Sie sind auf Seite 1von 63

Introduction

Studying the normal changes that occur in the facial complex is a very important aspect in orthodontics to identify and diagnose
any existing abnormalities to provide optimal treatment to the patient. It is, therefore, essential for dental surgeon to be aware of
how the face changes, where these changes occur, and when these changes usually take place. Such knowledge enables the
practitioner to modify the growth processes to meet the needs of those patients who seek treatment for various malocclusions.
The growth of the craniofacial complex that is relevant to the orthodontic professional can be divided into following areas:

• The cranial base


• Maxilla
• The mandible
• Dental arches
If the both the jaws grows in unison with one another, thy carry the dentition with them and the occlusion remains unchanged.
However, disproportionate growth leads to the development of abnormal relationship of jaws to each other. This change in jaw
relation ships is often associated with compensatory tooth movements in one or both the jaws. This disproportionate differential
growth can occur antero posteriorly, vertically or transversely.

Though the facial pattern established is a relatively constant but it can be changed to certain extent by Growth and by Orthodontic
treatment. As the changes in the face and dentition continue throughout life, the clinician must consider both the immediate
outcome of the treatment and the long-term stability and the benefits of the treatment as important goals.

This presentation discusses the complementary and compensenatory mechanisms that occur in maxilla and mandible in relevance
to the vertical pattern of growth.

I. CRANIAL BASE
The Cranial base or floor supporting the brain is formed by endochondral ossification. The syndhondrosis present in the midline
contribute to the adaptive bone growth that occurs at various sutures. Further the expansion of the brain lobes contributes to
transverse growth. During adaptation of the brain during its evolution the brain stem has changes its growth formed in a Bipedal
Human being. There is what is called as Cranio basal flexure which is around 65 degrees and the whole cranial base appears to
have flexed at the clivus. The middle and posterior cranial fossa are angulated to anterior cranial base and are situated at various
vertical planes. The corresponding growth of midbrain and brainstem adopts itself to this flexure of cranial base. The flexure is also
responsible for the anterior and inferior movement of the middle face. This flexure may result in the predominant downward rather
than forward displacement of the face during its growth from the cranial base. The abnormal flexure may result in some skeletal
sagittal and vertical malocclusions as it influences the position of the maxilla and mandible.

The growth at the medial fossa also relocates the relation between the glenoid fossa and condyle and can effect the growth of the
condyle to certain extent. Indirectly it exerts its influence by the Horizontal and vertical growth of the Nasomaxillary complex.

Basic Bone growth mechanisms


The Comprehension of postnatal growth of maxilla and mandible is made easy after the basic concepts of bone growth
movements are understood. There are two basic growth movements, drift and displacement. Drift is otherwise called cortical
remodeling. Primary
Displacement
It is the movement of the whole bones as a unit. Displacement can be of two types.
Primary Displacement or translation: This is the displacement of the bone as a result of its own growth and Secondary
Displacement or translocation: This is the displacement of the bone resulting from the pull or push of the growth of the
peripheral structures or an adjacent bone. The best exempliefiedis the growth of the maxilla for both the types of growth.
Cortical Drift (Transformation) All bone structures have one growth principle in common, which was termed as drift by DH Enlow.
Cortical drift is a type of growth movement occurring towards the depository surface by a combination of resorption and deposition
also called as remodelling . This may increase the size of bone or change the shape and orientation of the bone. Thus the
translocation of the bone occurs by both translation as well as transformation.

II. Naso Maxillary complex

Maxilla cannot be considered as a separate bone; instead its growth is best studied, taken into account the whole nasomaxillary
complex or midface. It is a complex system of sutures through which all the bones are in contact. According to Moyers, the
nasomaxillary complex functions are:

 To support the airway;


 Mastication
 Speech
 Swallowing

Motive force behind the growth of maxilla has been attributed to primary displacement, growth at synchondroses, sutures, septal
cartilage, etc.
Primary displacement of maxilla is due to growth of maxillary tuberosity and secondary displacement by the growth of the Anterior
cranial base and the growing soft tissue capsule around it. The growth at the Maxillary tuberosity results in lengthening of the
dental arch and enlargement of the antero-posterior dimension of the entire maxillary body. Thus posteriorly the space for erupting
molars is provided. As the cranial base grows anteriorly and superiorly, the midface grows anteriorly and inferiorly. This is termed
secondary displacement. The midfacial bones, by cortical apposition at the posterior end, reestablish contact with the cranial base.
The upper face grows upward and forward and lower face grows downward and forward as an expanding V. The Nasal septal
cartilage to be growth center has been accepted. Sutures are adaptive growth sites. Sutural tissues have no tissue separating
force( Cranial growth centers: Facts or fallacies?—Koski,AJODO 1968;566-83)
Growth of the face follows 'V' principle of growth. The nasomaxillary
complex moves downwards and forwards whereas the anterior
cranium moves upwards and forwards, thus following the expanding
"V" principle of Enlow. SO,Spheno-occipital synchondrosis;C,
condylar mandibular growth; NS,nasal septum; Se, sphenoethmoid
suture;ptp" pterygopalatine suture; pm, palatornaxillary suture; fe,
frontoethmoidal suture;em, ethmoidal-maxillary suture; Lm, lacrimal-
maxillary suture; fm, frontomaxillarysuture; zm, zygomaticomaxillary
suture.

III. Mandible
The basic mechanisms of Translation and Transformation occur also in Mandible also occur as that described for the maxilla. The
growth of mandible is mainly by adoptive remodelling and the growth of the mandible is peculiar because of the endochondrial
ossification of fibrous cartilage thought to occur principally by growth at condyle. Superior and posterior growth of condyle presses
against the glenoid fossa/cranial base (cartilage has pressure adapted bone growth), which provides an anterior thrust to displace
the lower jaw forward.
The Mandible consists of many functional and anatomical units that are compensatory to one another during growth. The various
anatomical units are Condyle, coronoid, Angle of the mandible corpus or Body, alveolar segment and Ramus. The abnormal or
disproportionate growth at one or the other sites is being masked by a compensatory change in the dimensions or directions in the
contagious parts of the skeleton .
There is posterior and inferior relocation of the mandibular fossa. Further,
the anterior and inferior displacement leads to separation of maxilla
and mandible to provide for enough interocclusal space for the tooth to
erupt. This growth is matched by the mandible mainly by the condylar growth
in superior and posterior direction to maintain condylar contact with temporal
fossa. Thus the condyle growth matches the forward and sagittal growth
of the naso maxillary complex. Ramus relocates posteriorly and
increases in height due to addition of bone at the superior border. Thus it
adopts itself increasing pharyngeal airway space. The corpus or body of
the mandible is formed at the expense of ramus repositioning in
posterior direction by resorption at anterior end and resorption at the
posterior border . In this manner the body of the mandible lengthens. Thus
additional space made available by means of resorption of the anterior border
of the ramus is made use of to accommodate the erupting permanent
molar tooth buds. The coronoid process has a propeller-like twist
mechanism of growth. It increases in height (superiorly), widens
(laterally) and at the same time, grows posteriorly. The differential
remodelling at the angle contributes to the growth particularly the
rotational tendencies. Chin contributes to the length by selective remodelling
at the posterior aspect by itself growing forward. Lingual tuberosity, as already mentioned, is a direct counterpart of maxillary
tuberosity and is equally an important growth site for the mandible.
The alveolar process ; The alveolar process grows upwards by the apposition (deposition) of bone on its occlusal border in
response to the tooth buds. Due to the growth of the alveolar process the height of the mandibular process increases. The
ascending ramus slopes (before the coronid process) upwards and backwards, the alveolar border increases in length to
accommodate posterior most teeth. In case of absence of teeth, the alveolar bone fails to develop and it resorbs in the event of
tooth extraction.
Arcial growth of the Ramal angle; This concept was proposed by Hunter. Later, it was found that mandibular growth cannot be
simplified into an anterior resorbing and posteriorly depository ramus. Mandible undergoes a rotational pattern of growth.
With the descent of the maxilla and separation of two bones, the mandibular anterior teeth erupt superiorly and lingually. Similar to
maxilla, mandibular width completes first, followed by depth and height.
The role of the condyle growth in the mandible is controversial
 The rest of the mandible determines the condylar growth
 The rest of the mandible determines the condylar Growth—carry away pattern.

