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INDIAN DENTAL ACADEMY Leader in continuing dental education

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CHICAGO

ER, Oprah, United Center, Early Edition, Hill Street Blues police station www.indiandentalacademy.com


THE KOTTEMANN GALLERY, UNIVERSITY OF ILLINOIS AT CHICAGO

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Brodie Laboratory for Craniofacial Genetics Dr. Thomas Diekwisch, Director

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SKELETAL TISSUE ENGINEERING LABORATORY DR. JEREMY MAO, DIRECTOR

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WORLD JOURNAL OF

ORTHODONTICS

WSO: August 1-2, 2003 San Diego www.indiandentalacademy.com


ESCO Electronic Study Club for Orthodontists

Dr. Joseph Zernik www.uic.edu listserv@listserv.uic.edu SUBSCRIBE ESCO <first name><last name> www.indiandentalacademy.com


Sadowsky, Mejia-Maidl, Kusnoto, Schneider, Sellke, Will, Muhl, Yoon-Tarlie, BeGole www.indiandentalacademy.com


Objectives-Driven Orthodontics • Accurate Diagnosis • Specific Treatment Goals • Understanding of Normal Growth Phenomena • Knowledge of Appliance Effectiveness www.indiandentalacademy.com


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Clinical records + Clinical Exam â&#x2021;&#x2019; DIAGNOSIS & PROBLEM LIST www.indiandentalacademy.com


DIFFERENTIAL DIAGNOSIS • • • • •

PATIENT COMPLAINTS PSYCHOSOCIAL NEEDS ORAL HEALTH FUNCTIONAL STATUS DEVIATION FROM NORMAL STANDARDS

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PATIENT DATA • HISTORY • CLINICAL EXAM • RADIOGRAPHS (INTRAORAL, CEPHS, HAND-WRIST, OTHERS) • PHOTOS (FACE, TEETH, CRANIUM) • STUDY MODELS • OTHER DIAGNOSTIC www.indiandentalacademy.com TECHNIQUES, E.G. MOUNTING


FUNCTIONAL EXAM • PART OF CLINICAL EXAM • EVALUATE JAW MOTION • DETECT FUNCTIONAL SHIFTS • HABITS • SPEECH, ETC. www.indiandentalacademy.com


NORMALIZATION •ANATOMIC NORMS •PSYCHOMETRIC NORMS (Giddon, Anderson, Arpino, Hier, Mejia) www.indiandentalacademy.com


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from PROBLEM LIST to TREATMENT OBJECTIVES www.indiandentalacademy.com


Start with problem list, then: • Derive specific treatment objectives • Assess therapeutic modifiability • Develop a realistic treatment plan • Choose appliances www.indiandentalacademy.com


FORMULATION OF SPECIFIC TREATMENT OBJECTIVES: e.g., SOFT TISSUES www.indiandentalacademy.com


Specific soft tissue objectives (1) • Retract, maintain, or protract upper and/or lower lip • Increase, maintain, or decrease vermilion display (lip thickness) • Reduce lip strain, mentalis muscle strain, and interlabial gap or maintain lip competence • Increase, maintain, or decrease nasolabial angle www.indiandentalacademy.com


Specific soft tissue objectives (2) • Increase, maintain, or decrease mentolabial angle • Increase or maintain cervicomental angle • Reduce, maintain, or increase the gingival display on smiling • Increase, maintain, or decrease the vertical and/or antero-posterior projection of the soft tissue chin www.indiandentalacademy.com


SOFT TISSUE FACIAL CONSIDERATIONS Mejia-Maidl & Evans www.indiandentalacademy.com


• • • •

Assessment of a Balanced Facial Profile Profile Lines for Evaluating the Face Soft Tissue Changes with Growth Soft Tissue Changes with Treatment – Effects of Extraction and Nonextraction Treatment – Effects of Headgear Versus Functional Appliances – Maxillary Protraction – Orthognathic Surgery

• The Smile www.indiandentalacademy.com


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THICKNESS MAY VARY www.indiandentalacademy.com


