Growth Modulation / orthodontic courses by Indian dental academy

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www.indiandentalacademy.comINDIAN DENTAL ACADEMY

Leader in continuing dental education www.indiandentalacademy.com

Growth modulation versus Orthognathic surgeriesDr. Yusuf ahammedB. D. C. H. DAVANGERE2www.indiandentalacademy.com

contentsIntroductionBasic definitionsNormal growth in 3 dimensionsEnvelope of discrepancyDevelopmental problems in three dimension.Growth modulation - Different treatment modalities for skeletal discrepancy Fourth dimension- timing for growth modulation

Growth modulation a) Functional appliance. b) Orthopedic applianceLimitations of growth modulation procedures.3www.indiandentalacademy.com

Day-2Orthognathic surgeries definitionIndications of surgeriesAims of the orthognathic surgeries Compensation and DecompensationExtraction pattern in different skeletal malocclusionSkeletal class -3 and class -2 malocclusionComparison Growth modulation Orthognathic surgeriesConclusion References

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Introduction The concept of beauty is central to all human cultures regardless of race , age and sex and it is deeply rooted in the nature of man .

In various ways ,human esthetics has been woven into the tradition of human civilization. Physical appearance has always played a significant role in the development of self-conceptualization and self esteem, in the establishment of inter personal relationship, in employment of opportunities and in quality of life.

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The human facial form is determined largely by the relative positioning of the maxilla and the mandible before , during and after the pubertal growth spurt . The harmonious positioning of the maxilla and the mandible relative to the cranium not only facilitates the ultimate function of the jaw and teeth to break up food , but also forms the anatomical basis of pleasing facial esthetics . 6


7The area of the body which maximally determines physical attractiveness is the face. It is a primary means of identification , expression and non-verbal communication.There is a high value of cosmetic characteristics in the current society and severe cranio-facial deformity may cause significant psychosocial problems.


For better or worse facial esthetics can influence many aspects of our life., 8


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Goals of orthodontics 10


To find out the abnormal, one should know what is normal. Further, a knowledge of the feasible treatment modalities is also essential. A correct diagnosis and an ideal treatment decision are the cornerstones of a successful treatment. They form the proper beginning.


Normal GrowthWhen the horizontal, vertical and transverse growth components of maxilla and mandible match that of each other, normal growth results.12www.indiandentalacademy.com

GrowthStewart 1982 : Growth may be defined as a developmental increase in mass. In other words it is a process that leads to increase in the physical size of cells, tissues, organs or organisms as a whole


Groeth is the copmosite changes of all componenets13

Profitt 1986 Growth usually refers to an increase in size and the number

Moyers 1988 Growth may be defined as the normal changes in the amount of living substance.


Development MoyersDevelopment refers to all naturally occurring progressive, unidirectional, sequential changes in the life of an individual from its existence as a single cell to its elaboration as a multifunctional unit terminating in deathEnlowDevelopment connotes a maturational process involving progressive differentiation at the cellular and tissue levels


Maxilla

Body Large and pyramidal in shape .

Four processes

FRONTALZYGOMATICALVEOLARPALATINE

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MaxillaThe growth mechanism is produced byDisplacementGrowth at suturesSurface remodelling

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Displacement

Primary Displacement displacement of a bone in conjunction with its own growth. Initiated by the sum of the expansive forces of the soft tissue.

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As a bone enlarges , it simultaneouslyCarried away from other bones in direct Articulation with it.www.indiandentalacademy.com

Secondary displacement-Movement of bone is not directly related to its own enlargement but by the growth of the other bones and their soft tissues.

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Frontozygomatic sutureFrontomaxillary sutureNasomaxillary sutureZygomaticomaxillary suture

Growth SuturesGreatest until the age of 4 years20www.indiandentalacademy.com

zygomaticoTemporal sutureMidpalatine suture

Growth Sutures


Surface remodelingDeposition occurs on side facing the direction of growth

Resorption on surface facing away from direction of bone growth.

Cortical drift

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Drift and displacement occur together and complement each other (that is, they move in the same direction) or they may take place in contrasting directions.

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As a bone enlarges , it simultaneouslyCarried away from other bones in direct Articulation with it.

Displacement.www.indiandentalacademy.com

24Growth Of The Mandible Primarily Involve

Bone remodelling- remodels differentially in direction that are predominantly posterior and superior.Cortical drift Growth movement ( relocation or shifting) of an enlarging portion of a bone by the remodeling action of its osteogenic tissues. Displacement Movement of whole bone as a unitPrimary displacementSecondary displacement


Main sites of post natal growth in the Mandible

Condylar cartilage

Posterior border of the Ramus.

