Management of skeletal discrepancies

MANAGEMENT OF
SKELETALSKELETAL
DISCREPANCIESDISCREPANCIES
www.indiandentalacademy.com

 Orthodontics has seen innumerable changes
ever since it came into existence.
 We have had hot debates on Extraction Vs
non-extraction, heavy forces Vs light forces,
headgears Vs no headgears, functional
appliances Vs non-functional appliances.

 We basically find two philosophies…..
…one of them preaching precision
mechanotherapy and the other
emphasizing on the biology of the
stomatognathic system.
 There appears to be no end to this tussle
between the two and they are yet to come
out of this confusion.

 This confusion can be attributed to the
autocratic nature of the personalities who
propound these philosophies and
techniques.

 Today orthodontics is practiced more as a
sciencescience than an artart alone as before.
 The orthodontists in our part of the world
who do not have the back up of basic
research look forward to these stalwarts
and get confused further.

 We Orthodontists tend to seek the finest
technique, the perfect appliance system
and the latest wires but we have mastered
neither the DIAGNOSISDIAGNOSIS nor the IDEALIDEAL
TREATMENT PLANNING.TREATMENT PLANNING.

 We are taught the basics of growth andgrowth and
development, diagnosis and treatmentdevelopment, diagnosis and treatment
planning,planning, but to what extent do we use
this knowledge in our day to day clinical
practice ?

 Instead of using a holistic approach to
resolve the problems our patients present
to us, too much emphasis is being placed
on treatment modalitiestreatment modalities which does not
tackle the root cause of the problem.

 Generally, the etiology is multifactorial.multifactorial. But too
often, we use the same mantra again and again to
handle these situations.
 We are on the lookout for a “ panacea - a cure all ”.“ panacea - a cure all ”.
 If you are one of those searching for a single
appliance to handle all situations, you may neveryou may never
find one.find one.

 A judicious and well balanced combination of
“perfect mechanics” with an appliance to
modulate growth in a favourable direction
would offer a better result in growing patientsgrowing patients..
 If growth is already over then orthognathicorthognathic
surgerysurgery is the only method to achieve ideal
results.

Successful Treatment is based on
 Sound knowledge of cranio-facial biology.
 Good clinical acumen for diagnosis & treatment
planning.
 Proper execution of the treatment.
 Ability to develop a good rapport with the
patient .
 In addition, the treatment should be modified to
suit the needs of the individual patient.

OUR MOTTO ISOUR MOTTO IS
The Right Appliance for the Right PatientThe Right Appliance for the Right Patient
at the Right Timeat the Right Time..

 A correct diagnosis and an ideal treatment
decision are the corner stones of a
successful treatment. They form the
proper beginning.

Envelope Of Discrepancy
 The “Envelope of discrepancy”
graphically illustrates the current concepts
of how much change can be produced by
the various treatment modalities.

7 12 15
2
5
15
2510
4
6
10
3 5 25
2
5
15
51012
4
6
10

 The inner circle indicates the limits to
orthodontic tooth movement
(Camouflage) alone; the middle circle,
tooth movement combined with growth
modification; and the outer circle, surgical
correction.

 The precise dimensions of the envelope
are much less important than the concept.

Growth Modification
 It is obvious that greater change can be
produced in a growing child by a
combination of growth modification and
tooth movement than could be produced
by tooth movement alone.

Orthognathic Surgery
 Likewise, a greater change can be
produced in an adult by a combination of
Orthognathic surgery and tooth movement
than by tooth movement alone.

 To find out the abnormal, one should
know what is normal. Further, a
knowledge of the feasible treatment
modalities is also essential.

Growth & Development
 However, before we go ahead with the
discussion on the treatment modalities, it
is imperative that we understand the
normal growth and how these deformities
develop.

 Facial structures grow from beneath the
cranium in a downward and forward
direction.

Normal Growth
 When the horizontal, vertical and
transverse growth components of maxilla
and mandible match that of each other,
normal growth results.
A N IMA TIO NA N IMA TIO N

Facial Discrepancies
 The facial discrepancies present in the
sagittal, vertical and transverse
dimensions.

Normal Face

Cranio-facial Structures

Sagittal Discrepancies
 First let us see, how the discrepancies in
the sagittal direction as Class II and Class
III malocclusions develop.

Class II Malocclusion
SAGITTAL PLANESAGITTAL PLANE
Normal Mandible, Prognathic Maxilla.
Normal maxilla, Retrognathic Mandible.
Prognathic maxilla, Retrognathic mandible.
A N IMA TIO NA N IMA TIO N

Normal Mandible, Prognathic Maxilla

Prognathic
Maxillary Dentition

Normal Maxilla, Retrognathic
Mandible.

Prognathic maxilla, Retrognathic
mandible.

Class III Malocclusion
SAGITTAL PLAN
Retrognathic Maxilla
Prognathic Mandible
Combination of the two
ANIMATIONANIMATION

Retrognathic Maxillary Dentition

Retrognathic Maxilla

Prognathic Mandible

Combination

VERTICAL PLANE
 Discrepancies in the vertical dimension
occur in the form of a long face or a short
face syndrome.

