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The document discusses the pre-natal and post-natal growth and development of the maxilla and mandible. It describes how the maxilla forms from embryonic development and ossification centers. It grows through displacement, remodeling at sutures, and increases in height, width and length. The mandible develops from Meckel's cartilage and also grows through remodeling at sites of growth. The palate develops from primary and secondary palatal shelves fusing in the midline. Post-natally, the maxilla grows through apposition at sutures and displacement downward and forward from cranial base growth. The mandible grows through remodeling at sites like the ramus and condyle.
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Growth & development of maxilla and mandibleRajesh Bariker
The document discusses the pre-natal and post-natal growth and development of the maxilla and mandible. It describes how the maxilla forms from embryonic development and ossification centers. It grows through displacement, remodeling at sutures, and increases in height, width and length. The mandible develops from Meckel's cartilage and also grows through remodeling at sites of growth. The palate develops from primary and secondary palatal shelves fusing in the midline. Post-natally, the maxilla grows through apposition at sutures and displacement downward and forward from cranial base growth. The mandible grows through remodeling at sites like the ramus and condyle.
1. POSTER NO:P55
ÜST ÇENE KİLİDİNİ SINIF 2 VE SINIF 3
VAKALARDA AÇIP KAPAYACAK
SEFALOMETRİK ANAHTAR:
PORİON LOCATİON VE DİĞERLERİ
Turan Çağrı DOĞAN
Dişhekimi
Özel Elif Andaç Ağız ve Diş Sağlığı Polikliniği
Ödemiş-İZMİR
Dt.Turan Çağrı DOĞAN
2. • GİRİŞ:
• Bu çalışmanın amacı,ortodontide ,üst çene kilidini ,sefalometrik
analizler ile tesbit etmek,Sınıf 2 vakalarda sadece üstçene genişletmesi
ile bu kilidi açarak,alt çenenin kendiliğinden öne doğru gelmesini
sağlamak,sınıf 3 vakalarda ise üst çene genişletmesi yaparken,kilidin
kapalı kalmasını ve mandibulanın öne transle olmasını engel olacak
lingual ark takmanın önemini vurgulamaktır.Birinci çalışma raporu olarak
aşağıda anlatılacaktır.
• Çalışmanın doğuşu ‘’Sınıf 3 Risk Analizidir’’(1).Analiz sonuçları
,aslında üst çene kilidinin varlığını gösterir.Üstçene kilidi :‘’alt ark,azalmış
transversal üst çene boyutlarına uyabilmek için geride konumlanmaya
zorlanmıştır’’ (1)şeklinde açıklanabilinir. Sınıf 3 riski demek,alt çenenin
daha fazla öne gidebilme ihtimali, riski demektir (Şekil 1) .‘’Ancak öne
rotasyon için hastada mandibuler büyüme potansiyelinin yeterli olması
gerekir’’(6) Özellikle Porion Location mesafesindeki artma ve Ramusun
konumundaki değişmeler ,en önemli bulgulardır.Analiz sonuçları ,sınıf 3
te kullanılabileceği gibi,sınıf 2 tedavi planlanmasında da kullanılabilinir
olduğu ,bu çalışmada gösterilecektir. Transversal yönde meydana gelmiş
bir anomalinin ,lateral yöndeki sefalometrik filim üzerindeki belirtileri
araştırılacaktır.
Dt.Turan Çağrı DOĞAN
3. • BİLİMSEL DAYANAKLAR:
• 2008 yılında yayınlanan ve Prof.Dr. Tülin Taner tarafından Türkçeye
çevrilmiş olan,’’Klinik Başarı,Erken Ortodontik Tedavi ‘’Antonio Patti,Guy
Perrier’in kitabı (1),bu çalışmanın temel yapı taşıdır ve ‘’sınıf 2 tedavileri ‘’
bölümünde şöyle bir tavsiye yeralır:
• ‘’ McNamara ve Brudon(1993) ve Gugino(2000)’nun önerdiği gibi
ortodontistler Sınıf II maloklüzyonları tedavi etme konusundaki kavramlarını
tekrar gözden geçirmelidirler.Bu anomaliler sagital ve vertikal
uyumsuzluklara ek olarak sıklıkla transvers interferensler de içerirler.İlk
olarak transvers sorunu çözerek ortodontist genelde alt çenenin daha normal
önde bir konum almasını olanak tanır.Bu hedefe ulaşmak için ortodontistin
sadece üst çene genişletmesi yeterli değildir,aşırı genişletme yapması gerekir
ki alt çene öne gelmek zorunda kalsın ,alt ve üst çenelerin transvers boyutları
uyumlu hale gelerek dişler Sınıf I ilişkiye oturabilsin.Bu durum alt çenenin
arka çapraz kapanış nedeniyle kilitli kaldığı durumun tersidir’’(1)
• Yine kitabın(1) maloklüzyonların tedavileri konusunun ilk maddesi
’’Kilitlenmenin Açılması Kavramı’’dır.Kilidin varlığı bilinmektedir
ama,sefalometrik anahtarının,aynı kitabın başka bir sayfasında yayınlanan
,Ricketts’e ait ‘’Sınıf 3 risk analizi’’ (Şekil1) olabileceği , hiç akla
gelmemiştir(1).
