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Clinical Implications of Growth and Om Development

INDIAN DENTAL ACADEMY Leader in continuing dental education

Practice should always be based upon a sound knowledge of theory. • Is there a problem? • What is the problem? • How is the problem typified? • What treatments are available for this problem? • Which of the treatments is/are more appropriate for us to use? • How is successful treatment defined? • How will the treatment be stabilized?

• Ideal - Set Values • Normal - Range • Abnormal – Deviation further from the range

Terminologies • Standardization • Easy understanding

• ‘Growth, Differentiation, Translocation, Development, Maturation’.

Precise/Imprecise Usage ‘Growth’ • Dimensional Increase

• Mandible ‘grew’ by 15mm

• General Increase

• This face ‘grew’ bigger

• Population Vector

• Face ‘grows’ forward and downward

• Specific Vector

• This mandible exhibits ‘clockwise’ rotation in ‘growth’

• Increase in rate of general growth

• He ‘grew’ rapidly during adolescence

• Predicting specific increase in timing of rate of growth

• We expect to see a spurt in the ‘growth’ in the next few weeks

• Assumption of group vectors

• This is a typical class III ‘growth’ pattern

• Estimate of future amount of growth change

• This patient has very little ‘growth’ left

• Qualitative description of growth

• He is a bad ‘grower’

• Expecting growth which will aid therapy

• We will wait for some ‘growth’ before starting treatment

• “Growth is said to be the raw material for Orthodontic Treatment”

• Growth leads to Biologic alterations 1. Short term – Response to pain 2. Long term – Mutations, Evolutionary changes

• Principles of developmental events • All changes from conception to death • Major themes of importance › Changing complexity › Shift from competent to fixation › Shift from dependent to independent › Ubiquity of genetic control modulated by environment

• Development = Growth + Differentiation + Translocation •


Knowledge of the following subjects • Gross and microscopic anatomy • Biochemistry • Physiology • Genetics • Anthropology

Study of Growth and Development is done in various divisions • Molecular biology • Developmental biology • Physical growth • Behavioral development

Study of Growth and Development is done in various divisions • Molecular biology • Study of physical and chemical phenomenon in living processes › Molecular genetics › Biophysics › Genetic engineering

• Developmental biology • Study from a single cell egg to adult comprising millions of cells › Cellular biology › Embryology › Teratology

• • › › › › › › ›

Physical growth Study of organ and body growth of analyzing – morphogenesis, height &weight, growth rates, retarded growth, developmental physical fitness, pubescence and morphometrics.

Physical growth • Team – Pediatrician, Anthropologist, Endocrinologist, Nutritionist and Dentist • Research Orthodontists have contributed extensively to the knowledge of postnatal growth of head and face • Clinical Orthodontics has been associated with study of physical growth of head and face – “Dentofacial Orthopedics”

• Behavioral development • Study of patterns of interaction with the environment › Embryologist, Psychologist, Psychiatrist, Physiologist, Physiologic psychologist and Geneticists › Striving to provide us answers to how we think, reason, remember and forget

Methods of studying Growth and Development • Types of growth data › › › ›

Opinion Observation Ratings and rankings Quantitative measurements

Methods of studying Growth and Development Direct data Indirect growth measurements Derived data – comparison/assumption

Methods of gathering growth data • Longitudinal • Cross sectional • Overlapping / Semi longitudinal Method

Evaluation of growth data • Statistics is a necessity for research or clinical Orthodontist › Decipher growth studies › Quantify morphology

Evaluation of growth data › Assess progress of treatment › Cephalometric analysis › Judiciously interpreting the significance of published findings in clinical and research journals

Variables affecting physical growth • Heredity • Nutrition • Illness • Race • Climate and seasonal effects

Variables affecting physical growth • Adult physique • Socioeconomic factors • Exercise • Family size and birth order • Secular trends • Psychological disturbances

Pattern • A set of constraints operating to preserve the integration of parts under varying conditions or through time • Interactions throughout life between heredity and environment determines the expression of pattern, quantifying them is the difficulty

