Contribution of Proffit in orthodontics.pptx

Presented by:
Dr. Mahipal Singh Chundawat
Junior resident
GDC, Kottayam

 Introduction
 Ackerman profit system of classification (1969)
 Treatment response as an aid in diagnosis and treatment planning(1970)
 Guideline to decide between surgery and camouflage
 Effects of form and function on swallowing and the developing dentition (1973)
 Equilibrium theory revisited: factors influencing position of the teeth (1978)
 The prevalence of facial asymmetry in the dentofacial deformities population at the University of North Carolina (1997)
 Outcomes in a 2-phase randomized clinical trial of early Class II treatment (2004)
 The timing of early treatment: An overview (2006)
 Pitch, roll, and yaw: Describing the spatial orientation of dentofacial traits (2007)
 Long-term stability of adolescent versus adult surgery for treatment of mandibular deficiency (2010)
 combined surgical – orthodontic treatment (2015)
 References

 William R. Proffit, was respected orthodontic educator, author, speaker.
 Dr Proffit received his dental degree from the University of North Carolina, beginning a life-long affiliation with the
school.
 He earned a PhD degree in physiology from the Medical College of Virginia, and completed the orthodontic residency
program at the University of Washington.
 He joined the faculty at the University of Kentucky in 1965 and served as the first chairman of the orthodontics
department, and then taught at the University of Florida for 2 years.
 In 1975, he returned to UNC and joined the orthodontics faculty. He served as a professor and later became chair of the
department of orthodontics, a post he held for 26 years.

 As per him, the goals of orthodontics treatment are to provide patient with best possible dental occlusion
function and stability of result.
 The main 2 problems, orthodontics fare are what would be best way to produce defined result.

 Four important areas of orthodontics treatment in which major changes have occurred are
1. Expansion vs Extraction in treatment of Class I, crowding.
2. Two stage treatment (pre adolescent, then adolescent) treatment of class II malocclusion vs one stage
treatment.
3. Orthodontic camouflage vs surgical correction of secure class II problems in older patients with limited
or no growth potential
4. Treatment of class III malocclusion

 Dr Proffit's textbook, Contemporary Orthodontics, the standard used in dental schools throughout the world, is the world's most
influential orthodontic resource.
 He contributed to and guided every chapter in every edition, and that is its strength and reason for its endurance.
 He coauthored Contemporary Treatment of Dentofacial Deformity and 2 other books on surgical-orthodontic treatment.
 He published more than 170 scientific articles in peer-reviewed journals and more than 50 book chapters and invited
contributions.
 He was recognized for excellence in clinical research with the Norton Ross award of the American Dental Association, for
teaching excellence with the Jarabak Award of the American Association of Orthodontists, and for contributions to orthodontics
with the Albert H. Ketcham Award of the American Board of Orthodontics.
 He was appropriately recognized in 2017 as the first recipient of the AAO's lifetime achievement award.

 In this article they proposed a diagrammatic classification of malocclusion to overcome the limitations of the
Angle classification.
 This system of classification is based on Venn symbolic diagram that identifies five major characteristic to be
considered and described in the classification.
 STEP 1- Alignment : Involve assessment of the alignment and symmetry of the dental arches.
 They are classified as- Ideal / crowded /spaced

 Step 2: Profile – Involves the consideration of the patients profile.
 The profile is described as convex/ straight/ concave.
 The facial divergence is also considered for example anterior or posterior divergence.
Step 3: Type - the transverse skeletal and dental relationship is evaluated.
 Buccal and palatal crossbites if any are noted.
 The crossbite is further sub classified as unilateral or bilateral.
 In addition differentiation is made between skeletal and dental crossbite.

 Step 4 Class-
 Involve the assessment of the sagittal relationship.
 It is classified as angle classification.
 Differentiation between skeletal and dental malocclusion.
 Step 5: Bite depth
 Malocclusion in the vertical plan are noted.
 Described as anterior or posterior open bite , anterior deep bite or posterior collapsed bite.
 A mention is made whether the malocclusion is skeletal or dental

1. The objective of orthodontic treatment is to establish optimal proximal and occlusal contact of the teeth within the framework of acceptable facial
esthetics, normal function, and reasonable stability.
2. Proper classification (systematic description) and diagnosis are prerequisites for determining the nature of an orthodontic problem.
3. Once the nature of the problem has been determined, a treatment plan can then define the steps necessary to achieve a balance of the objectives of
treatment.