Dt.Turan Çağrı DOĞAN
5. • Ayrıca bazı doktora tezi çalışmalarında,Türk araştırmacılar‘’Sınıf
2molar ilişkinin kendiliğinden düzeldiği olgularda mandibulanın daha
fazla öne ve yukarı rotasyonu görüldü.’’şeklinde görüşler
bildirmişlerdir.Bu tez çalışmalarında hasta sayıları ve grupları ayrıntılı
olarak ta belirtilmiştir(4,5)
• 2001 yılında Japonya’da ,karışık dişlenme döneminde meydana
gelen, ön bölge crossu üzerinde bir çalışma yayınlanmış (3), ve
diskriminal bir analiz geliştirilmiştir:
• Deciduous indicator (DI)= - 0.58(cranial length anterior) +
1.31(posterior facial height) -0.76(porionlocation) - 2.02(Wits
appraisal) -70.28.
• Japonya’daki bu araştırma sonuçları aslında,üst çene kilidinin
anahtarının ipuçlarını barındırmaktadır.
• Bu kilidin alt çeneyi nasıl kilitleyipte mandibulayı nasıl etkilediği,
Sayın Prof.Dr.Mustafa Ülgen’in büyüme gelişim kitabında (2)yer alan
Enlow ‘a ait ‘’V’’ şeklinde ‘’Transversal Yönde Mandibula Büyümesi’’
resmi,sınıf 2 ve sınıf 3 maloklüzyonların oluşum mekanizmasının
açıklanmasında temel kaynak teşkil edecek özelliktedir (Şekil 2)
Dt.Turan Çağrı DOĞAN
6. • BİREYLER VE YÖNTEM:
• Kliniğime ortodontik tedavi amacıyla başvuran 200 hastamın 100
adeti(Tüm ortodonti hastalarının %50 si) sınıf2 hastalarıdır ve
sefalometrik filimleri üzerinde yapılan analizler sonrası,üst çene kilidi
tesbit edilen 20 adet sınıf2 vakada(Sınıf2 olan100 vakanın 20 tanesi=
%20 si),sadece üst çene genişletmesi alt çenenin kendiliğinde öne
doğru translasyona uğradığı görülmüştür. Burada,tedavi öncesi ve
sonrası analizleriyle örnek bir vaka anlatılacaktır.Yine erken dönem sınıf
3 hastarının bir kısmında aynı sefalometrik bulgular görülmüş,alt
çeneye uygulanan ve aslında bir ankraj ünitesi olan lingual ark ile alt
çene büyümesi kilit altına alıp,yapılan üst çene genişletmesinden yani
kilidin açılmasından etkilenmesi engellenmiştir.
• Ama ,en güzel kilitli sınıf 2 vaka örneği ‘’Ortodontide Sefalometri
‘’kitabının ,Sefalometrik Analizler bölümünde anlatılan ve tüm
analizlerin uygulandığı,12 yaşındaki erkek ‘’Örnek Olgu’’ dur. Örnek
olgunun tedavisinde de ‘’molar kilitlenmesinin açılmasın’’dan
bahsedilmiştir(7).
•
Dt.Turan Çağrı DOĞAN
11. BULGULAR:
• Üst çene kilidinin sefalometrik anahtarları:
• 1-En önemli bulgu Porion Location (Porion –Pt) (mm.) mesafesinde ARTMADIR:
• Porion lokasyonu, dış kulak yolu(po) ile ptergoid nokta(pt) arasındaki mesafedir.
• Normali: -38.6mm. Standart Sapması: 2.2.
• Negatif işareti geriye doğru bir ölçüm olduğunu,bu nedenle Şekil 1 ‘de azalma olarak ,yani kilitli vakalarda
• ( -)41mm ,(-)50mm gibi ölçümler görülür.Kulak deliğinin kondil başıyla komşuluğu,bu ölçümü önemli
kılar(7).Hem sınıf 2 hem de sınıf 3 vakalarda, alt çenenin geride konumlandığını ve anteriore doğru
gidebileceğini gösteren önemli bir bulgudur.LAKİN,MESAFE ÖLÇÜMLERİNDE HATA YAPMA ORANI YÜKSEK
OLDUĞU İÇİN AŞAĞIDAKİ AÇISAL ÖLÇÜMLER İLE ‘’KİLİT’’ TANISI DESTEKLENMELİDİR.
• 2-Üst Gonial açıda (Upper Gonial Angle ,Ar-Go-Na) (º) ,kilitli sınıf 2 vakalarda AZALMA,
• Sınıf 3 vakalarda normal veya artma görülür.