Pattern › ‘That child has a class II facial pattern’ Morphologic pattern › ‘This child has a vertical growth pattern’ – Developmental pattern

Variability – Law of nature • What is normal? › Concepts of normality › Age equivalence › Significance of variability

Variability – Law of nature › Concepts of normality Statistical Evolutionary Functional Esthetic Clinical – Ideal / Normal

Variability – Law of nature › Age equivalence Chronological age Developmental age Skeletal age Dental age Mental age

Variability – Law of nature › Significance of variability Norm of a group/area/race Individual goal Group goal Familial variation Pathologic variation

Timing • Predominated by genetic control • Minimal alterations by environment › Timing of growth phenomenon Sex related Environment related Critical in the fusion of facial parts in prenatal growth Synchronous facial and dental growth

Prenatal Facial Growth • The fundamental plan of the individual face unfolds during the first four weeks in prenatal life

Zygote Morula Blastula Implantation Amniotic cavity

Bilaminar embryonic disc Yolk sac Chorionic sac Germ layers Primitive streak

Notochord Neural plate and tube Neural crest cells Migration

Prenatal Facial Growth • The minute proportional differences that occur in each human, make us a distinctly recognizable individual • The events leading to the organization of the face in its normal form is critical in understanding of various factors responsible for development

Physiologic factors of importance in prenatal growth • Genetically determined growth leads to formation of various – › Body type › Cephalic type › Jaw types • Migration of precursor cells to specific areas • Environmental factors in each region

Physiologic factors of importance in prenatal growth • Disappearance of branchial arches • Elevation of palatal shelves & depression of the tongue • Shift of blood supply ICA to ECA

Physiologic factors of importance in prenatal growth • Medially – cartilaginous growth, • Laterally – intra membranous growth • Muscles of mastication – confined growth within the mandibular arch • Muscles of facial expression – migration of the hyoid arch over the face

General outline of crucial growth events • Period of organization of the face • Development of oral structures • Differentiation of supporting structures • The fetal period

General outline of crucial growth events • Period of organization of the face › The branchial arches › Development of the perioral region › Changes in the facial proportions

› The branchial arches Initially its difficult to distinguish the primary craniofacial features of the human embryo from those of other mammals

4 th week IUL Invagination of the surface ectoderm  Oral pit – surrounding area differentiates into face Ectodermal oral plate meeting the endodermal lining of the gut  membrane disintegration  continuity between oral cavity and GIT gained

Heart begins to beat The growth pattern of the face is downward and forward between the forebrain prominence and cardiac bulge

This growth pattern is facilitated by the flexion of the Brain ventrally and then dorsally resulting in the erect head posture Differentiation of human face begins 5th and 7th week IUL

› Development of the perioral region 5 th week IUL Face is 1 ½ mm wide and as thick as of a sheet of paper Nasal pits – MNP, LNP – elongation – fusion Tissue underlying each nostril represents the first separation of the nasal cavity from the oral cavity – Primary palate

Mode of formation of these pits: Contact between the epithelium covering the medial border of the maxillary process and the lateral border of the MNP These epithelium together form a lamina – nasal fin – fuse to form a single sheath

Degeneration of nasal fin – connective tissue penetration – rapid expansion leaves the nasal fin at the anterior and posterior limits Unification of the lip anteriorly and separation of the floor of the pits in the form of cleft is prevented

The tissues underlying and between the two pits is – primary palate – forms separation between the Primitive nasal cavity and oral cavity The posterior opening of the nasal pit is termed as the internal nares and is the posterior limit of the primary palate Palatal shelves separate the oral and nasal cavities – also called secondary palate

• 6 th week IUL • Face is flat and broad • Inter nasal pit distance occupies 90% of the breadth of face • Mandibular arch starts differentiating along with the auricle of the ear • The first branchial slit later forms the external auditory canal

› Changes in the facial proportions • Tremendous changes are observed every 3-4 days • Expansion of anterior region of the brain • 90° rotation of the eyes and cheeks from side to the front of the face • Median nasal tissue - between the maxillary wedges – site of future philtrum of the upper lip • 7 th week IUL • Face is recognizable as a human