4. Therapeutic diagnosis is a procedure in which an initial diagnosis is made, in the face of some uncertainty, of the most
likely cause or nature of the problem.
5. An initial stage of treatment is based on this diagnosis and the response to treatment is used to confirm or modify the
original diagnosis and treatment planning.
6. Until we know more about growth prediction, the etiology of malocclusion, and the reasons for different responses to
treatment, a type of therapeutic diagnosis will continue to be an important adjunct in orthodontics.
7. The patient’s cooperation and oral hygiene are also variables which must be evaluated before an irrevocable treatment
plan is established.
8. Until more reliable diagnostic methods are available, perhaps orthodontists should view the testing of treatment response
as a tool rather than a shortcoming.

Ackerman and Proffit have enumerated some common denominators of relative dentofacial
attractiveness or unattractiveness. Parameters include following:
1. It is permissible to procline the upper and lower incisors in patients who have a large nose or a
large chin, provided the labiomental fold does not become excessive.
2. Moderate mandibular deficiency is well accepted by the lay public, and the mandibular
deficiency can be camouflaged by orthodontic treatment, thereby avoiding mandibular
advancement.

The prominence of the upper lip is influenced by the position of the upper incisors. Retracting maxillary incisors reduces
1. The prominence of the upper lip, and an important guideline for orthodontist is that the maxillary incisors should not be
retracted to a point that the inclination of the upper lip to true vertical line (TVL) becomes negative. Hence, in patients who already
have a retrusive upper lip, it is better to procline the incisors, even if it involves orthognathic surgery to correct the malocclusion.
2. Displaying moderate amount of gingiva adds to the attractiveness of the smile. Orthodontic camouflage should not be undertaken if
the quantum of incisor retraction will lead to excessive gingival display. Orthognathic surgery would be a better option in patients with
vertical maxillary excess.
3. Patients who have lower lip trap, resulting in a curled or everted lower lip can often be treated with orthodontics alone by retracting the
upper incisors.
4. A concave profile with thinning of upper lip and lack of vermillion show is an unaesthetic trait and can be corrected by proclining the
upper incisors, as proclination of upper incisors will lead to creating fuller lips that is perceived to be more attractive.

While moderate midface deficiency can be camouflaged with orthodontics, severe midface deficiency or severe
mandibular
1. prognathism creates unattractive lip position and affects throat form. These conditions are best addressed by
surgery and orthodontics.
2. Bidental proclination is an unaesthetic trait resulting in excessive lip protrusion; extraction of premolar and
orthodontic retraction of incisors will often result in dramatic reduction of lip protrusion.
 In general, patients in whom growth is completed, with a reverse overjet of greater than 3 mm, or Class II
patients with an overjet of greater than 10 mm, a mandibular body length of less than 70 mm or a facial
height of greater than 125 mm can be treated only by orthognathic surgery.

 Tongue fail to counteract the activity of buccinaters muscle which cause
narrowing of arch at premolars region given it V- shaped.
Also present is hyperactive mentalis which pressure lower anteriors flattening.

 The design similar to that of opening loop
 William R. Proffit (1993)
 0.016”/0.022” SS wire used in .018” slot and 0.018”/0.025” SS wire in .022” slot

 In a retrospective survey of 1,460 patients evaluated in the Dentofacial Clinic at the University of North Carolina, 495
(34%) were found to have clinically apparent facial asymmetry.
 When present, asymmetry affected the upper face in only 5% (n = 23), the midface (primarily the nose) in 36% (n =
178), and the chin in 74% (n = 365).
 The occlusal plane was canted, indicating vertical asymmetry, in 41% (n = 201).
 Patients with Class II problems, whether or not due to mandibular deficiency, had a 28% prevalence of asymmetry;
those with other types of problems (e.g., Class III, long face, Class I) had a 40% prevalence, which is significantly
higher than those with Class II occlusions.
 When the chin deviated transversely, there was an 80% chance that the deviation was to the left. Only in patients with
long face was there an equal distribution of left-right chin asymmetry.
 In the other groups, the prevalence of deviation of the chin to the left approached 90%. These findings are meaningful
for clinicians because asymmetry must be identified and planned for prior to initiating treatment

 In a 2-phased, parallel, randomized trial of early (preadolescent) versus later (adolescent) treatment for children
with severe (7 mm overjet) Class II malocclusions who initially were developmentally at least a year before their
peak pubertal growth, favorable growth changes were observed in about 75% of those receiving early treatment
with either a headgear or a functional appliance.
 After a second phase of fixed appliance treatment for both the previously treated children and the untreated
controls, however, early treatment had little effect on the subsequent treatment outcomes measured as skeletal
change, alignment, and occlusion of the teeth, or length and complexity of treatment.