LONG LIPS TOLERATE DENTAL PROTRUSION BETTER THAN SHORT LIPS www.indiandentalacademy.com


ANTERIOR ATTACHMENT OF THE LIP ON THE NOSE IS VERY DIFFICULT TO WORK WITH

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SYMMETRY

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(Luker)


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(after Lucker)


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MARK FACIAL MIDLINE AND CENTER OF MANDIBLE

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DENTAL SYMMETRY

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SMILE LINE

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INCISOR SHOW

2 - 4 mm crown visible at rest; no gingiva when smiling

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Treatment Effects

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TWINS: Extraction and NonExtraction

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Subapical Osteotomies

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LeFort I

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ANTEROPOSTERIOR SKELETAL CHANGE: GROWTH MODIFICATION www.indiandentalacademy.com


Specific objectives related to growth modification: • Maxillary protraction or retraction • Mandibular protraction or retraction • Control of vertical dimension (including rotating the mandible open or closed) • Skeletal maxillary expansion www.indiandentalacademy.com


After preparing a diagnosis and establishing the desired outcome, the orthodontist must select an intervention that will achieve the proposed treatment goals as closely as possible. www.indiandentalacademy.com


THERAPEUTIC MODIFIABILITY • GROWTH • APPLIANCE EFFECTS www.indiandentalacademy.com


Variability in facial growth: Normal growth Class II Class III www.indiandentalacademy.com


Superposition of tracings of annual cephalograms for a child who has a Class II Division 1 malocclusion www.indiandentalacademy.com


Class II Division 1: Observation group (No treatment) 5% considerable improvement 15% worsened

Tulloch et al., 1998 www.indiandentalacademy.com


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Disharmonious growth - Class III skeletal pattern www.indiandentalacademy.com


Disharmonious growth - Class III skeletal pattern www.indiandentalacademy.com


CHOICE OF MECHANOTHERAPY www.indiandentalacademy.com


Effectiveness of mechanotherapy: Exploitation of normal growth phenomena www.indiandentalacademy.com


Availability of reliable data is limited due to: • Variability of facial growth

• Problems of study design • Clinician bias www.indiandentalacademy.com


CASE REPORTS Impressive results seen in a case report may not reflect the usual or standard outcome of a treatment program, but merely the clinicianâ&#x20AC;&#x2122;s good fortune in selecting a suitable patient. www.indiandentalacademy.com


METHODS USED TO EVALUATE GROWTH MODIFICATION STUDY DESIGN: • INDIVIDUAL VARIATIONS IN GROWTH • INDIVIDUAL VARIATIONS IN PATIENT RESPONSE

INDIVIDUAL VARIATIONS ARE LARGE!! www.indiandentalacademy.com


Common problems: • Control groups not equivalent • Patient dropouts, changes in treatment • Animal experiments not equivalent (e.g., post treatment changes animals normal, human patients abnormal) www.indiandentalacademy.com


GROWTH MODIFICATION IN THE SAGITTAL DIMENSION www.indiandentalacademy.com


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Class II Growth Modification Maxillary Extraoral Traction High-Pull Headgear Cervical Headgear Functional Appliances Functional Appliances in Combination with Headgear Herbst www.indiandentalacademy.com


High-pull Headgear + Orthopedic Pressure Appliance

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HIGH-PULL HEADGEAR ANIMALS - resorption at sutures • Macaca mulatta (Meldrum, 1975) HUMANS - relative inhibition • (Firouz et al., 1992) • (Caldwell et al., 1984) • (Uner and Yucel-Eroglu, 1996) www.indiandentalacademy.com


Cervical Headgear

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Age 11 to 15

AGE 11 AGE 15

CERVICAL HEADGEAR + CLASS II ELASTICS

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Class II www.indiandentalacademy.com


CERVICAL HEADGEAR ANIMALS - suture changes â&#x20AC;˘ Monkeys (Trifthauser and Walter, 1976; Droschl, 1975)

HUMANS - sagittal and vertical, mandibular rotation and mandibular response (Melsen, 1978; Derringer, 1990; Cook et al., 1994; Kirjavainen et al., 1997; Hubbard et al, 1994; www.indiandentalacademy.com Burke, et al., 1992, Funk, 1967)


