the mandibular canal  The shape of the lower border of the mandible  Inclination of the symphysis  Interincisal angle  Interpremolar and molar angles  Lower anterior face height www.indiandentalacademy.com 41
  42. 42. www.indiandentalacademy.com 42
  43. 43. Condylar Inclination www.indiandentalacademy.com 43
  44. 44. Mandibular Canal www.indiandentalacademy.com 44
  45. 45. Lower Border & Inclination of Symphysis www.indiandentalacademy.com 45
  46. 46. Inter Incisal Inclination www.indiandentalacademy.com 46
  47. 47. Inter Molar Relation www.indiandentalacademy.com 47
  48. 48. Condylar Inclination www.indiandentalacademy.com 48
  49. 49. Mandibular Canal www.indiandentalacademy.com 49
  50. 50. Lower Border & Inclination of Symphysis www.indiandentalacademy.com 50
  51. 51. Inter Incisal Inclination www.indiandentalacademy.com 51
  52. 52. Inter Molar Relation www.indiandentalacademy.com 52
  53. 53. Mandibular morphologic characteristics in relation to various facial types and jaw rotations.- Dr. Violet Barbosa  Had divided the cases into 3 groups: Group A- Forward rotation. Group B- Normal rotation. Group C-Backward rotation. www.indiandentalacademy.com 53
  54. 54.  Index I = S-tgo/ N-Gn x 100  Lower gonial angle  Inclination of condylar head  Shape of lower border of mandible  Inclination of symphysis  Interincisal angle  Intermolar angle  Depth of antegonial notch www.indiandentalacademy.com 54
  55. 55.  Results: Index I, Lower gonial angle , Inclination of condylar head and Inclination of symphysis could be relied upon, to predict the type of rotation of the mandible to a limited extent. www.indiandentalacademy.com 55
  56. 56. Facial pattern and Tooth eruption  There is considerable difference in development and facial form.  Forward rotation-normal underdeveloped anterior face height. excess-  Backward rotation-overdevelopment of anterior face height.  Type of rotation depended on the condylar growth direction and intensity. www.indiandentalacademy.com 56
  57. 57. www.indiandentalacademy.com 57
  58. 58. Tooth eruption  The rotational pattern influences the magnitude and direction of tooth eruption.  Superimposition on lower border of mandible gives impression-teeth erupting vertical www.indiandentalacademy.com 58
  59. 59.  Implants-forward directed path of eruption in case of forward rotation.  Forward migration of the entire dentition.  Molar eruption more than anterior.  Lower molar teeth more upright than upperincrease in interpremolar and intermolar angles. www.indiandentalacademy.com 59
  60. 60. Average values:  Maxillary arch -Mesial migration I molars-5mm -central incisors-2.5mm Shortening of arch-1mm+1.5mm www.indiandentalacademy.com 60
  61. 61. Average values: Mandibular arch Mean forward migration of mandibular molars 5.2mm. Lower central incisors-3.2mm. Shortening of the dental arch-2.0mm. www.indiandentalacademy.com 61
  62. 62. www.indiandentalacademy.com 62
  63. 63.  Backward rotation-lower anterior teeth-tipped backward.  Reduced alveolar prognathism.  Molar eruption-diminished. www.indiandentalacademy.com 63
  64. 64. www.indiandentalacademy.com 64
  65. 65.  Proffit -The lower mandibular teeth erupt in upward and forward direction. -Forward rotation –alters the path of eruptiondirected posteriorly. www.indiandentalacademy.com 65
  66. 66. Clinical implications Extreme forward rotation       Short face type “Square jaw” type Low mandibular plane angle Skeletal anterior deep bite Crowding of anterior teeth Palatal plane is nearly horizontal. smile - lower incisors are visible with the upper incisors hidden behind the www.indiandentalacademy.com upper lip. 66