 The differences created between the treated children and untreated control group by phase 1
treatment before adolescence disappeared when both groups received comprehensive fixed
appliance treatment during adolescence.
 This suggests that 2-phase treatment started before adolescence in the mixed dentition might be no
more clinically effective than 1-phase treatment started during adolescence in the early permanent
dentition.
 Early treatment also appears to be less efficient, in that it produced no reduction in the average time
a child is in fixed appliances during a second stage of treatment, and it did not decrease the
proportion of complex treatments involving extractions or orthognathic surgery

 In determining the optimal timing for orthodontic treatment, 2 considerations are important: effectiveness (how
well does it work?) and efficiency (what is the cost-benefit ratio, with cost in its broader sense of the burden of
treatment?).
 The gold standard for orthodontic treatment timing is during the adolescent growth spurt, starting in the late mixed
or early permanent dentition.

1.What determines the success of early facemask treatment?
Most facemask patients significantly improve in the short term, but current data suggest that about 25%
eventually require orthognathic surgery anyway.
2. Early treatment for Class I problems ?
There is a clinical consensus that early correction is indicated for a posterior crossbite with a mandibular
shift.
3. Early treatment for Class II problems?
It now has been established that early treatment for most Class II children is no more effective, and
considerably less efficient, than later 1-stage treatment during adolescence.(RCT at the universities of
North Carolina, Florida, and Manchester) Yet the timing of Class II treatment remains controversial.

 The value of systematically enhancing the Angle classification by including transverse and vertical characteristics in
addition to anteroposterior relationships for the face and the dentition is universally accepted.
 Three aeronautical rotational descriptors (pitch, roll, and yaw) are used here to supplement the planar terms
(anteroposterior, transverse, and vertical) in describing the orientation of the line of occlusion and the esthetic line of
the dentition.
 Each of the latter traits affects the modern clinical practice of orthodontics because of its greater focus on dentofacial
traits beyond the correction of malocclusion.
 Consistent with the principle that every orthodontic intervention should begin with a thorough consideration of
variation in a patient’s dentofacial traits, this article offers further refinement of diagnostic description and
classification.

Airplanes can move in 3 planes (front/back, side to side, and up and
down), and can also rotate around 3 axes (horizontal, axial, and
vertical), thus giving pilots 6 options for changing direction of plane’s
motion. Movement around 3 axes is called pitch, roll, and yaw.
Complete description of plane’s orientation in space requires
consideration of all 6 attributes
3D analysis of orientation of the head, jaws, and
dentition is incomplete without also considering 3
rotational axes of pitch, roll, and yaw in addition to
planar terms anteroposterior, transverse, and vertical.

 A, In-vivo submentovertex cone-beam CT view of subject with normal occlusion.
 Angle’s line of occlusion (red) runs along buccal cusps and incisal edges of mandibular
teeth, and along central fossae and cingulae of maxillary teeth.
 Perfect alignment of maxillary and mandibular lines is the condition for ideal occlusion.
 If patient has asymmetry characterized by rotation of maxilla, mandible, or dentition (or
all of them) around vertical axis, it can be detected in this radiographic projection.
 Maxillomandibular yaw is often present in subdivision malocclusion. Second line (green),
which follows facial surface of maxillary teeth and is highly visible, is esthetic line of
dentition.
 It is particularly valuable in evaluating lip-tooth relationships and orientation of dentition
relative to pitch, roll, and yaw.

 In mandibular deficient patients, mandibular growth is not expected after the adolescent growth spurt, so
mandibular advancement surgery is often carried out at 13 years.
 To test if the long-term stability for younger patients is similar to that for adult patients, the authors compared
cephalometric changes from 1-year postsurgery (when changes due to the surgery should be completed) to 5-year
follow up.
 32 patients who had early mandibular advancement with or without simultaneous maxillary surgery (aged up to
16 for girls and 18 for boys), and 52 patients with similar surgery at older ages were studied.