Alveolar ridges

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Condylar cartilageCondyle plays significant role , it is directly involved as a unique , regional growth site ; it provides site for adaptive growth, it provides movable articulation , it is pressure tolerant and provides a means for bone growth (endochondral) in a situation in which ordinary periosteal (intramembranous ) growth would not be possible .26www.indiandentalacademy.com

Lattitude- freedom , leeway, autonomy , liberty. IF THE GROWTH, SHAPE, AND DIMENSIONS OF mandible were actually preprogrammed within the genes of condylar chondroblasts and if the condyle were indeed to function as a master center without taking into account structural and developmental vagaries in the rest of craniofacial complex, there is no way that fitting of mandible to basicranium on one end and to maxilla on other end could be achieved.

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Condylar cartilage - major growth site , having considerable clinical significance.

Is a secondary cartilage, which means that it does not develop by differentiation from the established primary cartilages of the fetal skull (the cartilages of the pharyngeal arches , such as Meckels cartilage, and the definitive cartilages of the basicranium) .


28Secondary type of cartilage

Secondary in evolutionSecondary in embryonic originSecondary in adaptive responses to changing developmental conditionsSecondary in histological structurewww.indiandentalacademy.com

29 Type of bone formationIntramembranous ossificationWhole body of mandible except the anterior partRamus of mandible as far as mandibular foramenEndochondral ossificationAnterior portion of the mandible (symphysis)Part of ramus above the mandibular foramenCoronoid processCondylar processwww.indiandentalacademy.com

Condyle was believed to be ultimate determinant of growth that establishes rate, amount, direction, size and shape. Functions as a growth site which provides an adaptation for its own localised growth circumstances.Acc to functional matrix 29

Post natal development of MandibleRamus

Superior part of ramus below sigmoid notch Lingual -Deposition Buccal - Resorption

Lower part of ramus below Coronoid processBuccal DepositionLingual - Resorption

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Ramus Moves progressively posterior by:- deposition of bone in the posterior region and resorption in the anterior region. 31


corpus lengthened by a 31

Coronoid processFollows enlarging V principleDeposition occurs medial surfaces and also vertical dimensions also increasesBriefly propellar- like twist, so that its lingual side surface three general directions all at once: posterio-superio- medially


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Lingual TuberosityDirect anatomic eqivalent of maxillary tuberosityMajor growth and remodeling siteEffective boundary between ramus and corpus


Grows posterior and medial by depositionResorptive field below-Lingual fossa

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WIDTH OF MANDIBLEGrowth in width is completed before adolescent growth spurtBoth molar and bicondylar width shows small increase until growth in length ends

GROWTH IN LENGTH

Growth in length continues through puberty Girls14-15 years boys---18-19 years


Homeostasis and adaptability.The adaptability of the condyle to various functional relationships during the growth period , which is one of the basic principles of the functional jaw orthopedics .

Function is indeed the common denominator joining the individual parts of the orofacial system into a dynamic , integrated and purposive systemPetrovic and Rakosi.35www.indiandentalacademy.com

Disturbances in one part of this system not only remain isolated but affect the equilibrium of the whole system .

This unique quality is important in not only etiologic considerations but also in the assessment of the effectiveness and various side effects of different orthodontic appliances.36www.indiandentalacademy.com

37DIFFERENT APPROACHES IN ORTHODONTICSEnvelope of discrepancy shows how much change can be produced by various treatment modalities.Envelope of discrepancywww.indiandentalacademy.com

38The envelope of discrepancy for the maxillary and mandibular arches in three planes of space

This envelope of discrepancy is not symmetric.

In general greater discrepancies can be corrected by orthodontic-functional treatment in the sagittal planes than in the vertical or transverse planes.


Envelope of discrepancy 39


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Maxilla- in transverse plane 41

Palatal Buccal

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2444101035Mandible- in transverseplaneBuccal Lingual


Dentofacial deformityRefers to deviations from the normal facial proportions and dental relationships that are severe to be handicapping .

The affected individuals are handicapped in two ways A) Jaw function is compromised .

B) Dental and facial appearance often leads to discrimination in social interaction 43www.indiandentalacademy.com

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Class I malocclusion could be a result of normal growth of all structures, orIt could be a product of various diverse growth of the dentofacial complex, compensating each other to create a balanced face.www.indiandentalacademy.com

Development problems Sagittal plane class -2; Prognathic maxilla, Retrognathic mandible Combination . class-3 ; Retrognathic maxilla Prognathic mandible Combination.Vertical problem Vertical excess (maxilla) (vertical deficiency) undecscended maxillaTransverse problem .