• Three important stages where malformations occur › Epithelial contact › Fusion of the sheath › Invasion of connective sheath • Due to the complexity of the events congenital defects are quite common to this area

General outline of crucial growth events • Development of oral structures › › › ›

Development of the tongue Palatal development Tooth development Salivary gland development

› Development of the tongue › Tongue musculature develops from occipital myotomes › Body – 1st branchial arch – 3 primordia Paired lingual swellings Tuberculum impar › Base – 2nd,3rd & 4th arches – median elevation The copula

› Lateral lingual swellings enlarge – furrow appears along the labial borders of the tongue, separating from the developing alveolar ridges › 8-9 weeks Clear differentiation of the muscles of tongue

› Palatal development Formation of the palatal shelves Normal palatal development Fusion of the palatal shelves

› Tooth development 7 th week IUL Epithelial labial lamina becomes apparent along the perimeter of the maxillary and mandibular processes

› Tooth development Separation of the alveolar ridge from lip 2nd lamina appears lingually – dental lamina – epithelial enamel organs The elongation of the developing crowns and roots later leads to the growth of alveolar process

› Salivary gland development 6 th week IUL – Begins in the connective tissue of the developing cheek – Parotid and submandibular 8 th week IUL – Sublingual Epithelial cells – grow to form solid cords and branch repeatedly

Site of origin of the gland – initial epithelial growth – orifice of main duct opening nto the oral cavity 3 rd month – Subdivision and organization is complete 6 th month – Acini of mucous glands are functional Birth – Acini of serous glands become functional

General outline of crucial growth events • Differentiation of supporting structures Development of the : › Chondrocranium › Maxillary complex › Bony palate › Mandible and temperomandibular joint › Facial muscles › Muscles of mastication

› Chondrocranium (Skeletal elements of the skull) Develop to support the brain Neurocranial elements surround the brain Bar of cartilage – Anterior nasal region to foramen magnum This cartilage provides support, anterior facial growth, early fibrous attachment to premaxilla

10th – 14th week  Doubles in length 17th week  Trebles 36th week  Six times

› Related to - olfactory nerve anteriorly - pitutary medially - otic capsule laterally - occipital cartilages posteriorly › Crucial in cranial base synchondroses

› Nasomaxillary complex Nasal capsule - only skeletal support of the upper face until bone formation occurs All bones of this region expand until they appear as bones separated by sutures

› Bony palate 8th week – bilateral ossification centers in anterior palate 14th week – established bony palate with a midline suture extending its length between the premaxilla, maxilla and palatine bones

› Mandible and temperomandibular joint Meckels cartilage  Rod shaped  extends from midline to otic capsule  functions to carry mandibular growth forward  2 posterior elements become malleus and incus Malleus and incus  Articular and quadrate in lower animals Evidence that they function to provide movable joint until the mandibular condyle develops in relation to glenoid fossa - i.e btw 8 th to 18 th week

16 th week - condyle – carrot shaped cartilage The cartilagenous head functions as a growth center until about 25 years of age Rapid bone formation along superior surface between developing teeth Symphyseal cartilage unites by 1 st year of life Angle of mandible - 130° - coronoid process projects above the head of condyle

General outline of crucial growth events • The fetal period 3 rd to 9 th month 3rd month – human appearance Until 5th month increase in height is maximum where width and length are proportional Apparently visible 3rd month – nasal bones - cranial base

General outline of crucial growth events 4th month – sella turica 6th month – sphenoethmoidal and sphenooccipital synchondroses Birth – mandibular midline suture disappears 6 to 7 years – Maxillary midpalatal sutures begin to close

• Face and associated roof of the mouth  most common areas of congenital defects • Anterior brain deficiency results in facial defects • Supporting structures cartilage develops in the midline intramembranous development laterally

Etiology of malformations • Genetic • Genetic influences • Intrauterine and neonatal environment

Various Cranio- facial defects • Acephaly (Absence of head) • Anencephaly (Absence of brain) • Acrania (Absent skull) • Acalvaria (Roofless skull) • Cranioschisis (Fissured cranium) • Premaxillary agenesis (Median cleft lip/palate) • Premaxillary dysgenesis (Bilateral cleft lip/palate) • Agnathia (Absent mandible)