Structural balance of cranium, Naso maxillary complex and the Mandible


The growing brain and increased functional demands exerts influence on the Cranial base. The middle cranial base grows pushing
the Anterior cranial base upwards and forwards and the Nasomaxillary downwards. Further with increasing demands for passage of
the airwat, the naso maxillary complex shifts downwards and forwards. The two jaws gets separated and coordinate with another in
the sagittal direction for proper masticatory function. Thus a balance between this structures is maintained or disturbed based on
the functional demands . These can be explained by Growth theories of Enlow, Moss and Petrovic.

GROWTH EQUIVALENTS CONCEPT/ENLOW COUNTERPART PRINCIPLE


According to this concept, the craniofacial complex can be viewed as in Horizontal counterparts and vertical counterparts.The
vertical or horizontal size of one given part is comparatively equivalent to its specific counterparts in dimensions and direction.
According to Enlow, the growth activity in one region is invariably accompanied by complementary growth in other regions. There is
called complementary growth between these parts for a harmonious growth. This complementary activity is essential for
maintaining functional demands and esthetic balance. Imbalances may result if this dimensional balance is lost or wont match and
misfit of the structures is seen. This 'counterpart principle' suggests that imbalances in the regional relationships are produced due
to variation in Magnitude, Directions, Timing of growth
The second one is compensatory growth or changes seen in the contagious structures seen. Similarly, alignment would affect the
vertical and anteroposterior position of the various skeletal units and could compensate or worsen a tendency toward imbalance.
This relates to the angulation, tilt, cant or rotational position.
Thus if the anterior facial height is long, facial balance is preserved if the posterior facial height and mandibular ramus height are
also relatively.
For example, if maxilla were rotated down posteriorly, a long ramus and acute gonial angle would compensate and allow normal
facial proportions, but even a slightly short ramus would produce downward-backward mandibular rotation and a long face-open
bite tendency. Thus, Enlow stresses the importance of complementary growth of facial skeleton to preserve the facial harmony.
Based on this concept of growth equivalents, Enlow introduced counterpart analysis to assess the rotation of jaw bases.
Growth equivalents concept of Enlow. (A) Components of craniofacial region (a=
anterior cranial base; b= spheno-occipital synchondrosis; c= nasomaxillary
complex; d= mandible) (B) Elongation of anterior cranial base (a) causes
simultaneous enlargement of nasomaxillary complex(c).
(C) Lengthening of spheno-occipital region (m) is the growth equivalent for
underlying pharyngeal region (p) and increasing length of ramus distance (d).
These growth equivalents cause normal positioning of mandible relative to
nasomaxillary complex. (D) Combined vertical lengthening of clivus (b) and
mandibular ramus (d) is the growth equivalent for the total vertical elongation of
nasomaxillary region

The various counterparts involve major boundaries which are coincident with key sites of growth and remodeling. The mandibular
condyle, maxillary tuberosity, sphenoethmoidal junction and all borders of the ramus and palate are examples of such major sites of
growth and remodeling. Most of these growth boundaries also coincide with principal sites at which displacement
(translatoryIntercanine movement) occurs.

Servo system theory


According to servo system theory, the midface grows downward and forward under the primary influence of emphasis on the
growth of the mandible. Anterior growth of
the midface (A) Results in a slight occlusal deviation between the maxillary and mandibular dentitions (B) Perception of this
occlusal deviation by proprioceptors (C) Triggers the protruder muscles of the mandible to become more active tonically (D) In
order to reposition the mandible anteriorly.
The muscle activity and the protrusion in the presence of appropriate hormonal factors (E) Stimulate growth at the mandibular
condyle (F). (Source: After David Carlson. Semin Orthod 2005;11:172-83)
Approach to servo system concept
Functional Matrix theory
The Functional Matrix Concept Melvin Moss introduced the functional matrix hypothesis to the orthodontic world in 1962. It was
developed complimentary to the original concept of functional cranial component by Van der Klaauw (1952). At present this is the
widely accepted growth theory.
According to the functional matrix hypothesis the origin, form, position, growth and maintenance of all skeletal tissues and organs
is always secondary, compensatory and mechanically obligatory necessary response to chronologically and morphologically prior
events or process that occur in specifically related non-skeletal tissues, organs or functioning spaces. In this view, the soft tissues
grow and both bone and cartilage react and are grown is response to the growth of soft tissue. This he stated as " Bones do not
grow; bones are grown."

Why do Bones Grow and how they coordinate with one another
The brain grows primarily due to functional and skeletal unit grows secondarily. Here, primary growth of the capsular matrix
(brain) results in a stimulus for secondary growth of the sutures and syndhondrosis, leading to overall enlargement of the
neurocranium (macroskeletal). we have seen that increasing cranial base exerts its influence on Maxilla and Mandible. Further the
basic increase in demand for the support of life such as respiration also pushes the maxilla forward. The next need for survival if
nutrition and of course proper mastication and thus the mandible follows the maxilla.

Direction of Growth vectors

Factor contributing to Vertical growth and Horizontal growth


Different concepts have been put by different researchers such as Bjork, Schudy, Solow, Profitt.etc.,, the essence of which is given
below. The following terminology is in use regarding the mandibular rotation.
Forward rotators, Horizontal Rotators, Hypordivergent, Anticlockwise rotation
Backward rotators, Vertical growth pattern, Hyperdivergent. Clock wise rotation
The term hyperdivergent is applied to mandibular downward rotation accompanying the retrognathic jaw.
The rotation of the mandible is the result of disharmony between vertical growth and anteroposterior or horizontal growth of jaws.
Disproportionate between the sagittal growth of maxilla and mandible, the difference in anterior and posterior facial heights may
result in rotation and growth pattern. These changes may occur due to growth variations or due to altered soft tissue growth and
functional spaces.
The factors favouring the Vertical growth of the chin( mandible) and the Horizontal growth of the chin ( Mandible) in uncompensated
mode.
Relation ship between the craniofacial structures and rotations ( Table)

The factors effecting the Rotational Factors favouring Factors


tendencies or leading to the favouring or
Vertical growth leading to the
Hyper divergent/ Horizontal growth
Openbite/ / Hypodivergent/
downward and closed bite/
backward / clock Forward and
wise rotators Upwards Growth/
Anticlock wise of
growth

1. The cranial base flexure angle Increased Decreased


(saddle angle) ( profitt)-
(Effects the mandible more )
2. The length of the Anterior Increased leading to Decreased leading
cranial base ( Effects the prognathic mandible to class III
Maxilla more) se- Na . tendency

3. The length of the middle Short and raised. Long and Lowered.
cranial fossa which indirectly close to the level of vertically away
effects the position of the the Anterior cranial from the Anterior
Glenoid fossa ( S-Ar) fossa cranial Fossa

4. Direction of the middle Increased angle Decreased angle.


cranial fossa which indirectly Inferior and Inferior and
effects the position of the Backwards Forwards fossa
Glenoid fossa displaced fossa leading to forward
( Articular angle) leading to positioning of
retropositioned mandible
mandible
5. The orientation of the maxilla: Ante( anti Retro( clockwise)
being up anteriorly and down clockwise) Anteriorly
posteriorly. (profitt) Anteriorly upwards downwards and
and posteriorly posteriorly upwards
downwards
6. Height of the nasomaxillary Increased decreased
complex