1.Saggital problem; retrognathic mandible 46


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Pavan 12 yer old male patient co forwardly placed anertrio teeth 47

2.Saggital problem; prognathic maxilla 48


3.Sagittal problem; combination 49


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Kumari roopashree 13 yr female patient combiantion prognathic maxilala and retrognathic mandible 50

4.Sagittal problem; prognathic mandible51


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Name- master Ajay. S age- 10 yearsSex- male .Prognathic mandiblewww.indiandentalacademy.com

Vertical problem Orthodontists must consider, understand ,and appreciate the value of vertical growth as it relates to antero-posterior growth.These two factors should be considered as opposing forces, each weighing for the control of pogonion. Vertical growth tries to carry pogonion downwards and anteroposterior growth tries to carry it forward.The interplay of growth in these two directions is responsible for various retrognathic and prognathic profiles.

Vertical growth versus anteroposterior growth as related to function and treatment.F. F. Schudy- angle 1964; vol-3453www.indiandentalacademy.com

Vertical descent of the maxilla.Vertical maxillary excess- clock wise rotation of the mandible.

Decrease in the condylar growth and decrease in the ramal height swings mandible backward.54


Vertical descent of maxilla 55

Increase in the Lower 1/3 rd of the face


Prognathic maxilla56


Shobha 12 yer prepobertal prognathic maxilla amd orthognathic mandible.56

compensating mandible for vertical descent of maxilla 57


Vertical problem; retrognathic maxilla; class -3 .58

Decrease in the lower facial height


Crouzans syndrome . Apert syndrome etc58

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Miss nagveni 13 year old crouzan syndrome

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Transverse dimension problem

In contrast to the aggressive approaches often taken in treating skeletally based anteroposterior and vertical problems , orthodontists traditionally have been reluctant to change the arch dimensions transversly .

Yet it appears that the Transverse dimension of the maxilla may be the most adaptable of all the regions of the craniofacial complex.


The key to such adaptations in the transverse dimension is the use of rapid maxillary expansion as routine treatment procedure .

Most orthodontists cite crossbite as the primary reason to alter the transverse dimension clinically


It is very common for one or more of the maxillary posteriors to be in a lingual orientation relative to the mandibular teeth

Through the widening of the midpalatal suture , the correction of a posterior crossbite is accomplished quite readily in a patient in whom the maxillary sutural system is still patent.


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Kumari - Kavitha 12 year old female patient Complains of forwardly placed upper front teethwww.indiandentalacademy.com

Teratment plan rme foot shoe principle 63

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Maxillary expansion 65


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Rotation of the jaw bases.Bjork in 1969(AJO) differentiates the two types involved in rotional growth of the mandible. 68www.indiandentalacademy.com

Rotation can be differentiated as shown by Lavergne and Gasson 1982 in human implant studies.Convergent rotation of the jaw bases-

Divergent rotation of the jaw bases. Cranial rotation of the jaw bases.

Caudal rotation of the jaw bases.


Converging jaw bases 70


Rotation of the jaw bases; Diverging jaw bases 71


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Master abhishek 9 years male complains of forwrdly placed upper Front teethwww.indiandentalacademy.com

Master abhishek skeletal open bite72

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Caudal Rotation of the jaw bases 74


Cranial Rotation of the jaw bases 75


Fourth dimension To use functional appliance growth is essential .

Success can be achieved in some cases in the pre pubertal or post-pubertal growth period , the optimum time should include the period of maximum growth velocity. 76


77TIMING OF TREATMENT

Growth modulation is possible only in patients who are growing actively

Girls before boys- as they mature earlier.

Severe cases should begin earlier than mild cases

Retention must continue until active growth is essentially complete


78Where prominent upper incisors are vulnerable to trauma - early treatment is indicted.Class III malocclusion also responds to early interventionAbnormal perioral musculature must be eliminated at the earliest.

Ideally, treatment would be provided when it is most effective and most efficient.


GROWTH MODULATON A variety of different functional appliances are available. The appliance selected for the treatment can be adapted to the type of anomaly and to the growth pattern. The growth direction, the growth amount, and the timing are relevant to the ultimate success of the treatment. Consequently, diagnosis and case selection are critical for functional treatment.


Functional treatment in general is the principle that a "new pattern of function," dictated by the appliance, leads to the development of a correspondingly "new morphologic pattern."The "new pattern of function" can refer to different functional components of the orofacial system for example, the tongue, the lips, the facial and masticatory muscles, the ligaments, and the periosteum. 80www.indiandentalacademy.com

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The "new morphologic pattern" includes a different arrangement of the teeth within the jaws, an improvement of the occlusion, and an altered relation of the jaws.