Fetal alcohol syndrome

Formation of germ layers

Day 17

Migration and proliferation of cell population

Treacher Collin Day 19-28 syndrome

[mid face deficiency]

Pre natal growth Primary palate 28-38 formation days

Cleft lip /cleft palate other facial clefts Cleft palate/synostosi

Secondary palate formation

42-55 days

CROUZON syndrome Epithelial pearls Torus palatinus high arched palate

Malformation syndromes associated with mandibular deficiency • Pierre Robin complex syndrome • Treacher collins syndrome • Nager acrofacial dysotosis • Wildervanck-Smith syndrome • Goldenhar syndrome • Mobius syndrome • Hallermann-Streiff syndrome

Malformation syndromes associated with mandibular prognathism • Gorlin syndrome • Klinefilter syndrome • Marfan syndrome • Ostegenesis imperfecta • Waardenburg syndrome

Malformation syndromes associated with facial height / symmetry • Amelogenesis imperfecta • Beckwith-Wiedmann syndrome    

Goldenhar syndrome Hemi hypertrophy Neurofibromatosis Parry Romberg syndrome

Normal body somatoypes • Ectomorph › Tissues predominantly derived from ectoderm › Linearity and fragility – preponderence › Large surface area › Thin muscles and subcutaneous tissue › Heavily developed viscera

Normal body somatoypes • Mesomorph › Tissues predominantly derived from mesoderm › Muscle, bone and connective tissue preponderence › Heavy physique of rectangular outline

Normal body somatoypes • Endomorph › Tissues predominantly derived from endoderm › Soft roundness of body › Large digestive viscera › Accmulations of fat › Large trunk and thighs › Tapering extermities

• Brachycephaly • Short and wide head • Cephalic index of 80 – 85.4 • Americans, Indians, Malayans and Burmese • Euryprosopic jaws • Wide jaws

• Dolichocephalic › Long headed › Cephalic index < 75.9 • Leptoprosopic jaws › Narrowness of jaws › Slender features › Long nose, narrow nostrils and small mouth

• Mesocephalic › Average skull length and breadth › Cephalic index 75 – 79.9

• Mesoprosopic › Face of moderate width

Growth of craniofacial skeleton • Osteogenesis • 2 basic modes  Endochondral  Intramembranous • 2 basic processes  Resorption  Deposition

• Mechanism of bone growth • Deposition and resorption • Growth feilds • Remodelling • Growth movements  Drift  Displacement

Concepts of craniofacial growth

• Genetic concept

• Functional concept

Hypothesis of craniofacial growth • Genetic theory  initially first four weeks • Sicher’s sutural dominance theory – nasomaxillary complex • Scott’s cartilagenous theory –nasal septum, mandible and cranial base • Moss’s functional matrix theory Functional matrices • Petrovic’s cybernetics or servosystem – Action of functional appliances

Controlling factors in craniofacial growth • Natural factors › › › ›

Genetics Function General body growth Neurotrophism

• Disruptive factors › Elective › Environmental › Congenital

Compensatory mechanism – Regional development • Cranial vault • Basicranium • Nasomaxillary complex • Mandible • Temporomandibular joint • Overall pattern • Adult craniofacial growth

Clinical Implications of Growth and Om Development

• Growth status • Problems during Deciduous dentition • Early mixed dentition • Late mixed/early perm dentition/preadolescent • Adolescent • Adult – Surgical orthodontics • Naso alveolar molding

Growth Percentiles • Using the quantitative measurements of height and weight percentile charts are referred • Average child should be in the 50th percentile of growth • Anything lesser than 30th percentile suggests a physical or psychological problem

Growth spurts • Birth to 1st year of life • 6 to 7 years • Pubertal growth spurt

Pubertal growth spurts • ♀ • Pubertal growth spurt usually precedes 1 year before menarche • Menarche is basically used to decide whether growth modification is still feasible • 10 – 12 yrs • Lasts for 3 ½ yrs

