Clinical implications of growth and development

Om
Clinical Implications of Growth
and Development
www.indiandentalacademy.com

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?

• Ideal - Set Values
• Normal - Range
• Abnormal – Deviation further from the
range

Terminologies
• Standardization
• Easy understanding
• ‘Growth, Differentiation, Translocation,
Development, Maturation’.

Precise/Imprecise Usage
‘Growth’
• Dimensional Increase
• Mandible ‘grew’ by
15mm

• General Increase
• This face ‘grew’
bigger

• Population Vector
• Face ‘grows’ forward
and downward

• Specific Vector
• This mandible
exhibits ‘clockwise’
rotation in ‘growth’

• Increase in rate of
general growth
• He ‘grew’ rapidly
during adolescence

• Predicting specific
increase in timing of
rate of growth
• We expect to see a
spurt in the ‘growth’ in
the next few weeks

• Assumption of group
vectors
• This is a typical class
III ‘growth’ pattern

• Estimate of future
amount of growth
change
• This patient has very
little ‘growth’ left

• Qualitative description
of growth
• He is a bad ‘grower’

• Expecting growth
which will aid therapy
• We will wait for some
‘growth’ before
starting treatment

• “Growth is said to be the raw material for
Orthodontic Treatment”

• Growth leads to Biologic alterations
1. Short term – Response to pain
2. Long term – Mutations, Evolutionary
changes

• 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

• Development = Growth
+
Differentiation
+
Translocation
• Maturation

• Gross and microscopic anatomy
• Biochemistry
• Physiology
• Genetics
• Anthropology
Knowledge of the following
subjects

• Molecular biology
• Developmental biology
• Physical growth
• Behavioral development
Study of Growth and Development
is done in various divisions

• 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

• Developmental biology
• Study from a single cell egg to adult
comprising millions of cells
› Cellular biology
› Embryology
› Teratology

• Physical growth
• Study of organ and body growth of analyzing –
› morphogenesis,
› height &weight,
› growth rates,
› retarded growth,
› developmental physical fitness,
› pubescence and
› morphometrics.

• 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

• 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

• Types of growth data
› Opinion
› Observation
› Ratings and rankings
› Quantitative measurements
Methods of studying Growth and
Development

Direct data
Indirect growth measurements
Derived data – comparison/assumption
Methods of studying Growth and
Development

• Longitudinal
• Cross sectional
• Overlapping / Semi longitudinal Method
Methods of gathering growth
data

• Statistics is a necessity for research or
clinical Orthodontist
› Decipher growth studies
› Quantify morphology
Evaluation of growth data

› Assess progress of treatment
› Cephalometric analysis
› Judiciously interpreting the significance of
published findings in clinical and research
journals
Evaluation of growth data

• Heredity
• Nutrition
• Illness
• Race
• Climate and seasonal effects
Variables affecting physical
growth

• Adult physique
• Socioeconomic factors
• Exercise
• Family size and birth order
• Secular trends
• Psychological disturbances
Variables affecting physical
growth

• 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

› ‘That child has a class II facial pattern’ -
Morphologic pattern
› ‘This child has a vertical growth pattern’ –
Developmental pattern
Pattern

• What is normal?
› Concepts of normality
› Age equivalence
› Significance of variability
Variability – Law of nature

› Concepts of normality
Statistical
Evolutionary
Functional
Esthetic
Clinical – Ideal / Normal

› Age equivalence
Chronological age
Developmental age
Skeletal age
Dental age
Mental age

› Significance of variability
Norm of a group/area/race
Individual goal
Group goal
Familial variation
Pathologic variation

• 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

Prenatal Facial Growth
• The fundamental
plan of the
individual face
unfolds during the
first four weeks in
prenatal life

Zygote
Morula
Blastula
Implantation
Amniotic cavity

Bilaminar embryonic disc
Yolk sac
Chorionic sac
Germ layers
Primitive streak

Notochord
Neural plate and tube
Neural crest cells
Migration

• 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

• 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

• Disappearance of branchial arches
• Elevation of palatal shelves & depression
of the tongue
• Shift of blood supply ICA to ECA
prenatal growth

• 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
prenatal growth

• Period of organization of the face
• Development of oral structures
• Differentiation of supporting structures
• The fetal period
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

› The branchial arches
Initially its difficult to distinguish the
primary craniofacial features of the human
embryo from those of other mammals

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

Heart begins to beat
The growth pattern of
the face is downward
and forward between
the forebrain
prominence and
cardiac bulge

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

› 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 palatewww.indiandentalacademy.com