• Normali: 54.3 º Standart Sapması: 7.0
• 3-Ramusun konumu(Ramus Position, Xi-CF ile FH arasındaki posteriore bakan açı,) (º)
• Sınıf 2 vakalarda AZALIR ,Sınıf 3 vakarda ise ARTAR
• Normali: 76.0 º Standart Sapması: 3.0
• YUKARDAKİ ÜÇ ANA BULGUDAN EN AZ İKİSİ KİLİTLİ VAKALARDA GÖRÜLÜR ,AŞAĞIDAKİ ÜÇ YAN BULGU
DA EŞLİK EDER:
• 4-FH-NaBa düzlemeleri arasındaki Cranial Deflection (º) açısında az miktarda sapmalar görülür.Sınıf 2
vakalarda AZALMA,Sınıf 3 vakalarda ARTMA eğilimindedir,ama az miktarda,standart sapma sınırları içinde
kalır.
• Normali: 27.3 º Standart sapması: 3.0
• 5-Cranial Length anterior (CC-Na) (mm) mesafesinde SINIF 2 ve SINIF 3 ‘te AZALMA eğilimindedir.
• Normali: 59.5mm. Standart Sapması: 2.5
• 6-Posterior Facial Height (Go-CF) (mm) mesafesinde SINIF 2 ve SINIF 3 ‘te ARTMA eğilimindedir.
• Normali: 54.8mm. Standart Sapması: 3.3
Dt.Turan Çağrı DOĞAN
12. • SONUÇ:
• 1- Üst çene kilidi tesbit edilen sınıf 2 vakalarda ,çekimli
tedavilerden kaçınılmalıdır.Üstçene normal boyutlarına
getirilip ,hatta fazlaca genişletilip,enaz 3ay bekletildikten
sonra aktivatör kullanmaya gerek kalmadan,altçenenin
kendiliğinden önegelmesi şeklinde tedavi yapılabilinir.Sınıf2
tedavisinde ise,lingual ark benzeri ,alt çenenin transversal
büyümesini engelleyen parçalar kullanılmamalıdır(Herbst ve
Twin-block ‘ta kullanılan lingual ark benzeri parçalar).
• 2-Sınıf 3 tedavisinde mutlaka alt çeneye lingual ark
takılıp,alt çene kilitlenmeli , daha fazla büyümesi
engellenmelidir.
• 3- Üst çene genişletmesine karar verilen tüm vakalarda
sınıf 1-2-3,openbite,deepbite,iskeletsel,dişsel,erken-genç
yaş, erişkin, ne olursa olsun,genişletme sonrası manbibulanın
hangi konuma geleceğini öngörebilmek için yukarıda yeralan
sefalometrik ölçümlerden yararlanılabilinir.
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13. KAYNAKLAR
1. Klinik Başarı,Erken Ortodontik Tedavi . Antonio Patti,Guy Perrier .Türkçe Çeviri Editörü:Prof.Dr.Tülin Taner Quintessence Yayıncılık.Sayfa:31,104,115
2. Ortodonti,Anomaliler,Sefalometri,Etiyoloji,Büyüme ve Gelişim,Tanı. Prof.Dr.Mustafa Ülgen Sayfa:256,282
3. Angle Orthod. 2001 Oct. 71(5):390-5.
Prediction of the permanent dentition in deciduous anterior crossbite.
Nagahara K,Murata S,Nakamura S,Tsuchiya T.
School of Dentistry,Aichi-Gakuin University ,Nagoya,Japan.
PMID:11605874(PubMed )
4. Sınıf II, Bölüm2 Maloklüzyonlarının Erken Dönem Tedavisinin Dentofasiyal Yapılara Etkisinin İncelenmesi .Nuri Selçuk KARAHAN,
Doktora Tezi Ondokuz Mayıs Üniversitesi Samsun, Ağustos 2005(Giriş sayfası no: V,sayfa :88)
www.belgeler.com
5. Büyüme Ve Gelişim Dönemindeki Sınıf II Hastalarda Rapid Maksiller Ekspansiyonlu(RME) Ve RME’siz Servikal Headgear Kullanımının Maksilla Ve Mandibula Üzerindeki
Etkilerinin Karşılaştırmalı Olarak İncelenmesi
Seda KARAHANOGLU
Ortodonti Anabilim Dalı Doktora Tezi,Isparta 2008 (Sayfa:2,95)
www.belgeler.com
6. Sabit Ortodontik Apareylerin Biyomekanik Prensipleri.Yahya TOSUN Sayfa:146
7. Ortodontide Sefalometri.İlter UZEL,Ayhan ENACAR,2000 yılı 2. baskı(Sayfa:99,135,164)
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14. İLGİNİZE TEŞEKKÜRLER
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Dişhekimi
Özel Elif Andaç Ağız ve Diş Sağlığı Polikliniği
Ödemiş-İZMİR
turancagridogan@gmail.com
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