 The rotation of the mandible due to vertical
growth discrepancies also has to be
distinguished.
MORPHINGSMORPHINGS
H & V GROWTHH & V GROWTH

 Forward or backward rotation of the
mandible occurs in both class II and class
III skeletal conditions.
CLASS2ROTCLASS2ROT CLASS3ROTCLASS3ROT

 For eg., a class I skeletal case can be
rotated into class II skeletal condition due
to rapid downward descent of the maxilla.

TRANSVERSE DIRECTION
 Transverse discrepancies can be of two
types, laterognathy and laterocclusion.

Laterognathy
 When the dental and skeletal midlines do
not coincide both at rest and in occlusion.

 This condition could be due to basal
skeletal abnormalities such as a unilateral
condylar hyperplasia.

Laterognathy

Laterocclusion
 When the midlines coincide at rest but the
mandible deviates during closure to the
right or the left side.

 Laterocclusion develops when the
maxillary arch is severely constricted.
 On closure, since the mandibular dentition
cannot be accommodated within the
maxillary arch, the mandible deviates in a
convenience bite to one side.

Laterognathy Vs Laterocclusion
 It is very critical to distinguish between
these two because the treatment varies
depending on the problem.
 In the former situation, a predominantly
surgical approach is required.
 In the latter however, an expansion of the
constricted maxilla will usually take care
of the mandibular deviation.

CASE REPORTS

Archana Pretreatment

Splint H.G

Archana Post-Treatmentwww.indiandentalacademy.com

Kiran kumar Pretreatment

Activator H.Gwww.indiandentalacademy.com

Kirankumar Post-Orthopaedic

Kavitha Pretreatment

Activator H.G. & Lip Bumperwww.indiandentalacademy.com

kavitha Post-treatment

Pramode Pretreatment

Fr 2

Pramode Post-Treatmentwww.indiandentalacademy.com

Arjun Pretreatment

Activator H.G.www.indiandentalacademy.com

Arjun Post-Treatment

Now let us come to theNow let us come to the cruxcrux of theof the
matter!!!matter!!!

 Every patient scheduled to undergo a
surgical approach should have a
presurgical orthodontic treatment to carry
out decompensation of the dentition.

 What is compensation and
decompensation ?

ANIMATIONSANIMATIONS
Compensation
 In cases of severe jaw imbalances, the
teeth are inclined in such a way as to
partially offset the discrepancies.
 For eg., the lower anteriors may be
upright or retroclined in a case of
mandibular prognathism and proclined in
mandibular retrognathism.

 This is nature’s mechanism to compensate
for the jaw imbalance by proclining or
retroclining the teeth i.e., as a
compensation for the jaw discrepancy.

Decompensation
 Presurgical orthodontics is aimed at
removing this natural compensation i.e.,
decompensationdecompensation.

ANIMATIONANIMATION
Decompensation
 In mandibular prognathism for eg., the
retroclined incisors should be brought into
the ideal axial inclination by proclining
them. In mandibular retrognathism, the
proclined teeth are brought back.
 Often, teeth are extracted for
decompensation.

Reverse Orthodontics
 Decompensation makes the maxillo-
mandibular dental relation temporarily
worse. Hence it is sometimes called
“Reverse Orthodontics”.“Reverse Orthodontics”.
CEPH TRACINGCEPH TRACING

Reverse Orthodontics

 Once decompensation is over, surgery can
be carried out. Decompensation
compliments surgery.
 One of the most common surgical
techniques for mandibular advancement
or setback is the sagittal split osteotomy.
A N I M A T I O NA N I M A T I O N

Why is presurgical decompensation so
important ?
 To position the teeth in an ideal axial
inclination with respect to the jaws.
 To optimize the magnitude of the surgical
advancement or setback.
 For better esthetics, stability and function.

A N I M A T I O NA N I M A T I O N
 If malpositioned anterior teeth are not
corrected they hinder the repositioning of
the jaws at the time of surgery.

SurgicalSurgical
CASE REPORTS

Nandini Pretreament

Nandini Presurgical

Post treamentNandini

PretreatmentArthi

Pre-surgicalArthi

Lefort I Osteotomy Premaxillary setback
Genioplasty

ARTI Post-Treatment

Komal Saakha Pretreatment

Komal Saakha Post treament

Savitha Pretreatment

Pre-surgicalSavitha

Lefort I Osteotomy
B.S.S.O. & Advancement Genioplasty

Savitha Post-Treament

CONCLUSION

CONCLUSION
 Hope you have become familiar with the
variety of problems, their correct
diagnosis and the best treatment solution
possible.
 Every case is a challenge requiring
versatile thinking and imagination
rather than opting for a dogmatic
conventional cook book approach .

 Our profession is at the cross roads now.
We are at a critical point in history where
we should make conscious decisions
which will determine the way the future
unfolds.

 We should make a sincere effort to lay an
enduring foundation for a robust and a
lasting co-operation between thebetween the
specialitiesspecialities for the sake of providing
excellent care for our patients.excellent care for our patients.

 We should be open to criticisms and
update ourselves. We should be careful
not to get entangled in dogmatic
philosophies and treatment approaches.

QuickTimeMovie

 Let us work together to usher in a new era
of integrated multidisciplinary treatment
philosophy.

 I would like to leave you with an
inspirational saying
““Coming together is a beginningComing together is a beginning
Keeping together is progressKeeping together is progress
Growing together is success”.Growing together is success”.

Management of skeletal discrepancies

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Management of skeletal discrepancies