7. The length of the Maxilla and Relatively Increased Relatively


the mandible maxillary length Increased
mandibular length
8. Condylar inclination and Condylar inclined Condylar inclined
direction of growth superiorly and superiorly and
backwards. The anteriroly . The
condylar condylar
predominantly predominantly
growing in growing in superior
posterior(Horizontal ( vertical direction)
) direction direction
9. Glenoid fossa displacement Displaced less Displaced more
and remodelling inferiorly and more inferiorly
posteriorly or ( vertically) and
dorsally posteriorly
10. Length and slope of the Short and Backward Long and forward
ramus (profitt) sloping inclined

11. open Gonial angle ( profit) Open Closed


12. Ratio of anterior and Anterior Face height Posterior face
posterior face heights increased height increased
13. Vertical heights of the Increased decreased
maxillary and Mandibular
Posterior alveolar
bone( Molar eruption)
14. Hinge effect Distally erurpting Mesial movement
molars of molars
15. Disparity between muscle Dolichocephalic Brachycephalic
growth and condylar growth. and weak elevator and strong elevator
( profit)

The opposing vertical and horizontal forces were competing for the overall direction of pogonion growth. These factors have ‘cause
and effect’ as well as ‘effect and cause’. The interaction of this factors with compensations occurring due to disproportionate growth
may result a composite form of face with a vertical growth or Horizontal growth. This may or may be associated with the openbite
or closed bite( Incisor relation)..The different types of Forward growth patterns and backward growth patterns are due to change in
the counterparts length or alignment or directions.

Middle Cranial Fossa Length and Inclination; The anteroinferior inclination of this part of the basicranium affects the placement
of the mandible complex relative to the Maxilla . A greater forward downward inclination of middle cranial fossa may be expected in
deep bite while posterosuperior or more upright inclination of middle cranial fossa results in the corresponding positional deviations
that are associated with open bite. As the length increases, the maxilla also increases horizontally leading to a class II pattern. The
opposite is true for class III pattern.

Ramus Inclination ; The ramus is the horizontal counterpart of the middle cranial fossa, a more backward position of the ramus
may be expected to produce anterior open bite and forward inclination produces deep bite. Height of the ramus is pronounced in
case of vertical growth at the mandibular condyles. Inclination of the mandibular ramus appeared to be significant in determining
how the chin point would respond to treatment. Mair AD, Hunter WS. Mandibular growth direction with conventional class II
nonextraction treatment. Am J Orthod Dentofac Orthop 1992;101:543-549.)
Gonion angle : The size of the gonion angle has an important influence upon the number of degrees of resultant counterclockwise
rotation. The smaller the gonion angle, the greater the rotation which is produced for each millimeter of forward movement of
pogonion. When this angle is extremely small, it results in extreme flattening of the mandibular angle together with forward growth
of the pogonion.

Posterior facial height: The increase in the posterior face height has two components. The first is the lowering of the middle
cranial fossa in relation to the anterior one as the cranial base bends, and the condylar fossa then being lowered. The second
component is the increase in the height of the ramus, which is pronounced in case of vertical growth at the mandibular condyles.

Posterior Maxillary Height; If the posterior part of the nasomaxillary complex is long vertically with respect to its counterparts,
which is the combined heights of the ramus and middle cranial fossa, a relative downward and backward relationship of the entire
mandible and open bite will be expected.

Horizontal Maxillary Inclination An antero superior tilt of the maxillary alveolar process or the anterosuperior tilt of the palatal
plane might contribute to the skeletal open bite tendency.
Mandibular Plane Inclination A downwardly inclined mandibular plane can contribute to the development of open bite. Besides
this, a horizontally long mandible, a more open gonial angle, a lack of compensating curve of spee can contribute to open bite
malocclusion
Vertical condylar growth versus combined vertical growth face( alveolar bone height and Maxillary vertical height)
Growth at the mandibular condyles basically produces a forward component of the chin, not a downward and forward component
initially. When the vertical increments of facial growth begin to assert their influence on condylar growth through occlusal contact,
then a downward and forward direction of the chin is produced. Thus, it can be said that condylar growth is pitted against the
combined vertical elements of growth.

If vertical growth of condyle predominates, chin is prominent. since it increases the prominence of the chin, it is called horizontal
growth vector of the chin. The final vector of growth of the chin is a resultant of the struggle between horizontal growth and vertical
growth factors. in other words, between condylar growth and vertical elements. The vertical components pitted against the condyle
are:-

Growth at the nasion and in the corpus of the maxilla which produces an increase in the distance from nasion to anterior nasal
spine and causes the maxillary molars and posterior nasal spine to move away from the sella-nasion plane;
 Growth of the maxillary posterior alveolar processes causing the molar teeth to move away from the palatal plane; and
 Growth at the mandibular posterior alveolar processes causing the molar teeth to move occlusally
The vertical growth of the anterior alveolar processes does not seem to have an appreciable effect on facial height. It is merely
expressed in varying degrees of overbite
When vertical growth factors exceeds horizontal growth factors (condylar growth), pogonion cannot keep pace with the forward
growth of the upper face and the mandibular plane must become steeper. This has an influence on the treatment also. Obviously,
this condition would not help reduce the ANB angle, and it would not aid in correction of a class II molar relation. Counterclockwise
rotation of the mandible is a result of more condylar growth than combined vertical growth of the face. This type of rotation is nearly
always accompanied by a forward movement of pogonion and an increase in the facial angle. If the condylar Vertical growth is
greater than vertical growth in the molar area, the mandible rotates counter clockwise and results in more horizontal change of the
chin and less increase in anterior facial height. Extremes of this condition causes closed bites. Conversely, if vertical growth in the
molar region is greater than that at the condyles, the mandible rotates clockwise resulting in more anterior facial height and less
horizontal change of the chin. Extremes of this condition cause open bites. (Maxillary molar vertical control with the use of
transpalatal arches John B. Wise, DDS," W. Bonham Magness, DDS, ~ and John M. Powers, PhD ~ Allen and Houston, Texas (AM
J ORTHOD DENTOFAC ORTHOP 1994;106:403-8.)
However It is unclear if the increased molar height is a consequence of skeletal open bite by their altered facial growth or that the
skeletal open bite occurs as result of an maxillary molar over eruption caused by an increased posterior discrepancy---cause or
effect

CONDYLAR GROWTH AND GLENOID FOSSA DISPLACEMENT DURING GROWTH AND IN MALOCCLUSION
Concurrent with the elongation of the posterior cranial base, the fossa and the temporal bone are displaced inferiorly and
posteriorly. Such movements are important because the direction of fossa displacement in treated patients has been related to their
overall growth patterns. The condyle has to adjust to the height accordingly. So the condyle grows posteriorly or superiorly
depending on the condylar fossa relocation which is again related to the length of the middle cranial fossa and the flexure ( see
Table). If the fossa is relocated in anterior and inferior direction, more Anterior chin changes will be produced by the vertical
superior growth changes at the condyle. Class II skeletal disharmony is associated with a more posterior position of the glenoid
fossa when compared to class III skeletal disharmony. Subjects presenting with high angle vertical relationships show a more
cranial position of the glenoid fossa and more caudal positioning of the fossa in horizontal growers. Orthopedic forces can stimulate
remodeling in the glenoid fossa. Normally, remodeling in the glenoid fossa is downward and backward. The varied position of
glenoid fossa is linked to different malocclusions. Proper knowledge about normal condyle growth and fossa displacement will help
in differentiating the growth changes from the changes produced due to growth. The condylar head inclination and superior joint
space proved to be the most significantly correlated condylar characteristics to facial morphology. Patients with vertical facial
morphology displayed decreased superior joint spaces and posteriorly angled condyles, whereas, patients with horizontal facial
morphology demonstrated increased superior joint spaces and anteriorly angled condyles
A large angle between the anterior and posterior cranial bases, measured cephalometrically as N-S-articulare (Ar), indicates a
posterior position, and a
small angle indicates an anterior position of the fossa.

