Growth Modulation / Orthodontic Courses by Indian Dental Academy

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com
INDIAN DENTAL ACADEMY

Leader in continuing dental education
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Growth modulation
versus Orthognathic
surgeries
Dr. Yusuf ahammed
B. D. C. H. DAVANGERE
2 www.indiandentalacademy.com
contents
Introduction
Basic definitions
Normal growth in 3 dimensions
Envelope of discrepancy
Developmental 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 appliance
Limitations of growth modulation procedures.
Day-2
Orthognathic surgeries definition
Indications of surgeries
Aims of the orthognathic surgeries
Compensation and Decompensation
Extraction pattern in different skeletal
malocclusion
Skeletal class -3 and class -2 malocclusion
Comparison Growth modulation
Orthognathic surgeries
Conclusion
References

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.
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 .
7
The 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.
,
9
Soft tissues
Dentition
skeletal
Goals of orthodontics
10

Achieve good
occlusion
Class -1
Hormonise
the skeletal
bases Balance
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 Growth
When the horizontal, vertical and transverse
growth components of maxilla and mandible match
that of each other, normal growth results.
Growth
Stewart 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


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
Moyers
Development 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 death
Enlow
Development connotes a maturational process involving
progressive differentiation at the cellular and tissue levels

Maxilla

Body Large and pyramidal in shape .

Four processes

FRONTAL
ZYGOMATIC
ALVEOLAR
PALATINE
Maxilla
The growth mechanism is produced by
Displacement
Growth at sutures
Surface remodelling

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.

18
As a bone enlarges , it simultaneously
Carried away from other bones in direct
Articulation with it.
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.

Frontozygomatic suture
Frontomaxillary suture
Nasomaxillary suture
Zygomaticomaxillary suture
Growth Sutures
Greatest until the age of 4 years
zygomaticoTemporal suture
Midpalatine suture
Growth Sutures
Surface remodeling
Deposition occurs on side facing
the direction of growth

Resorption on surface facing away
from direction of bone growth.

Cortical drift

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.

23
As a bone enlarges , it simultaneously
Carried away from other bones in direct
Articulation with it.
Displacement.
24
Growth 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 unit
Primary displacement
Secondary displacement

Main sites of post natal
growth in the Mandible

Condylar cartilage

Posterior border of the Ramus.

Alveolar ridges

Condylar cartilage
Condyle 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 .
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) .

28
Secondary type of cartilage

Secondary in evolution
Secondary in embryonic origin
Secondary in adaptive responses to changing
developmental conditions
Secondary in histological structure
29
Type of bone formation
Intramembranous ossification
Whole body of mandible except the anterior part
Ramus of mandible as far as mandibular foramen
Endochondral ossification
Anterior portion of the mandible (symphysis)
Part of ramus above the mandibular foramen
Coronoid process
Condylar process
Post natal development of Mandible
Ramus
Superior part of ramus below sigmoid notch
Lingual -Deposition
Buccal - Resorption

Lower part of ramus below
Coronoid process
Buccal Deposition
Lingual - Resorption

30


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

31

Coronoid process
Follows enlarging V principle
Deposition occurs medial surfaces and also vertical
dimensions also increases
Briefly propellar- like twist, so that its lingual side
surface three general directions all at once:
posterio-superio- medially

33
Lingual Tuberosity
Direct anatomic eqivalent of maxillary tuberosity
Major growth and remodeling site
Effective boundary between ramus and corpus
WIDTH OF MANDIBLE
Growth in width is completed before adolescent
growth spurt
Both 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 system
Petrovic and Rakosi.
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.
37
DIFFERENT APPROACHES IN ORTHODONTICS
Envelope of discrepancy shows how much
change can be produced by various
treatment modalities.
38
The 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
4
6
10
2
2
7 12
15
5
10
5
15
40
4
6
10
5 10
12
2
5
15
3 5
25
Maxilla- in transverse plane
41
Palatal Buccal
2
2
3 3
3
4
4
3
4
10
10
7
42
1
2
2
3
2
4
4
4
10
10
3 5
Buccal Lingual
Dentofacial deformity
Refers 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

44
Class I malocclusion could be a result of normal
growth of all structures,
or
It could be a product of various diverse growth of the
dentofacial complex, compensating each other to
create a balanced face.
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 maxilla
Transverse problem .