• ♂ • There is no single indicator to judge the exact developmental status • Facial hair appears usually near or following peak sutural growth • 12- 14 yrs • Lasts for 5 years

Primary dentition 3 - 6 years • Alignment problems › Hollywood smile › Loss of teeth Incisor Canine Molar

Primary dentition 3 - 6 years • Incisor protrusion-retrusion › Habits › Anterior cross bite  Remove interference  Extract › Posterior cross bite Expansion indicated

Primary dentition 3 - 6 years • Anteroposterior discrepancies • Flush terminal plane • Mesial step • Distal step – Definite class II permanent relationship • Vertical problems • Open bite • Deep bite

Early mixed dentition Moderate


• Space problems  < 3mm


• Skeletal

Grth Mod

 no treatment

Early mixed dentition • Serial extraction • No skeletal disproportions • Class I molar relationship • Normal overbite • Large arch perimeter deficiency  10mm> • Primary lateral incisors  Primary canines  Primary 1st molars  1st Premolar

Late mixed dentition/Early permanent dentition â&#x20AC;˘ Depending on the severity all orthodontic treatment procedures are carried in this period of development

â&#x20AC;˘ Growth modification

Growth modification – how it works? • Growth modification appliances change size of one or both the jaws • Work by accelerating the desired growth but not changing the ultimate size or shape of the jaw • Changing the spatial relationship of the jaws Reorientation

Growth modification • Patient must be growing, preferably 6-12 yrs • Accurate diagnosis of source of discrepancy and application of appropriate amount and direction of force to correct • Growth modification is only one portion of a treatment plan

Growth modification • Psychological and functional benefits • Child prone to trauma as in extreme severity X Prolonged treatment X Patient cooperation X Cost X Variable stability • ‘GOLD STANDARD’

Adolescent Early – 12 to 14 yrs

Late – 16 to 19/21yrs

• Skeletal problems › Growth modifications › Camouflage- when soft tissue profile is acceptable and when tooth movement will not change or compromise the profile › Orthognathic surgery

Adolescent • Important trends to remember • Camouflage of class II skeletal problems is more acceptable in women • Convex profile better accepted • Camouflage of class III problems is more acceptable in males • Straight profile better accepted

• For the 3 planes of space in both maxilla & mandible • Definite sequence of growth completion – WIDTH – LENGTH – HEIGHT

Transverse relationship • Usually completed at the time of adolescent growth spurt. • Narrow skeletal width Narrow palatal vault Narrow dental arch Cross bite • Maxillary constriction

Structure of the suture at different ages:

Infancy Juvenile


• Ideal patients for RME treatment. – Full cusp cross bite with a skeletal component – Some degree of dental as well as skeletal constriction initially – No pre-existing dental expansion.

Transverse relationship • Rapid Maxillary Expansion (Haas 1965) › › › › › › › ›

More skeletal changes Less dental changes Not used in preschool children 0.5mm/day 10-20 pounds Occlusal radiographs Clinical examination 3-4 months of retention

• Haas expander

• Hyrax expander

• Minn expander

â&#x20AC;˘ Activation of RME. Upto 15yrs of age 180 (2 turns daily) 15-20yrs. of age 180 (4 turns daily) Over 20yrs 90 (2 turns daily)

â&#x20AC;˘ Effects of RME:-Midpalatal suture opens anteroinferiorly. -Midline diastema. -Buccal flaring of posteriors.

Adverse effects of RME:• Nasal hump & paranasal swelling. • Pain. • Buccal tipping of posteriors. • Root resorption. • Fenestration of roots

• Slow expansion (Hicks 1978) › › › › › › › ›

Less force 1mm/week 5mm expansion achieved Reduced tissue damage Reduced hemorrhage 2-4 pounds of force More physiologic response More stable results

•Dental cross bites are corrected by › Quad helix › W arch › Arch wire

Skeletal & Dental changes in Expansion â&#x20AC;˘Rapid


Antero posterior/Vertical • Head gear › Cervical pull › Occipital pull › High pull head gear