GROWTH ROTATION OF MAXILLA


Maxilla undergoes extensive remodeling and displacements when subjected to various functional demands. Generally, the vector
of maxillary growth is in anterior and inferior direction (downward and forward displacement). Due to the varying growth activities of
middle cranial fossa, the sutural attachments of midface and surface remodeling, the maxilla tends to get rotated by displacement.
Sometimes, this rotational pattern is extreme which could result in canting and misfit of the palate and maxillary arch. Here, the
maxilla is inclined upward and forward, that is, the anterior end is tipped up. This is also called ante inclination as coined by
Schwarz. He also named this condition as pseudo-protrusion. This actually aggravates maxillary protrusion. This forward rotation
also tends to tip the incisors forward, increasing their prominence. Backward rotation: Backward rotation of maxilla is exactly
opposite to that of forward rotation where there is downward and backward tipping of the anterior end of the palatal plane and the
maxillary base. This is otherwise called as retroinclination, a term coined by Schwarz. In this type of maxillary displacement, the
jaw bases are translated posteriorly and the upper incisors appear to tip lingually. The angle between palatal plane and the anterior
cranial base is lesser than the normal value.
various environmental influences such as neuromuscular dysfunction, occlusal forces, gravity and nasorespiratory malfunctions can
cause extreme rotations of jaw bases. An upward and forward tipping of the anterior part of maxilla is often confirmed in mouth
breathers, while a downward and backward tipping of anterior part of maxilla is observed as a natural compensation in patients
with vertically growing faces.
.
Inclination of teeth :

The inclination of the teeth is also greatly influenced by the rotation of the jaw. The position of the lower incisors seems to be
functionally related to the upper incisors, as is reflected by the fact that the interincisal angle undergoes a smaller change than the
rotation of the jaw.
Forward rotation of the mandible: In forward growers there is lingual inclination of the anterior teeth and the teeth grow in the
mesial direction, thereby tending to create crowding in the anterior segment through what may be referred to as “packing”. The
rotation also affects the position of the lower posterior teeth in relation to the upper teeth. Forward growth rotation thus causes the
lower posterior teeth to be more upright than usual in relation to the upper posterior teeth, with an increase in what may be called
interpremolar and intermolar angles. Due to the lingual movement of lower incisors, there is reduction in arch length because of
rotational changes and this is more evident the in mandible when compared to the maxilla. Inclination changes in Maxilla are
described above.

Backward rotation of the mandible : Crowding develops due to lip tension in the anterior region due to inability to close the lips.
Since the position of the lower incisors, as mentioned earlier, is functionally related to the upper incisors, they become retroclined
in the mandible and the alveolar prognathism is reduced. The lateral teeth are not guided distally in their eruption to the same
extent, and crowding tends to develop in the anterior segment of the lower arch.
See the difference, In both the type of growers there is crowding but the lip strain is absent forward growers. Because of the
backward rotation of the mandible, the interpremolar and intermolar angles are small, which means that the premolars and molars
are inclined forwarding relation to the maxillary ones.

Mutual Rotation of jaw bases


Four types of mutual rotation of jaw bases were proposed by Lavergne and Gasson after extensive implant studies (1982). This is
important clinically because dentoalveolar malocclusion depends on the combination of these rotations.
 Convergent rotation of jaw bases,  Divergent rotation of jaw bases:  Cranial rotation of maxilla and mandible:  Caudal

rotation of maxilla and mandible:

Form and Function


MUSCLE FUNCTION-BUCCINATOR MECHANISM ( in relation to Hyperdivergent growth patterns)

Note: It appears to be more likely that the skeletal pattern and vertical facial growth tendency are predominantly genetically
determined, but that environmental influences may result in additional changes.

Bone is plastic in nature and is responsive to the muscular forces exerted on it. The entire dentition is held in a state of neutral
zone from the forces acting from within and outwards. The bands of musculature from anterior to posterior are orbicularis oris,
buccinators and superior constrictor of pharynx; these three muscles constitute the buccinator mechanism. The opposite
mechanism is the Tongue pressure. The same mechanism plays an important role in the etiology of tongue thrusting and thumb
sucking. The tongue pressure is not effectively neutralized resulting in flaring of incisors and open bite. If the buccinator
mechanism is dominated, it results in constriction of Maxillary arches and concurrent vertical growth pattern as seen in class II div
1 cases and in some mouth breathers.
Tongue size, resting position and/or activity/Resting tongue position: A forward resting tongue position (between the incisor teeth)
may impede anterior vertical dentoalveolar development, leading with the incisors at a different vertical level to the posterior
dentition.

 Habit: digit sucking/ Adaptive swallowing pattern: There is an atypical adaptive swallowing pattern - i.e., an anterior oral
seal is formed by contact between the lower lip or the tongue and the anterior palatal mucosa. This is likely to be an adaptation to
the vertical separation of the anterior teeth ( some times cause –effect is reverse)

Nasorespiratory function and head posture


If respiration had an effect on the jaws and teeth, it should do so by causing a change in posture that secondarily altered long
duration pressures from the soft tissues. Postural changes to the head (extending the head back by tilting it around the transverse
axis of rotation) due to partial nasal airway obstruction and excessive long-term mouth breathing allow downward and backward
posturing of the mandible, downward positioning of the tongue, and overeruption of the posterior teeth in both dental arches. . For
instance, when the nose is completely blocked usually there is an immediate change of about 5 degrees in the craniovertebral
angle. The jaws move apart, as much by elevation of the maxilla, because the head tips back, as by depression of the mandible.
When the nasal obstruction is removed, the original posture immediately returns. This physiologic response occurs to the same
extent, however, in individuals who already have some nasal obstruction, which indicates that it may not totally result from
respiratory demands.
Mandibular muscles form and function ( in relation to Hyperdivergent growth patterns)
Mandibular muscle form and function have previously been shown to be closely associated with the morphologic features of the
skeletal structures to which the muscles are attached.

Characterstic features Dolichofacial Brachyfacial


Bite force smaller molar bite forces Heavy molar bite force
Cross section of Massetor Have smaller cross have large cross-sections
and Medial pterygoids section with large Gonial in people with shorter
angles anterior face heights and
relatively smaller gonial
angles
Inclination of masseter In long faces, a short In short faces, a long
posterior face height, a posterior face height, a
steep mandibular plane flat mandibular plane and
and large gonial angles small gonial angles are
are often associated with often associated with a
anteriorly inclined straight vertically oriented
superficial masseter masseter muscles in
muscles in relation to the relation to the occlusal
occlusal plane and the plane and the inferior
superior positioning of the positioning of the
masseter insertion onto masseter insertion onto
the mandible. the mandible.

Mechanical advantage Reduced due to small Increased due to small


bite force and inclinationbite force and inclination
of elevators of elevators
Temporalis activity Decreased Increased and may cause
rotation of mandible as it
is attached to the
coronoid and reduces the
mandibular plane angle
Mentalis Hyperactive but normal Hyperactive and deep
mentolabial sulcus and no mentolabial fold and
eversion of lips everted lips
The form and function question
In all living things, there is often a definite relationship between form and function. Despite much previous research, it is still not
absolutely known whether a genetically-determined facial pattern dictates the strength of the mandibular muscles or whether a
strong musculature influences the ultimate form of that genetically- derived face.