1.Saggital problem; retrognathic mandible
46

2.Saggital problem; prognathic maxilla
3.Sagittal problem; combination
49

50

4.Sagittal problem; prognathic mandible
51

52
Name- master Ajay. S age- 10 years
Sex- male .
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-34
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.
Vertical descent of maxilla
55

Increase in the
Lower 1/3 rd of the face
Prognathic maxilla
compensating mandible for vertical descent of maxilla
Vertical problem; retrognathic maxilla;
class -3 .
58

Decrease in the
lower facial height
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.

63
Kumari - Kavitha 12 year old female patient
Complains of forwardly placed upper front teeth
Maxillary expansion
Rotation of the jaw bases.
Bjork in 1969(AJO) differentiates the two types
involved in rotional growth of the mandible.

68
Forward rotation
Forward rotation centers in
the joints- type1
Forward rotation center
located at the incisal edges of
the lower incisors. Type 2
Type 3 . Center of rotation lies at the
premolar region .
Backward rotation-
less frequent
Type-1 center of the rotation lies at
the joint

Type 2 backword rotation occurs about
the center situated at the most dital
occluding molar.
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

72
Master abhishek 9 years male complains of forwrdly placed upper
Front teeth
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.
77
TIMING 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
78
Where prominent upper incisors are vulnerable to
trauma - early treatment is indicted.
Class III malocclusion also responds to early
intervention
Abnormal 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.
81

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
Growth modification
Headgears
Face mask
Chin cup
Functional appliances
1 Activator
2. Bionator
3 . Frankel appliance
4. Twin block appliance

Goals and benefits of growth
modulation
Superior facial esthetics
Greater ability to modify the growth process
Fewer extractions
Reduction 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 therapy
87

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

88
The 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

89
PRINCIPLES 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.
90
FORCES
The 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
91
Applied 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
92
Classification of functional appliances
Group 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
Myodynamic
93
Increased contractile activity of LPM
Intensification of the repetitive activity of the Retrodiscal pad
Increase in growth-stimulating factors
Enhancement of local mediators.
Reduction in factors having negative feedback effects on cell multiplication
rate
Change in condylar trabecular orientation
Additional growth of condylar cartilage
Additional subperiosteal ossification of the posterior border of the mandible.
Supplementary lengthening of the mandible.
MODE OF ACTION OF
FUNCTIONAL APPLIANCES
94
The 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
95
MUSCULAR ADAPTATION

Within the central nervous system
At the muscle/bone interface
Within muscle tissue

1. Geometric rearrangement of fibers
2. Changes in Sarcomere number.
3. Changes in Sarcomere length.
4. Changes in muscle physiology

96
Although 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 1998
97
One 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.

98
Master Pavan 14 yrs male c/o forwardly placed upper front teeth
99
Activator 6mm advancement and
4 mm vertical opening
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
appliances
104
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.
105
The 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

106
Smitha k.T 11 yrs c/o forwardly placed upper front teeth
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 forward
Favorable propioceptive contacts of inclined planes.
Adaptation of the muscles of mastication
Advantages over other Functional appliances;TWIN
BLOCK
1. Functional mechanism similar to natural dentition.
2. Occlusal inclined planes give greater freedom of
movement in anterior and lateral excursions.
3. Less interference with normal function.
4. Improved appearance and function due to absence
of lip, cheek and tongue pads.
5. Esthetically acceptable.
6. Can be worn 24 hrs.
7. Indepedent control over upper and lower arch
width.
112
Seemashree 14 female pretreatment c/o forwardly placed upper front teeth
115
Post functional photographs.
Orthopedic Appliances
These 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.
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 skeletal
morphology as this will be minimally affected by
extraoral forces.

Potential for continued mandibular growth
IDEAL PATIENTS FOR TREATMENT WITH
HEADGEARS:
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 given
Interocclusal 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 bite
Patients with vertical maxillary excess:
121


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.
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.
128
Pavan 10 yr old male patient c/o forwardly growing lower jaw.
130

Limitations of growth modulation
Neuromuscular 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.
134
Name- master Ajay. S age- 10 years
Sex- male .
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.
136

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