Growth modulation /certified fixed orthodontic courses by Indian dental academy

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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

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 it’s
existence as a single cell to it’s 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 22www.indiandentalacademy.com

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 displacementwww.indiandentalacademy.com

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 Meckel’s 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

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

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
 Girls—14-15 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 15510
5
15

40
4
6
10
51012
2
5
15
3 5 25

Maxilla- in transverse plane
41
Palatal Buccal2
2
33
3
4
4
3 4
10
10
7

42
1
2
2
3
2
4
4
4
10
10
35 BuccalLingual

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

2.Saggital problem; prognathic maxilla

3.Sagittal problem; combination

4.Sagittal problem; prognathic mandible

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

Rotation of the jaw bases; Diverging jaw bases

72
Master abhishek 9 years male complains of forwrdly placed upper
Front teeth

Caudal Rotation of the jaw bases

Cranial Rotation of the jaw bases

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:

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 Delaire’s 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.

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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