The fact that the dolichofacial pattern can be recognized before an age at which decreased occlusal forces are present strongly
suggests that the decreased forces are an effect of the condition, rather than a cause. (MG Woods. The mandibular muscles in
contemporary orthodontic practice: a review. Oral and Maxillofacial Surgery, Melbourne Health and The Royal Melbourne Hospital.
© 2017 Australian Dental Association 78-82)

Clinical implications
Thus the various growth changes occurring at the various growth sites may contribute to the overall facial pattern. The changes at
one site may be compensated at the other contagious structure to mask the effect. The overall growth pattern is the net result of the
compensatory changes occurring in the facial skeleton. The clinician should be able to asses the changes that have occurred and
a treatplan have to be drafted to occur a balance in the structural, functional and esthetic balance.
Compensations

The compensation of the contiguous structures in the craniofacial structures is an important phenomenon that masks the
disproportionate growth. This compensation helps whether the skeletal discrepancy can be corrected during the growth phase
A posteroinferior inclination of the mandibular ramus and corpus contributes to an
anterior open bite. ACF: anterior cranial fossa; MCF: middle cranial fossa; UMx:
upper maxillary region; PM: posterior part of maxilla (vertical); AM: anterior part of
maxilla; Mx: maxillary arch; Ra: ramus; Md: mandibular arch (Source: Trouten JC.
Morphologic factors in open-bite and deep bite. Angle Orthod 1983;53:192-211)
A horizontally long mandibular arch, opening of the gonial angle and lack of a
compensating curve of spee contribute to an anterior open bite (Source: Trouten
JC. Morphologic factors in open bite and deep bite. Angle Orthod 1983;53:192-
211)
Similarly if the maxilla were rotated down posteriorly, a long ramus and acute
gonial angle would compensate and allow normal facial proportions, but even a
slightly increased gonion angle leads to openbite.



Horizontal inclination of the maxillary plane: An anteroinferior inclination of the
maxillary alveolar process or the palatal plane results in deep bite
Besides these, an upwardly inclined mandibular plane, a horizontally short
mandible, a more closed gonial contribute to deep bite (Source: Trouten JC.
Morphologic factors in open bite and deep bite. Angle Orthod 1983;53:192-211
Features of hyperdivergent face

Extraoral features s Intraoral features Cephalometric finding


Dolicocephalic head  Open bite relationship  Prognathic maxilla
Leptoprosopic face High and narrow arched Retrognathic mandible
Convex profile palate
Long sloping forehead Arch length discrepancy FMA > 28
with heavy glabella SN-MP > 32
Long and thin nose Over erupted incisors Small interincisal angle
Large gonial angle Impacted third molars
Short ramus Vertical mandibular
growth
Long anterior face height
Short posterior face
height
Downward and backward
position of mandible

Convex soft tissue profile

Vertical mandibular
growth

Ectomorphy
Backward sloping chin
Weak temporal muscles
Incompetent lips

Features of hypodivergent face

Extraoral features s Intraoral features Cephalometric finding


Brachycephalic  Closed bite relationship  Prognathic maxilla
Europrosopic Head Broad and Flat palate Retrognathic mandible
Prominent cheek bone Arch length discrepancy FMA < 28
in anterior crowding SN-MP< 32

Staright profile Deep bite with lingually


tilted incisors
Small gonial angle
Vertical ramus
Short anterior face height
Long posterior face height
Forward and upwards
position of mandible

Convex soft tissue profile

Horizontal mandibular
growth

Prominent chin forward


growth
Strong elevator and
temporal muscles
Everted lips but
competent

Strong mentalis activity

Timing and Growth spurts


The growth changes can be best explained by cephalocaudal gradient of growth and scammons growth curves. The structures
close to the skull completes their growth initially or structures away from the sella grows intensively after birth. The dimension of
face that completes growth early is width, followed by depth and adult height is achieved last. By 8 years almost 95 percent of
neural growth is complete. The somatic growth follows an 'S' shaped curve, there is decreased growth rate during childhood and
an increase during puberty. Maxillary and mandibular growth curves are between the neural and general tissues.

Of all the bones in the facial skeleton, mandible is the one that has relatively higher potential to grow and the time limit for
mandibular growth is not as restricted as that of maxilla or cranial base. This should be utilized in the treatment of skeletal
malocclusion involving mandible. Mandibular growth follows the general body growth curve, with slowing of growth in childhood
and peaking during puberty. These concepts of growth show us how different maxilla and mandible are in growth and how different
they should be dealt with during treatment, though they are in absolute contact with each other (occlusion).
Mandible seems to grow more and appears to take its own time. There is mandibular surge in adolescents whereas maxillary
growth is hardly evident after 11 to 12 years of age. This aspect of mandibular growth should be taken into account while treating
patients with skeletal malocclusion with fault in mandible. Skeletal class II patients with mandibular retrognathism are treated
usually with functional appliances if they are in the "growing age". On an equivalent level, when treating a skeletal class III patient
due to mandibular prognathism, cephalocaudal gradient of growth makes us understand that there might be residual growth of
mandible after the pubertal surge. Maxillary curve follows the neural growth curve closer than the mandible. It is now easy to
comprehend that maxillary growth is completed quite early in life. Orthopedic appliance therapy to correct maxillary deficiency
(face mask) should be started in deciduous or mixed dentition but after the eruption of all permanent teeth, there is little or no
scope for correction of maxillary retrognathism.
Circummaxillary sutures are fused during adolescence and correction of maxillary retrognathism is less effective after 10 years of
age. Maxilla yields to protraction force mandibular growth closely follows general body growth.
Treatment of class III malocclusion should be done early. Maxillary retrognathism is not easily corrected because maxillary growth
follows the neural growth curve and is completed early. Maxilla yields to protraction force only if the treatment is started in mixed or
deciduous dentition stage.
In other words, circummaxillary sutures are fused during adolescence and correction of maxillary retrognathism is less effective
after 10 years of age. The idea behind including an expansion screw in the maxillary orthopedic protraction appliance is not only
expansion of maxilla but also loosening of circummaxillary sutures so that they respond readily to protraction force. Once the
sutures are interdigitated, protraction becomes difficult and the treatment results are compromised. Mandibular prognathism treated
during adolescence responds well, the reason being obvious. Transverse maxillary correction by skeletal expansion has similar
restriction as the protraction of maxilla. According to Melsen, the intermaxillary suture is smooth and open in children (6-8 years), in
early adolescence(10-12 years) the sutural edges are overlapping, but in late adolescence (14-16 years) the sutures become
interdigitated and fused. Maxillary expansion can be skeletally effective if the treatment is completed in early adolescence. During
the pubertal spurt, another important parameter of growth that needs to be considered is the growth direction, there is a change in
direction of mandibular growth from vertical to horizontal.
Growth Spurts
There is an adolescent growth spurt in the length of the mandible, though not nearly as dramatic a spurt as that in body height, and
a modest although discernible increase in growth at the sutures of the maxilla.

The cephalocaudal gradient of growth, which is part of the normal pattern, is dramatically evident at puberty. More growth occurs in
the lower extremity than in the upper, and within the face, more growth takes place in the lower jaw than in the upper. This
produces an acceleration in mandibular growth relative to growth of the maxilla and results in the differential jaw growth.