It also includes changes in the amount and direction of growth of the jaws, and differences in the facial size and proportions.


Depending on the type of appliance, its proponent puts more emphasis on one of these different functional components.Eg Frankel emphasis on perioral musculature.


Skeletal malocclusions Skeletal Class II or Skeletal Class III

Treated by ---- a) Functional appliances b) Headgear c) Combination d) Camouflage e) Surgical intervention

Growth Modulation


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Growth modification HeadgearsFace maskChin cupFunctional appliances 1 Activator 2. Bionator 3 . Frankel appliance 4. Twin block appliance 84www.indiandentalacademy.com

Goals and benefits of growth modulation Superior facial estheticsGreater ability to modify the growth processFewer extractionsReduction in the duration and difficulty of subsequent therapy Improvement in patients self concept


Reduction potential of in fracture protruding incisors

Greater patient compliance

Eliminate , if not reduce the need for future jaw surgery

Greater stability.


Functional appliance therapy87

In the last 40 years, functional appliance therapy has become a generally accepted method to treat severe and moderate discrepancies of sagittal jaw relations in children.

Until now, functional appliance therapy had its greatest application and success in Class II malocclusion


88The success of functional appliance therapy depends on the neuromuscular response.

Mandibular orthopedics must modify growth signals targeted at both the ramus and condyle to be maximally effective


89PRINCIPLES AND MODE OF ACTION OF FUNCTIONAL APPLIANCES

A primary objective of functional appliances is to take advantage of natural forces and transmit them to selected areas to produce the desired change.www.indiandentalacademy.com

90FORCESThe duration of force in most functional appliance treatment is interrupted

The direction of force for the movement of teeth should be consistent

The magnitude of force is small in functional appliance therapy www.indiandentalacademy.com

91Applied force may be compressive or tensile.

Depending on the type applied, two treatment principles can be differentiated: force application and force elimination

In force application, compressive stress and strain act on the structures involved, resulting in a primary alteration in form with a secondary adaptation in function In force elimination, abnormal and restrictive environmental influences are eliminated, allowing optimal development www.indiandentalacademy.com

92Classification of functional appliancesGroup I Transmit muscle force directly to the teeth Group II - All reposition the mandible downward and forward Group III - Major operating area is in the vestibule

Also been classified as Myotonic and Myodynamicwww.indiandentalacademy.com

93Increased contractile activity of LPMIntensification of the repetitive activity of the Retrodiscal padIncrease in growth-stimulating factorsEnhancement of local mediators.Reduction in factors having negative feedback effects on cell multiplication rateChange in condylar trabecular orientationAdditional growth of condylar cartilageAdditional subperiosteal ossification of the posterior border of the mandible.Supplementary lengthening of the mandible.MODE OF ACTION OF FUNCTIONAL APPLIANCES


94The Pterygoid Response

Within a few days of the fitting of functional appliances, the position of muscle balance is altered so greatly that the patient experiences pain when retracting the mandible

Due to the formation of a tension zone distal to the condyle www.indiandentalacademy.com

95MUSCULAR ADAPTATION

Within the central nervous systemAt the muscle/bone interface Within muscle tissue

Geometric rearrangement of fibersChanges in Sarcomere number.Changes in Sarcomere length.Changes in muscle physiology


The myofibroblast 95

96Although it has been generally accepted that the orofacial musculature has a profound influence on the development of the face and dentition, it may be very difficult to evaluate and quantify this effect as it relates to the morphology, to the relative position, and to the functional behavior of the muscular components.

The importance of the lateral pterygoid muscle has conclusively been demonstrated in the experiments of McNamara, Petrovic, and their respective colleagues.Volume Aug (162 - 168):AJO DO 1998www.indiandentalacademy.com

97One of the earliest functional appliances was called the Activator because it was supposed to activate the masticatory, facial, lip, and tongue musculature. Andresen believed that the protractor muscles of the mandible especially were stimulated by the use of the activator.


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Master Pavan 14 yrs male c/o forwardly placed upper front teethwww.indiandentalacademy.com

12 mm overjet stepwise advancement .98

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Activator 6mm advancement and 4 mm vertical opening www.indiandentalacademy.com

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Post -functionalwww.indiandentalacademy.com

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The Functional Regulator

Prof -Rolf Frankel.