 Beyond 1-year postsurgery, the younger patients showed significantly greater change in the horizontal and vertical position
of points B and pogonion, the horizontal (but not vertical) position of gonion, and mandibular plane angle. 50% of younger
patients had 2–4 mm backward movement of Pg and another 25% had >4 mm.
 15% of older patients had 2–4 mm change and none had >4 mm. Long-term changes in younger patients who had two-jaw
surgery were greater than for mandibular advancement only.
 Changes in younger groups were greater than for adult groups. Satisfaction with treatment and perception of problems were
similar for both groups.

 It has been 50 years since the landmark presentation by Hugo Obwegeser at Walter Reed Army Hospital. At that conference, Professor
Obwegeser offered American surgeons techniques to correct facial skeletal deformities with access through intraoral incisions.
 As important advances in surgical technique and anesthesia evolved for the surgical procedures, a major contribution by American
orthodontists in collaboration with surgeons was the creation of a common diagnostic, planning, and treatment scheme for use by both
clinician groups in the treatment of dentofacial deformities, the skeletal and dental problems of the most severely affected 5% of the
population.
 In This article summarizes what American orthodontists and surgeons have learned in the late 20th and early 21st centuries, and
forecasts what might be the future of treatment for patients with dentofacial deformities.

 The basic technique of BSSO has not
changed, but some important modifications
have been introduced in recent years. The
key element in this surgical procedure is the
split within the ramus to obtain good bony
apposition of the condylar and body
segments after the body segment has been
repositioned.

 The basic technique of the LeFort I down-
fracture remains unchanged, with
important modifications through the years.
Its critical element is osteotomy cuts that
make down-fracture possible, giving
access to superior structures so that
segmentation of the maxilla and
modifications in the nose are possible .
This surgery also is described and
illustrated in detail in current texts.

 In the later decades of the 20th century, lower
border osteotomy of the mandible was added more
often to the surgical plan. This procedure allows
repositioning of the bony chin in all 3 planes of
space . In contrast to BSSO and LeFort I down-
fracture, it has not been widely presented in the
orthodontic literature

 A lower border osteotomy to move the chin upward
and forward is termed a functional genioplasty
because it allows normal lip function after correction
of excessive chin height and inadequate chin
projection. The procedure can be done at any time
after the mandibular canines erupt. It is much less
invasive than LeFort I or mandibular ramus surgery.
and can greatly improve the functional and esthetic
outcomes of orthodontic treatment for long-face
Class II patients.

 short-term and long-term stability Much of what had been learned during the 20th century about postsurgical stability with
orthognathic procedures is summarized in chapter 12 of Contemporary Treatment of Dentofacial Deformity.
 There are 2 important points to keep in mind when stability is considered.
1. It often is more useful to discuss postsurgical stability with patients in terms of the percentage of patients who have
clinically significant changes: ie, “Ms Jones, there are 4 chances out of 5 that you will have little or no postsurgical change,
but you should understand that means there is a 20% chance of change toward your original jaw position.”
2. Although it seems reasonable that postsurgical changes related to the surgery itself should be completed well within the
first year, this simply is not true. Changes often continue to 5 years postsurgery and look as if the patient is having further
growth in the pattern that produced the problem initially, even though he or she would seem too old to have that much
growth.

 The determining factors will be considered separately:
 education of providers, clinical sites for treatment,
 practice patterns of treating clinicians,
 impact of health insurance on access to care, and shifts in the commitment of the United States to provide care for all
or most of the population

 “When you make a statement, it is either a fact or an opinion. If it is a fact, be able to
cite your reference, and if it is an opinion, just say so. Don't try to bluff your way
through it!”

 Ackerman profit system of classification (1969)
 Treatment response as an aid in diagnosis and treatment planning(1970)
 Effects of form and function on swallowing and the developing dentition (1973)
 Equilibrium theory revisit (1978)
 The prevalence of facial asymmetry in the dentofacial deformities population at the University of
North Carolina (1997)
 Outcomes in a 2-phase randomized clinical trial of early Class II treatment (2004)
 The timing of early treatment: An overview (2006)
 Pitch, roll, and yaw: Describing the spatial orientation of dentofacial traits (2007)
 Long-term stability of adolescent versus adult surgery for treatment of mandibular deficiency
(2010)
 combined surgical – orthodontic treatment (2015)

Contribution of Proffit in orthodontics.pptx

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