Although jaw growth follows the curve for general body growth, the correlation is not perfect. Longitudinal data from studies of
craniofacial growth indicate that a significant number of individuals, especially among girls, have a “juvenile acceleration” in jaw
growth that occurs 1 to 2 years before the adolescent growth spurt. This juvenile acceleration can equal or even exceed the jaw
growth that accompanies secondary sexual maturation. In boys, if a juvenile spurt occurs, it is nearly always less intense than the
growth acceleration at puberty.This tendency for a clinically useful acceleration in jaw growth to precede the adolescent spurt,
particularly in girls, is a major reason for careful assessment of physiologic age in planning orthodontic treatment

If it were possible, the best way to correct a jaw discrepancy would be to get the patient to grow out of it. That requires inducing
differential growth of one jaw relative to the other, either stimulating one to grow faster or restraining it so the other jaw can catch
up. Because the pattern of facial growth is established early in life and rarely changes significantly, this is unlikely without treatment.
Three important principles must be kept in mind when growth modification is considered for a preadolescent or adolescent child: (1)
if you start growth modification too late, it doesn’t work, but if you start too soon, it takes too long; (2) growth occurs on a different
timetable for the three planes of space; and (3) children’s compliance with treatment is affected by both
their stage of maturation and the difficulty of doing what the doctor wants

If treatment is delayed too long, the opportunity to use the growth spurt is missed. In early-maturing girls, the adolescent growth
spurt often precedes the final transition of the dentition, so by the time the second premolars and second molars erupt, physical
growth is all but complete. The presence of a juvenile growth spurt in girls accentuates this tendency for significant acceleration of
jaw growth in the mixed dentition.For many girls, if they are to receive orthodontic treatment while they are growing rapidly, the
treatment must begin during the mixed dentition rather than after all succedaneous teeth have erupted

In slow-maturing boys, on the other hand, the dentition can be relatively complete while a considerable amount of physical growth
remains. In the timing of orthodontic treatment, clinicians have a tendency to treat girls too late and boys too soon, forgetting the
considerable disparity in the rate of physiologic maturation.
Growth sequence
More congruence exists on the sequence of growth patterns than the age at which maximum growth is achieved. Growth follows
the sequential completion of cranium followed by facial width (transverse), then facial depth (sagittal), and lastly height (vertical).
Although AP and vertical growth continue well into adulthood, Class II, Class III relations and relapse of deep bites and open bites
are often seen. These continued structural changes are also responsible for deterioration of occlusal relationships and the relapse
of malocclusion after completion of orthodontic treatment. Interestingly, facial width, the largest facial dimension at infancy, shows
the least relative growth rate compared with the facial depth and height. Transverse growth is found to achieve near completion by
late adolescence; however, sagittal and vertical growth continue well into adulthood.

Direction of Growth
Not only is the functional treatment dependent on growth direction but extraction/ non extraction decision, time taken for extraction
space closure, prognosis of other orthopedic therapy like expansion, mesial migration of teeth distal to extraction site, time taken for
treatment, response to a particular treatment are all dependent on growth direction. The change from vertical to horizontal
direction, if any, should be looked for horizontal direction, if any, should be looked for.
Dimensions of the face complete growth of width first, followed by depth and height. The width of mandible is completed first, the
mandibular intercanine width is established at 9 years in girls and 10 years in boys. There is hardly any increase in width after this
age. The maxillary canine erupts after the mandibular intercanine width (in other words, mandibular anterior arch width) is
established, infact it appears that the maxillary canines waits for the mandibular horizontal spurt, to be completed.
During the pubertal growth spurt, there is a change in direction of growth of mandible from vertical to horizontal. There will be
disturbance of equilibrium in musculature which will add to the failure.
Thus, maxillary intercanine dimension acts as a safety valve for the horizontal mandibular spurt in puberty. Width increase in
maxilla is not possible after 12 to 13 years in girls, but in boys maxillary intercanine dimension increase is seen till 18 years of age.
Width of the face thus follows the neural curve with depth and height following general body growth of Scammon's curve.

Reichenbach and Taatz used the example of a foot and shoe principle, with the foot representing the mandible and the shoe
representing the maxilla. If the shoe is too narrow, it is impossible for the foot to slide fully into the shoe. By widening the shoe, the
foot slides forward into its usual position. From an orthopedic standpoint, the widening of the maxilla allows for the spontaneous
repositioning of the mandibular jaw into a more forward position. spontaneous mandible repositioning in a forward position, solving
or improving sagittal malocclusion.

The anteroposterior dimension of face completes next, followed by height. Downward and forward growth of maxilla is seen till 14
to 15 years in girls. Increase in height is due to the separation of the jaws during displacement, growth of alveolar bone and
eruption of teeth. Late increase in height of face is seen particularly in the lower third. According to Behrent, forward growth of jaws
is noticeable after puberty and in adulthood and modest increase in the vertical growth of jaws is seen in adulthood.

During the development of dentition, a number of unstable occlusal states called transient malocclusions are encountered. To
name a few, they are flush terminal plane relation, spacing in deciduous dentition—primate spaces, ugly duckling stage and these
are best left untreated. Deciduous dentition presents with a transient deep bite which is corrected by contributions like change in
the axial inclination of the permanent teeth when they erupt (deciduous teeth are more upright), physiological bite raisers, etc. In
certain instances, this deep bite may restrict the downward and forward growth of mandible, thus the full intercanine width might not
be expressed
in the mandible. The narrow mandibular intercanine width might be accentuated by the presence of class II skeletal base with
increased overjet. Simple procedures
like giving a bite plane might be enough to relieve the bite and facilitate forward growth of mandible.
The growth of jaws is determined by the growth of functional matrix and cranial base. Remodeling follows a specific pattern that
appears to be repetitive and inherent to the human race. Balanced facial form and functions are derived from a harmonious
integration of the various components of the craniofacial complex. These components grow and develop throughout life in a
sequential, predictable, and orderly fashion, albeit with a wide range of variation in the amount and timing of growth.

Treatment plan
The treatment plan for the mismatching of the maxilllo mandibular relations depends upon the basic growth pattern, Misproportion
or misfit in a particular direction of jaw bases, the growth potential of the individual , severity of the mismatch, Functional
abnormalities, compensenatory changes and growth and adaptability of the soft tissues.

Growth Modulation : In a growing patient the functional abnormalities can be corrected and direction of the skeletal growth can be
brought to a favourable condition based on the patients original skeletal pattern. To a little extent absolute increase in the structural
units can be achieved

Comouflage: This is masking of the abnormal growth of skeletal units by effecting only the movements of the dental units. This is
done in patients in whcom active growth is completed

Orthognathic surgeries: The absolute increase or decrease of the skeletal units for a match obtained and the direction to certain
extent. If possible all the dental compensations are removed.

Hyperdivergent Growth rotation


With this thing in Background Further we will discuss the implications of this growth rotations in Treatment planning. Careful
attention to these details is important in effective orthodontic treatment management, especially during the retention period to
control for the effects of late growth changes have been used to monitor growth increments. Vertical facial growth is the last to stop.
It often continues into the late teens in girls and early 20s in boys, and prolonged retention is needed for both long-face.
The treatment objectives of patients with skeletal open bite include preventing further development of the upper and lower posterior
dentoalveolar regions and the downward development of the maxilla, increasing the vertical development of the mandibular ramus
and the condyle, and obtaining an anterior autorotation of the mandible.

Growth modulation:
In the long-face patient, controlling the vertical dimension has been particularly challenging. It depends upon the concurrent sagittal
mal relation. We can see that the vertical direction of growth is a prolonged one and even extends into the adult life.
Treatment of long-face problems usually can be deferred until adolescence because: • Long-face or open bite problems can
improve during preadolescent growth but can be aggravated by growth that persists until the late teens and can outstrip early
focused intervention.