He has been an outstanding contributor to functional appliance thought & the creator of the Function regulator (Frankel) system of appliances103www.indiandentalacademy.com

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The treatment with this appliance is not primarily directed toward the teeth or the skeletal tissues themselves but rather to the functional disorders

The primary aim of treatment is to identify a faulty postural performance of the orofacial musculature and to correct it by a functional therapy. www.indiandentalacademy.com

105The reestablishment of adequate space conditions of the oral functioning space is primary aim of a functional treatment

However, we must not only correct the existing structural aberrations but also the functional performances of the muscles forming the circumoral capsule


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Smitha k.T 11 yrs c/o forwardly placed upper front teeth


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Twin block Theraphy ( William J.Clark )Introduced in 1977 as a two-piece appliance resembling a Schwarz double plate and a split activator.

Further reviewed by clark ( 1982, 1988, 1995 )

Replacement of occlusal inclined planes by means of acrylic inclined planes on bite blocks Guide mandible downward and forwardFavorable propioceptive contacts of inclined planes.Adaptation of the muscles of mastication


Advantages over other Functional appliances;TWIN BLOCKFunctional mechanism similar to natural dentition.Occlusal inclined planes give greater freedom of movement in anterior and lateral excursions.Less interference with normal function.Improved appearance and function due to absence of lip, cheek and tongue pads.Esthetically acceptable.Can be worn 24 hrs.Indepedent control over upper and lower arch width.111www.indiandentalacademy.com

112Seemashree 14 female pretreatment c/o forwardly placed upper front teeth


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Post functional photographs.www.indiandentalacademy.com

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Post functional www.indiandentalacademy.com

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Orthopedic AppliancesThese appliances are used in the growing stage to control or alter the growth of the maxillo-mandibular skeletal components in the anteroposterior, vertical and transverse directions.Hence they are termed growth modulation appliances.118www.indiandentalacademy.com

Patients with maxillary excess skeletal class II malocclusion with a component of excessive horizontal or vertical growth of the maxilla and some protrusion of maxillary teeth.Reasonably good mandibular dental and skeletalmorphology as this will be minimally affected by extraoral forces. Potential for continued mandibular growthIDEAL PATIENTS FOR TREATMENT WITH HEADGEARS:119www.indiandentalacademy.com

3. In these patients, restriction of vertical maxillary growth is needed along with an augmentation of mandibular growth that is left. Control of vertical eruption of teeth in both the arches is important.high pull headgear for upper molars is givenInterocclusal bite blocks can also aid in prevention of eruption of posterior teeth. E.g. high pull HG with functional appliances.

Ideal patients are long face patients skeletal open bitePatients with vertical maxillary excess:120www.indiandentalacademy.com

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Gajendra 14 yr male www.indiandentalacademy.com

Gajendra 14 male c/o forwradly placed upper front teeth aactivator head gear 121

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Patients with horizontal maxillary deficiency:

These patients are ideal candidates for treatment with extraoral forces using the reverse pull headgear. This causes reciprocal downward and backward rotation of the mandible. Ideal patients should have normally positioned or slightly retrusive but not protrusive maxillary teeth Normal or short but not long anterior facial height

Ideal age of 8 yrs


REVERSE PULL HEADGEAR

Maxillary protraction is recommended for skeletal Class III patients with maxillary deficiency. Delaire and others used face mask for maxillary protraction. Petit later modified Delaires concept by increasing the amount of force generated and thus reducing the overall treatment time. In 1987, McNamara introduced the use of bonded acrylic expansion appliance with acrylic occlusal coverage for maxillary protraction. Turley improved patient co-operation by fabricating customized facemasks. 126


The current literature indicates that reverse pull head gear is an effective treatment for growing class 3 maloccusions with average to deep bite.

The correction occurs by combination of skeletal and dental movement in the anteroposterior and vertical planes of space.127www.indiandentalacademy.com

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Pavan 10 yr old male patient c/o forwardly growing lower jaw.www.indiandentalacademy.com

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Bonded RME www.indiandentalacademy.com

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Limitations of growth modulationNeuromuscular disorder children with neuromuscular disorder such as poliomyelitis and cerebral palsy cannot be treated successfully with functional appliance therapy .

Unfavorable growth pattern functional appliance are contraindicated. 133www.indiandentalacademy.com

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Name- master Ajay. S age- 10 yearsSex- male .Prognathic mandiblewww.indiandentalacademy.com

Age factor McNamara in 1984 used five cases (adult) and treated with functional appliances and noted that the malocclusion present at the beginning of the treatment was still present to a large degree at the end of treatment.135www.indiandentalacademy.com

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To be continued

Thank you

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