Functional Appliances www.indiandentalacademy.com


Interpret literature with caution! www.indiandentalacademy.com


FUNCTIONAL APPLIANCES, FUNCTIONAL APPLIANCES IN COMBINATION WITH HEADGEAR, HERBST • Animals - mandibular length, mandibular position, dentoalveolar changes • Human patients - retrospective, groups not similar www.indiandentalacademy.com


Class III Growth Modification Protraction Face Mask Chin Cup Mandibular Headgear

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RETROGNATHIC MAXILLA

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PROTRACTION HEADGEAR ANIMALS - protraction feasible

• Primates (Kambara, 1977; Jackson et al., 1979; implants- Smalley et al., 1988. HUMANS - much dentoalveolar change, vertical change • Ngan et al, 1996; Nartallo-Turley and Turley, 1998; Kilicoghu and Kirlic, 1998; Chong et al, 1996; Takada et al., 1993;Kim et al., 1999; Nanda, 1980) www.indiandentalacademy.com


Class III www.indiandentalacademy.com


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CHIN CUP, MANDIBULAR HEADGEAR

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CHIN CUP - vertical, shape Allen et al., ; Thilander, 1965; Vego, 1976; Graber, 1977; Deguchi and McNamara, 1999)

MANDIBULAR HEADGEAR vertical, dental, skeletal (animals)

Joho, 1973, Matsumoto, 1987; Battagel and Orton, 1995; Orton, et al., 1983, Battagel and Orton, 1993, Arun and Erverdi, 1994) www.indiandentalacademy.com


CONTROL OF THE VERTICAL DIMENSION Kusnoto www.indiandentalacademy.com


• Forces acting on both jaws – Vertical Pull Chin Cup – Occlusal Splints – Herbst, Jasper Jumper, Twin Block, Frankel IV – Multiloop Edgewise Appliance

• Single arch appliances – High-Pull Headgear – Low-Transpalatal Arch – Low Mandibular Lip Bumper and Lingual Arch – Wedge Principle in Extraction Treatment – Anti-extrusive Force Systems – Implant-Basedwww.indiandentalacademy.com Skeletal Anchorage


1. Force acting on two jaws Vertical Pull Chin Cap in extraction cases --Pearson

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1. Forces acting on two jaws Vertical Pull Chin Cap Level of force of 250-300 grams/ side Appliance Design based on : a. Force Level b. Age (Graber) 12-16 ounce force + CHG (Haas) www.indiandentalacademy.com


A. Class II elastics B. Herbst www.indiandentalacademy.com


1. Forces acting on two jaws

Occlusal Splints -inhibits dentoalveolar development -- Woodside

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1. Forces acting on two jaws Magnets (Dellinger)

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1. Forces acting on two jaws - Removable : Frankel, Twin Block

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1. Forces acting on two jaws Functional Appliances Unfavorable growth in dolichofacial patients Reduced overbite and anterior openbite Careful selection of functional appliance www.indiandentalacademy.com


1. Forces acting on two jaws Multiloop Edgewise Arch Wire - KIM

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2. Forces acting on one jaw High Pull Headgear

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2. Forces acting on one jaw High Pull Headgear vs. CHG Baumrind (AJODO 1978) No differences in mandibular rotation

Burke & Jacobson (AJODO 1992) No differences between CHG & HPHG www.indiandentalacademy.com


2. Forces acting on one jaw b. Transpalatal Arch

Wise (AJODO, 1994) No difference www.indiandentalacademy.com


2. Forces acting on one jaw Lingual Arch and Lip Bumper Cetlin and Ten Hoeve (JCO 1983) No difference in vertical control Fabrizia, Monsurro, Perrilla (AJODO, 2000) Sagittal and vertical changes after treatment of Class II Div 1 malocclusion according to the Cetlin method www.indiandentalacademy.com


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2. Forces acting on one jaw Utilizing Appropriate Force System