• Functional appliances › Removable – Activator, Bionator, Twin block, Frankel regulator › Fixed – Herbst, Jasper jumper, Forsus, Eva,Churro

• Timing of Functional appliance wear • Growth has a circadian rhythm • Most growth is during evening hours 8pm-1am • Active tooth eruption takes place • 12 hour wear per day • 4 – 6mm movement seen in 6 – 12 months of wear

Antero posterior skeletal problems • Maxillary excess  Class II › Cervical pull head gear › Distal and occlusal force on the maxillary dentition and maxilla – but not selectivily › Very heavy forces  tooth movement › Heavy – light forces  skeletal movement › Functional appliances › Stimulate mandibular growth › Has secondary effects of restricting forward maxillary movement

Adolescent Antero posterior skeletal problems

Antero posterior skeletal problems • Mandibular deficiency  Class II › Stimulate or accelerate mandibular growth › 2 4mm/year › Headgear is used in conjunction for restricting maxillary growth

Antero posterior skeletal problems • Maxillary deficiency  Class III › Reverse pull Headgear or facemask › Ideal between 6-8yrs › Attached to removable splint or fixed appliance • Functional appliance › Not effective in stimulating maxilla

Delaire Petit Face Facemask mask

Reverse Functional appliances: Twin Block Functional Regulator

Antero posterior skeletal problems • Mandibular excess  Class III › Chin cup therapy › Distal rotation of the mandible and lingual tipping of the lower incisors › Short to normal face height individuals › Contraindicated in long face individuals • Functional appliances › Frankel regulator III › Very minor changes

Antero posterior skeletal problems

Vertical skeletal problems â&#x20AC;˘ Long facial height â&#x20AC;˘ High pull headgear attached to bite blocks on functional appliance

Vertical skeletal problems

Vertical skeletal problems • Short facial height • Cervical pull headgear or functional appliance depending on the antero-posterior relation • Functional appliance designed to prevent eruption of anterior teeth and facilitate eruption of posterior teeth

Vertical skeletal problems â&#x20AC;˘ Highpull headgear to a maxillary splint

Vertical skeletal problems • Magnetic splints for intrusion of posterior teeth • Rare earth magnets • Treatment to be continued as long as the patient is growing

Adolescent Dental problems â&#x20AC;˘ Space maintenance

â&#x20AC;˘ Potential alignment and space problems

TMJ disorders • Etiology › Inherited › Acquired › Factitial › Neoplastic › Idiopathic

TMJ disorders • Clinical features • Occlusal wear or interferences • Joint sounds • Limitation of opening and mandibular deviation on opening

TMJ disorders • Maximum opening  35 – 45 mm • Lateral movements  8 – 12 mm • Clicking  In coordination between disk and condyle on movement • Treatment › Avoid elastics as far as possible › Splint › Correction of malocclusion › Muscle physiotherapy

Adult Orthodontics >19 yrs • Characteristic features › Waning craniofacial growth › Decision of the individual › Malocclusion often complicated by periodontal disease or loss of teeth

Adult Orthodontics • Three groups according to etiology › Orthodontic treatment with good oral health › Orthodontic treatment of malocclusions complicated by periodontal disease and loss of teeth › Treatment of severe skeletal dysplasias requiring both orthognathic surgery and orthodontic correction

Surgical orthodontics • Sagittal relation • Vertical relation • Transverse relation

Sagittal relationship â&#x20AC;ş Movement of maxilla and mandible is relatively easy â&#x20AC;ş Extreme movement affects stability because neuromusculature adaptation and stretch of investing soft tissue

Sagittal relationship • • • • › ›

Maxillary excess/deficiency Leforte I fracture Posterior movement of maxilla Extreme posterior placement causes Speech alteration Nasopharyngeal incompetence

Sagittal relationship • Mandibular deficiency/excess • BSSO › Paresthesia • TOVRO › Less time consuming procedure › No altered sensation

Sagittal relationship

Vertical relationship • Maxilla › Moved superiorly - successfully › Inferior positioning  less predictable • Mandible • Difficulty in moving downwards at the gonial angle  Stability affected due to the muscular sling