A complex open bite (one with skeletal involvement or posterior dental manifestations) or any open bite in an older patient whose
teeth have erupted is a severe problem

Second the direction of growth in most of the individuals changes from vertical to horizontal growth pattern during the pubertal
growth phase. This may be advantage. If the compensations show a favourable growth pattern, the growth modulation can be
attempted. The initial treatment of this condition at least prevents worsening of the condition and the associated functional
abnormalities and anaesthetic appearances.
Patients who have dolichofacial growth patterns (increased lower facial height) often have a reduced overbite and an anterior open-
bite. Careful management of these patients is needed because the vertical growth pattern that they have is often unfavorable for
conventional functional appliance therapy.
The backward tilt of the maxilla at the posterior region can be corrected by the High pull head gears. If accompanied by the class II
retrognathic mandible, a Herbst appliance with increase vertical bite may be attempted
The vertical chincap has been used as a supplementary device with intraoral appliances in early functional orthopedic treatment of
skeletal open bite. The effect of the vertical-pull chin cup was evident only in the mixed dentition, with little effect noted in the
permanent dentition even though the appliance was worn at night for 5.5 years on average. Vertical pull chin cup with direction of
force along the orbital margin can redirect the mandible in upward and forward direction. The vertical chincap (vertical-pull chincap,
highpull chincap)15,23-31 has been used to obtain the anterior rotation of the mandible, with the resultant force vector passing
through the anterior part of the mandibular corpus and 3 cm from the outer canthus of the eye
The Frankel IV appliance was developed in conjunction with muscle training to overcome openbite malocclusions caused by
abnormal perioral muscle function. The Frankel IV appliance attempts to reverse the unfavorable growth pattern

Any functional shifts in the mandible and habit breaking can be considered at this stage. Anterior open bite in a young child with
good facial proportions usually needs no treatment because there is a good chance of spontaneous correction with additional
incisor eruption, especially if the open bite is related to an oral habit such as finger-sucking.
Treatment considerations during camouflage
The fact that changes in the vertical dimension occur together with changes in the anteroposterior dimension makes control of the
vertical dimension an important aspect in planning orthodontic treatment. In many patients, the normal downward and forward
displacement of the maxilla and mandible has been replaced by a more vertical displacement of these bones, result ing in
prolonged treatment times, compromised treatment objectives, and, often, poor esthetic results. Vertical control is often difficult, in
part because most methods used to exert vertical control are highly patient-dependent.
Controlling vertical dentoalveolar development is often difficult, because most orthodontic mechanotherapy tends to produce
vertical movement of teeth. From the initial placement of separators, which elevate the teeth from their alveoli, to the lighter leveling
arch wires, teeth undergo movement in a vertical direction. Perhaps the reason is that vertical movement represents the path of
least resistance and is therefore the most immediate response.
Another factor influencing vertical development is the musculature. The so-called "low-angle" cases tend to have stronger
musculature that will counteract the extrusive forces of orthodontic treatment. In contrast, the "high-angle" cases are associated
with weaker musculature, which allows for the greater expression of vertical forces that are generated during treatment which may
disadvantage sometimes

In the treatment of patients with severe hyperdivergent skeletal pattern, the counter clockwise autorotation of the mandible after
intrusion of the posterior teeth has an essential role in improvement of the facial profile. However, the following factors affecting
facial profile changes should be considered. (Budi Kusnoto and BernardJ. Schneider. Control of the Vertical Dimension(Semin
Orthod 2000;6:33-42,)
1. Intrusion of the upper posterior teeth The first consideration is the intrusion of the upper posterior teeth. To achieve
counter clockwise rotation of the mandible, the first thing to be considered is the intrusion of the upper posterior teeth.

2. Second, the anteroposterior occlusal plane cant should be checked. A large amount of intrusion of the upper posterior
teeth can make the occlusal plane steep and guide the mandible backward, and this restricts the amount of
counterclockwise autorotation of the mandible.

3. The third factor is bodily retraction of the upper incisors. If the upper incisors are tipped lingually during retraction,
this causes contact between the upper and lower incisors and tends to open the mandibular plane angle, thus reducing
autorotation of the mandible. Therefore, bodily retraction of the upper incisors plays an essential role in profile changes.

4. The fourth factor is the intrusion of the upper incisors. In open bite with hyperdivergent skeletal pattern, the intrusion
of the posterior teeth causes autorotation without incisal contact, but autorotation of the mandible causes incisal contact
with normal overbite.In this case, the intrusion of the upper incisors should be considered to provide space for
autorotation of the mandible.

5. Intrusion of the Lower Posteriors. For the fifth factor, the lower posterior teeth also need to be intruded in severe
cases. The intrusion of only the upper teeth can induce extrusion of the lower posterior teeth, which should be prevented
by microimplants, and the active intrusion of the lower posterior teeth is required in severe hyperdivergent cases.

6. The sixth factor is the vertical position of the lower incisors. The lower incisors are retracted by tipping in most
cases, and tipping may bring the incisal tip upward and cause incisal contact. Therefore, intrusion of the lower incisors is
required in patients with severe hyperdivergent skeletal pattern.
7. Coordination of movement at the upper and lower posterior teeth and the upper and lower incisors, which is very
important. In patients with hyperdivergent skeletal pattern, interdigitation of the teeth is not obtained easily. If 1 cusp of a
tooth has occlusal contact only, the occlusion stays with no contact at the other teeth. Therefore, the coordination of
movement is most important.

8. For the eighth factor, the extraction of the lower second premolars is better in terms of profile improvement,
because the mesial protraction of the lower posterior teeth is helpful in reducing vertical dimension or autorotation of the
mandible by moving the fulcrum forward.

Treatment mechanics in vertical growers:


An undesirable backward rotation of the mandible can easily occur during treatment if the underlying muscle pattern is not properly
considered. This might lead to a detrimental increase in profile convexity in dolichofacial patients. In dolichofacial patients, it is very
important to control the vertical dimension if stability and facial balance are to be achieved. The use of interarch elastics and
various headgears and functional appliances should be carefully considered and controlled in vertically-growing patients.

Timing of Comprehensive Treatment : In dolichofacial subjects, the tendency will be to commence full active treatment later, in
the permanent dentition, so that the teeth can be carefully moved (often retracted) to positions of balance within the fully-grown
face. Extraction/non-extraction and missing-tooth replacement decisions.
Extractions: Because of the need to avoid undue opening of the vertical relationship during treatment and to avoid increasing lip
protrusion and convexity, extractions of premolar teeth (with or without enhanced vertical and anteroposterior anchorage) may be
necessary in dolichofacial patients, in particular.
In many mesofacial and dolichofacial patients, a missing lower second premolar may be advantageous, especially in the presence
of considerable crowding. Whatever the case, in a weaker muscular environment, controlled space closure may be relatively
straight forward.
It has been shown that, if premolars are extracted in dolichofacial patients, there is still likely to be an increase in overall vertical
facial dimension. The rule suggests that the natural individual muscle-related vertical dimension will be maintained dimension.

Vertical control of molars. TPA stops continued vertical descent of the upper buccal teeth and therefore stops maxillary alveolar
vertical growth. It is believed that this Alveolar growth is equal to a third of the total vertical growth of the face; therefore, whenever
a palate bar is being worn, it is the same as stimulating a third additional mandibular length. Another anecdotal method of this
inhibition is tongue pressure against the arch (Maxillary molar vertical control with the use of transpalatal arches John B. Wise,
DDS," W. Bonham Magness, DDS, ~ and John M. Powers, PhD ~ Allen and Houston, Texas (AM J ORTHOD DENTOFAC
ORTHOP 1994;106:403-8.)