Intrusion force of approximately 100 grams for 4 lower incisors should be produced by the 17x25 ss wire www.indiandentalacademy.com


1. Occlusal splint, vertical pull chin cap, twinblock were found to be effective 2. No difference in controlling vertical between CHG vs HPHG, but only limited data are available • Transpalatal arch, lingual arch, “wedging” effect of extraction have not scientifically proven • The effectiveness of fixed functional appliances (such as Herbst, Jasper) in controlling vertical growth in the long run is not known www.indiandentalacademy.com


Pitchfork Analysis (Johnston) Maxilla (Max) Upper molar (U6)

Skeleton (ABCH)

Molar Relation (6/6)

Lower Molar (L6) Mandible (Mand)

Upper Incisor (U1) Overjet (1/1) Lower Incisor (L1) MAX + MAND = ABCH (Growth relative to cranial base)

ABCH + U6 + L6 = 6/6 (Molar relation)

ABCH + U1 + L1 = 1/1 www.indiandentalacademy.com

(Overjet change)


Modified Pitchfork Analysis for Vertical Assessment

Maxillary Displacement

Mandibular Displacement + Remodeling

U6 eruption

U1 eruption Overbite

L6 eruption

L1 eruption

www.indiandentalacademy.com Maxillary Displacement + U6 eruption = Mandibular Displacement - L6 eruption


DENTAL AND SKELETAL CHANGES IN THE TRANSVERSE DIMENSION Will www.indiandentalacademy.com


Treatment Modalities Jackscrew Appliances Removable Expanders Nonscrew Expanders Slow Expansion Functional Appliances Timing of Expansion

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MANAGEMENT OF ANTEROPOSTERIOR DENTAL MOVEMENTS Yoon-Tarlie and Sadowsky

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• Distal Molar Movements • Leveling the Curve of Spee • Differential Anteroposterior Movement Via Extraction • Differential Jaw Growth • Correction Via Interarch Elastics

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MANAGEMENT OF OVERBITE BY CONTROLLING INCISOR AND MOLAR MOVEMENTS Sadowsky and Sellke www.indiandentalacademy.com


• • • • • •

Full-Arch Mechanics Utility Arches Segmental Arch Mechanics Forces and Intrusion Root Resorption and Incisor Intrusion Increasing the Vertical Dimension

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Intrusion arch puts moment on molar to enhance anchorage and simultaneously resolves deep bite during incisor retraction. www.indiandentalacademy.com


Use of cantilever mechanics, auxiliaries, segmented arches to achieve specific objectives. www.indiandentalacademy.com


INTERPRETING THE LITERATURE ON THE EFFECTIVENESS OF CLINICAL PROCEDURES BeGole www.indiandentalacademy.com


• Use of Statistics in Orthodontics • Comments on the Correct Use of Statistical Analysis – Parametric Versus Nonparametric Tests – Tests of Normality and Homogeneity of Variance – One-Tailed Versus Two-Tailed Tests – Randomization – Independent and Paired Samples – Sandard Deviation Versus the Standard Error – Statistical Inference – The Null Hypothesis www.indiandentalacademy.com – Statistical Significance


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CONCLUSIONS - 1 In human therapy, current orthodontic appliances are inefficient at best in eliciting predictable skeletal responses. Sagittal corrections occur as a combination of skeletal and dentoalveolar changes with considerable individual variability. www.indiandentalacademy.com


CONCLUSIONS - 2 Physiologic recovery after orthopedic intervention may reduce the amount of change finally realized. Occlusal outcomes are remarkably stable with improvement in lip harmony and balance. Future directions in research will evolve from objectives-driven treatment. www.indiandentalacademy.com


THE WORLD IS FLAT. 1492 MAN CAN’T FLY. 1902 ORTHODONTISTS DON’T GROW MANDIBLES.

2003??? www.indiandentalacademy.com


Message to those who say, “Don’t bother me with why, just teach me how……”

Treatment methods will change. Define specific treatment objectives. www.indiandentalacademy.com


www.indiandentalacademy.com Leader in continuing dental education

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Carla/ dental implant courses by Indian dental academy