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

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

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

• 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

› 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 humanwww.indiandentalacademy.com

• 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

• Development of oral structures
› Development of the tongue
› Palatal development
› Tooth development
› Salivary gland development

› 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

› 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

› Palatal development
Formation of the palatal shelves
Normal palatal development
Fusion of the palatal shelves

7th week IUL
Epithelial labial lamina becomes apparent
along the perimeter of the maxillary and
mandibular processes

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

› 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

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

• Differentiation of supporting structures
Development of the :
› Chondrocranium
› Maxillary complex
› Bony palate
› Mandible and temperomandibular joint
› Facial muscles
› Muscles of mastication

› 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

10th – 14th week 
Doubles in length
17th week  Trebles
36th week  Six times

› Related to - olfactory nerve anteriorly
- pitutary medially
- otic capsule laterally
- occipital cartilages posteriorly
› Crucial in cranial base synchondroses

› 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

› 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

› 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

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

• 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

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

• 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

• Genetic
• Genetic influences
• Intrauterine and neonatal environment
Etiology of malformations

Various Cranio- facial defects
• Acephaly (Absence of head)
• Anencephaly (Absence of brain)
• Acrania (Absent skull)
• Acalvaria (Roofless skull)
• Cranioschisis (Fissured cranium)
• Premaxillary agenesis (Median cleft lip/palate)
• Premaxillary dysgenesis (Bilateral cleft
lip/palate)
• Agnathia (Absent mandible)

Formation of
germ layers
Day 17
Fetal alcohol
syndrome
[mid face
deficiency]
Migration
and
proliferation
of cell
population
Day 19-28
Treacher Collin
syndrome

Pre natal growth
Primary palate
formation
28-38
days
Cleft lip /cleft palate
other facial clefts
Secondary
palate
formation
42-55
days
Cleft palate/synostos
CROUZON syndrome
Epithelial pearls
Torus palatinus
high arched palatewww.indiandentalacademy.com

• Pierre Robin complex syndrome
• Treacher collins syndrome
• Nager acrofacial dysotosis
• Wildervanck-Smith syndrome
• Goldenhar syndrome
• Mobius syndrome
• Hallermann-Streiff syndrome
Malformation syndromes
associated with mandibular
deficiency

• Gorlin syndrome
• Klinefilter syndrome
• Marfan syndrome
• Ostegenesis imperfecta
• Waardenburg syndrome
associated with mandibular
prognathism

• Amelogenesis imperfecta
• Beckwith-Wiedmann syndrome
 Goldenhar syndrome
 Hemi hypertrophy
 Neurofibromatosis
 Parry Romberg syndrome
associated with facial height /
symmetry

• Ectomorph
› Tissues predominantly derived from
ectoderm
› Linearity and fragility – preponderence
› Large surface area
› Thin muscles and subcutaneous tissue
› Heavily developed viscera
Normal body somatoypes

• Mesomorph
mesoderm
› Muscle, bone and connective tissue
preponderence
› Heavy physique of rectangular outline

• Endomorph
endoderm
› Soft roundness of body
› Large digestive viscera
› Accmulations of fat
› Large trunk and thighs
› Tapering extermities

• Brachycephaly
• Short and wide head
• Cephalic index of 80 – 85.4
• Americans, Indians, Malayans and
Burmese
• Euryprosopic jaws
• Wide jaws

• Dolichocephalic
› Long headed
› Cephalic index < 75.9
• Leptoprosopic jaws
› Narrowness of jaws
› Slender features
› Long nose, narrow nostrils and small
mouth

• Mesocephalic
› Average skull length and breadth
› Cephalic index 75 – 79.9
• Mesoprosopic
› Face of moderate width

• Osteogenesis
• 2 basic modes  Endochondral
 Intramembranous
• 2 basic processes  Resorption
 Deposition
Growth of craniofacial skeleton

• Mechanism of bone growth
• Deposition and resorption
• Growth feilds
• Remodelling
• Growth movements  Drift
 Displacement

• Genetic concept
• Functional concept
Concepts of craniofacial growth

• 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

• Natural factors
› Genetics
› Function
› General body growth
› Neurotrophism
Controlling factors in craniofacial
growth

• Disruptive factors
› Elective
› Environmental
› Congenital

• Cranial vault
• Basicranium
• Nasomaxillary complex
• Mandible
• Temporomandibular joint
• Overall pattern
• Adult craniofacial growth
Compensatory mechanism –
Regional development

• Growth status
• Problems during Deciduous dentition
• Early mixed dentition
• Late mixed/early perm
dentition/preadolescent
• Adolescent
• Adult – Surgical orthodontics
• Naso alveolar molding