Buccal tube angulation : Changes in angulation of the first permanent molars are inextricably linked to changes in anchorage.
The Molars are tipped distally in class II patients. Therefore, the straight archwire in conventional 0° or 5° buccal tubes on UMs
should be considered more carefully if it is used on the more distally tipped molars in Class II cases. The already distally tipped
upper molars cannot provide adequate anchorage with this Buccal tubes with 0° or 5°. Under the mesial tipping moment of a NiTi
wire, the first molar tips mesially and then occupies the extraction space, resulting in loss of anchorage. The maxillary molars are
also distally inclined. This may also be a reason why high-angle cases tend to lose anchorage more easily, in addition to the
explanation of weak masticatory forces.The maxillary first molars (which are usually employed as anchorage teeth) have varied
mesiodistal angulations that are affected by growth stages, malocclusion classification, and jaw growth patterns. Almost all UM
buccal tubes have the same angulation based on ideal normal occlusion, as demonstrated by Andrews. Hence, the forward tipping
moments on molars may be larger for growing adolescents, Class II cases and/or high-angle cases than for adults, Class III cases
and/or low-angle cases if using the same straight archwire to differences in the initial molar angulation. Tipping compensatory
molars into ideal molar angulation with a straight archwire might cause early loss of anchorage, exaggerate the Class II molar
relationship and reduce the natural occlusal curve, which could increase the risk of instability.
The lower molar angulation to mandibular plane shows less changes after growth is completed. It can be used as starting point of
reference for the orthodontic treatment. (Hong Su, Bing Han. Compensation trends of the angulation of first molars: retrospective
study of 1 403 malocclusion cases. International Journal of Oral Science)
Intrusion of Posterior Teeth to Close Anterior Open Bite. Most patients with anterior open bite have elongation of the maxillary
and/or mandibular posterior teeth, so the mandible is rotated downward and backward. The maxillary incisor segment often is
reasonably well positioned relative to the upper lip. Extrusion of the upper incisors to close the bite in a patient with this issue is
neither esthetically acceptable nor stable. Intrusion of the maxillary posterior segments so that the mandible can rotate upward and
forward is the ideal approach to treatment. Moving the maxilla up with a Le Fort I osteotomy is highly stable and predictable.
. Skeletal anchorage to intrude the posterior teeth has the potential to create the same mandibular response. This now makes
orthodontic intrusion a possible alternative to surgery, at least for patients with the less severe long-face problems. This has made it
possible to correct anterior open bite/ long-face problems that previously could not be corrected. Maxillary posterior teeth can be
intruded with miniplates at the base of the zygomatic arch, long bone screws reaching into the same area, or palatal anchorage

Adults—How much intrusion

• Maxillary molar intrusion can give satisfactory correction of moderately severe open bite (up to 6 mm in the long term from
intrusion, more with extrusion of incisors). • Control of lower molar eruption now is recognized as important in gaining the desired
skeletal change and should be included routinely when maxillary molar intrusion is done. Clinical experience (unfortunately, not
well documented beyond case reports) suggests that intrusion of both maxillary and mandibular posterior teeth can allow closure of
more severe open bites. Eruption of maxillary and/or mandibular incisors partially compensates for re-rotation of the mandible, so
bite opening after open bite correction rarely occurs. It appears that Le Fort I surgery to superiorly reposition the maxilla is more
likely to produce a significant shortening of anterior face height.
It is clear now that 3 to 4 mm of intrusion can be achieved, with an expected short-term relapse of about 1 mm, and that for the
average patient, 2 mm of closure of the open bite occurs for every 1 mm of posterior intrusion. This means that closure of a 6-mm
anterior open bite is about the limit unless lower as well as upper molars are intruded, and that a surgical procedure still will be
required unless the mandible rotates to the correct position as face height decreases. If mandible is not able to rotate to the fullest
extent, reduction or elongation of ramus is required. For example, it can also rotate into an anterior crossbite that cannot be
managed with either mandibular dental retraction or maxillary proclination.
Retention When a Class II Growth Pattern Exists

Recurrence of a Class II relationship must result from some combination of tooth movement (forward in the upper arch, backward in
the lower arch, or both) and differential growth of the maxilla relative to the mandible. Overcorrection of the occlusal relationships
as a finishing procedure is important in controlling tooth movement that would lead to Class II relapse. In Class II treatment it is
important not to move the lower incisors too far forward, but this can happen easily with Class II elastics. In this situation, lip
pressure will tend to upright the protruding incisors, leading relatively quickly to crowding and return of both overbite and overjet.
Often this occurs in only a few months after full-time retainer wear is discontinued. As a general guideline, if more than 2 mm of
forward repositioning of the lower incisors occurred during treatment, permanent retention is very likely to be required. Class II
problems, this can be controlled in either of two ways. The first, if headgear was used in treatment, is to continue its use on a
reduced basis (at night, for instance) in conjunction with a retainer to hold the teeth in alignment. The other method is to use a
functional appliance of the activator or Bionator type to hold both tooth position and the occlusal relationship

Retention When a Class III Growth Pattern Exists.

Retention after correction of a Class III malocclusion early in the permanent dentition period can be frustrating, because recurrence
from continuing mandibular growth is very likely and extremely difficult to control mandibular growth, surgical correction after the
growth has expressed itself may be the only answer. In mild Class III problems, a positioner may be enough to maintain the
occlusal relationships during post treatment growth.

Retention After Anterior Open Bite Correction


Relapse into anterior open bite can occur by any combination of of depression of the incisors and elongation the molars. In patients
who do not place some object between the front teeth, return of open bite is almost always the result of elongation of the posterior
teeth, particularly the upper molars without any evidence of intrusion of incisors. Controlling eruption of the upper molars therefore
is the key to retention in patients with an open bite. The preferred method to do that is a palate-covering removable appliance
(modified Hawley retainer, discussed later) with bite blocks between the posterior teeth to create several millimeters of jaw
separation. This stretches the patient’s soft tissues to provide a force opposing eruption.

As we have noted previously, bite blocks are ineffective in intruding posterior teeth, but they are capable of impeding eruption. The
recent increase in reports of successful treatment of mild open bite malocclusion with clear aligners has led to suggestions that
vacuum-formed retainers with thickened plastic over the posterior occlusal surfaces may be useful for retention of these patients
The theory is that this would provide enough of a bite block effect to prevent posttreatment eruption of the posterior teeth and that
patient compliance would be better, but no good data exist It is possible that open bite retention with vacuum-formed retainers
also would work mostly by encouraging eruption of anterior teeth.

Orthognathic surgery

The surgeries may involve a Le fort I differential or plane reposition of the maxilla depending the inclination angle. The Mandibular
surgeries involve BSSO with corpus rotation, chin augmentation. The anterior teeth compensation and the occlusal plane correction
has to be done depending upon the situation. Neuromuscular adaptation is essential for stability. Fortunately, there is good
neuromuscular adaptation to most orthognathic procedures. When the maxilla is moved up, the postural position of the mandible
alters in concert with the new maxillary position, and occlusal forces tend to increase rather than decrease. This controls any
tendency for the maxilla to immediately relapse downward and contributes to the excellent stability of this surgical movement.
When the mandible is moved forward, a similar adaptation in tongue posture can be advantageous in patients with sleep-
disordered breathing, and a lower border osteotomy to bring the chin forward also produces forward movement of the tongue
because the tongue is attached to the genial tubercles. In contrast, neuromuscular adaptation does not occur when the
pterygomandibular sling is stretched during mandibular osteotomy, as when the mandible is rotated to close an open bite as it is
advanced or set back, so movement of the mandible that stretches the elevator muscles should be avoided.

Stability is greatest when soft tissues are relaxed during the surgical procedure and least when they are stretched. Moving the
maxilla up relaxes tissues
The least stable advancements are those that rotate the gonion angle down, lengthening the ramus and rotating the chin up.
The least stable orthognathic surgical procedure, widening the maxilla, stretches the heavy, relatively inelastic palatal mucosa.

Neuromuscular adaptation affects the length of the masticatory muscles but not their orientation, and adaptation to a new
orientation cannot be expected

This concept is best illustrated by the effect of changing the inclination of the mandibular ramus when the mandible is set back or
advanced. Successful mandibular advancement requires keeping the ramus in an upright position rather than letting it incline
forward as the mandibular body is brought forward. The same is true, in reverse, when the mandible is set back: a major cause of
instability appears to be the tendency at operation to push the ramus posteriorly when the chin is moved back, thus changing its
orientation. The orientation is restored when jaw function resumes after operation, and that moves the jaw forward again.

Some of the cases with various modalities of treatment are discussed.

Das könnte Ihnen auch gefallen