  67. 67. Backward rotation Long face type  “Round jaw” type  Steep mandibular plane angle  Skeletal anterior open bite  Dental protrusion  Negative inclination of palatal plane www.indiandentalacademy.com 67
  68. 68.  Can have various combinations of rotations of maxilla and mandible.  Convergence or divergence of jaw bases leads to various types of malocclusions. www.indiandentalacademy.com 68
  69. 69. TREATMENT OF SKELETAL PROBLEMS IN PREADOLESCENT CHILDREN GROWTH MODIFICATION Before the adolescent growth spurt ends www.indiandentalacademy.com 69
  70. 70. FUNCTIONAL JAW ORTHOPEDIC APPLIANCES: MANDIBULAR DEFICIENCY REMOVABLE: Activator, Bionator, Frankel 1&2,Bimler’s appliance & Twin block appliance FIXED: Herbst appliance, Jasper jumper www.indiandentalacademy.com 70
  71. 71. MANDIBULAR EXCESS: FUNCTIONAL JAW ORTHOPEDICS Frankel 3 appliance Reverse activator www.indiandentalacademy.com 71
  72. 72. MANDIBULAR EXCESS  extra oral force  orthopedic chin cup  occipital pull chin cup vertical pull chin cup Steep mandibular plane angle & excessive lower facial height. www.indiandentalacademy.com 72
  73. 73. ADULTS BILATERAL SAGITTAL SPLIT OSTEOTOMY SET BACK ADVANCEMENT www.indiandentalacademy.com 73
  74. 74. Maxillary excess:For restriction of maxillary growth in growing individuals appliances like 1.Headgear 2.Functional appliances www.indiandentalacademy.com 74
  75. 75. Cervical head gear: used in patients with horizontal growth pattern with reduced lower facial height. www.indiandentalacademy.com 75
  76. 76. Occipital pull Head gear:Used in long face patients with high mandibular plane angle. www.indiandentalacademy.com 76
  77. 77.  Maxillary Deficiency: Growth modulation in sagittal plane can be done : 1.face mask Delaire facemask 2.reverse functional appliances. www.indiandentalacademy.com Petite facemask 77
  78. 78. Combination of maxillary excess and mandibular deficiency High pull headgear with functional appliance www.indiandentalacademy.com 78
  79. 79. References  Contemporary orthodontics - William.R.Proffit(2nd &3rd ed.)  Essentials of of facial growth - Donald.H.Enlow.  Dentofacial orthopaedics with functional appliances -Thomas M.Graber, Thomas Rakosi, Alexandrer G.Petrovic. www.indiandentalacademy.com 79
  80. 80.  Facial growth and facial orthopedics. -van der Linden.  Determinants of mandibular form & growth (CFGS) Monograph-4  Factors effecting growth of the midface (CFGS) Monogrph-6.  The rotation of mandible resulting from growth;Its implications in orthodontic treament -F.F.Schudy-AO 1965.no.1,36-50. www.indiandentalacademy.com 80
  81. 81.  Prediction of growth rotation - A.Bjork-AJODO-1969,jun 39-53.  Facial development and tooth eruption :an implant study at the age of pubertyA.Bjork,V.Skieller AJO-DO 1972,62,4;339-383.  Normal and abnormal growth of mandible.a synthesis of longitudinal cephalometric implant studies over a period of 25 www.indiandentalacademy.com 81 years.A.Bjork,V.Skieller.EJO-1983,5;1-46.
  82. 82.  The puzzle of growth rotation. J.M.H.Dibbets – AJO-DO June 1985 ,87,6;473-480.  Mandibular rotations – concepts & terminology Beni Solow & William Houston J B-EJO1988,10;177-179.  Mandibular rotation and enlargement. J.M.H.Dibbets.AJO-DO July 1990,29-32.  Mandibular morphologic characteristics in relation to various facial types and jaw rotations.- Dr. Violet Barbosa Aug 1996. www.indiandentalacademy.com 82
  83. 83. Thank you www.indiandentalacademy.com Leader in continuing dental education www.indiandentalacademy.com 83

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