• 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

Growth spurts
• Birth to 1st year of life
• 6 to 7 years
• Pubertal growth spurt

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

Primary dentition 3 - 6 years
• Alignment problems
› Hollywood smile
› Loss of teeth
Incisor
Canine
Molar

• Incisor protrusion-retrusion
› Habits
› Anterior cross bite  Remove interference
 Extract
› Posterior cross bite Expansion indicated

• Anteroposterior discrepancies
• Flush terminal plane
• Mesial step
• Distal step – Definite class II permanent
relationship
• Vertical problems
• Open bite
• Deep bite

Early mixed dentition
Moderate
Severe
• Space problems  < 3mm >5mm
• Skeletal “  no treatment Grth
Mod

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

Late mixed dentition/Early
permanent dentition
• Depending on the severity all orthodontic
treatment procedures are carried in this
period of development
• Growth modification

• 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?

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

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’

• 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

• 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

• For the 3 planes of space in both maxilla &
mandible
• Definite sequence of growth completion
–WIDTH
–LENGTH
–HEIGHT

Transverse relationship
• Usually completed at
the time of adolescent
growth spurt.
• Narrow skeletal width
Narrow palatal vault
Narrow dental arch
Cross bite
• Maxillary constriction

Infancy
Juvenile
Adulthood
Structure of the suture at different ages:

• 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.

• 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

• Haas expander
• Hyrax expander
• Minn expander

• 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)

• Effects of RME:-
-Midpalatal suture opens
anteroinferiorly.
-Midline diastema.
-Buccal flaring of
posteriors.

• Nasal hump & paranasal
swelling.
• Pain.
• Buccal tipping of
posteriors.
• Root resorption.
• Fenestration of roots
Adverse effects of RME:-

• 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

•Dental cross bites are corrected
by
› Quad helix
› W arch
› Arch wire

Skeletal & Dental changes in Expansion
•Rapid •Slow

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

• 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

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

Adolescent

• Mandibular deficiency  Class II
› Stimulate or accelerate mandibular growth
› 2 4mm/year
› Headgear is used in conjunction for
restricting maxillary growth

• 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

Petit Face maskDelaire Facemaskwww.indiandentalacademy.com

Twin Block
Reverse Functional appliances:
Functional Regulator

• 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

• Long facial height
• High pull headgear attached to bite blocks
on functional appliance
Vertical skeletal problems

• 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

• Highpull headgear to a maxillary splint

• Magnetic splints for
intrusion of
posterior teeth
• Rare earth magnets
• Treatment to be
continued as long
as the patient is
growing

• Space maintenance
• Potential alignment and space
problems
Adolescent
Dental problems

• Etiology
› Inherited
› Acquired
› Factitial
› Neoplastic
› Idiopathic
TMJ disorders

• Clinical features
• Occlusal wear or interferences
• Joint sounds
• Limitation of opening and mandibular
deviation on opening
TMJ disorders

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

• Characteristic features
› Waning craniofacial growth
› Decision of the individual
› Malocclusion often complicated by
periodontal disease or loss of teeth
Adult Orthodontics >19 yrs

• 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

Surgical orthodontics
• Sagittal relation
• Vertical relation
• Transverse relation

Sagittal relationship
› Movement of maxilla
and mandible is
relatively easy
› Extreme movement
affects stability
because
neuromusculature
adaptation and
stretch of investing
soft tissue

• Maxillary excess/deficiency
• Leforte I fracture
• Posterior movement of maxilla
• Extreme posterior placement causes
› Speech alteration
› Nasopharyngeal incompetence

• Mandibular deficiency/excess
• BSSO
› Paresthesia
• TOVRO
› Less time consuming procedure
› No altered sensation

• 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

• 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

• 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

• Symmetrical narrowing
• Symmetrical widening
• Asymmetry

• Maxilla
• Expansion relatively more stable than
constriction
• Mandible
• Anterior constriction more stable than
expansion
• Constriction to a limited extent in the
canine region

Other surgeries
• Genioplasty
• Rhinoplasty

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

• Extraction v/s Non-extraction
• Esthetic considerations
• Stability

• 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

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

Stability
• Class III  Less
stable
• Class II  More
stable

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

• 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

• 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

Cleft lip & palate
• Infant orthopedics
• Late primary & early mixed dentition
treatment
• Early permanent dentition treatment
• Orthognathic surgery

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

Starts from first 2 weeks of birth

• 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.

• 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

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

16-24
month
s
 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
adjustment

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

Clinical implications of growth and development

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