Vertical relationship • Long face › Superior positioning of the maxilla › Excellent stability › Some vertical growth of maxilla should be expected ‹ Ramus surgery to decrease the MPA is highly unstable ‹ Mandibular surgery preferred when there is excess of incisor eruption › Inferior border osteotomy › Chin augmentation

Vertical relationship • Short face › Sagittal split mandibular ramus surgery › Facilitates forward and downward rotation of the mandible › Orthodontic levelling of COS to be done after surgery ‹ Maxillary Leforte I down surgery ‹ Relapse ‹ Grafts used are of less help

Vertical relationship

Transverse relationship • Symmetrical narrowing • Symmetrical widening • Asymmetry

Transverse relationship • Maxilla • Expansion relatively more stable than constriction • Mandible • Anterior constriction more stable than expansion • Constriction to a limited extent in the canine region

Transverse relationship

Other surgeries â&#x20AC;˘ Genioplasty

â&#x20AC;˘ Rhinoplasty

Timing • After growth modulation • Too severe to camouflage • When surgery has little inhibitory effect or further growth • Delay in mandibular prognathism • Rarely done before adolescent growth spurt

• Extraction v/s Non-extraction • Esthetic considerations • Stability

• One phase • Moderate discrepancies • No choice of extn/nonextn • Major psychological complex develops in the individual

• Two phase • Severity of malformation • Growth changes can avoid extraction • Psychologically reasons

Early v/s late surgery • Early surgery • Congenital/Genetic defects • Cleft lip and palate • Ankylosis • Progressive deficiency ‹ Vertical repositioning of maxilla can cause supraeruption of posterior teeth

• Late surgery • Vertical excess of mandible • Severe but stable deficiencies

Stability • Class III  Less stable

• Class II  More stable

Retention • Class II • Class III • Open bite • Deep bite • Late incisor crowding • Timing - Initially - 3 to 4 months, part time for 12 months or till growth completion

Cleft lip and palate • Nasoalveolar Molding • Dr. Barry Grayson and Dr. Court Cutting • Nasoalveolar molding is a nonsurgical method of reshaping the gums, lip and nostrils before cleft lip and palate surgery, lessening the severity of the cleft • Surgery is performed after the molding is complete, approximately three to six months after birth

Conventional techinique • Fixing a large cleft required multiple surgeries between birth and age 18, putting the child at risk for psychological and social adjustment problems • The first procedure pulled the lip together, a second improved the position of the lip, another two would be for the nose, then another—often including a bone graft—would close the palate, and so on

Cleft lip & palate • Infant orthopedics • Late primary & early mixed dentition treatment • Early permanent dentition treatment • Orthognathic surgery

Nasoalveolar molding â&#x20AC;˘ With nasoalveolar molding, the orthodontist and surgeon can improve a large cleft in the months before surgery â&#x20AC;˘ This helps the surgeon get a better shape of the nose and a thinner scar in only one surgery

Starts from first 2 weeks of birth

• After the baby has worn the molding plate for a week, the orthodontist slowly adjusts the shape by sculpturing the plastic • Each adjustment is very small, but it starts to guide the baby’s gums as they are growing • Adjustment of the molding plate is done by the orthodontist weekly or every other week depending on progress.

• Dr. Cutting  Using a technique of dissecting out missplaced muscles in the soft palate that would otherwise interfere with complete closure • The usual success rate in achieving a fully closed palate is about 80%; ours is 96% • A more complete closure has dramatically improved the ability of children with cleft lip to speak more clearly

Key interventions in cleft lip and palate 1-4 months

5-15 months

• Check feeding and growth • Repair cleft lip • Check ears and hearing • Check feeding, growth, development • Check ears and hearing; consider ear tubes • Repair cleft palate • Provide oral hygiene instructions

16-24 • Assess ears and hearing months • Assess speech and language • Check development

2-5 years

• Assess speech and language; manage Velopharyengeal Insufficiency • Consider lip/nose revision before school • Assess development and psychosocial adjustme

References • Contemporary Orthodontics 3 rd Edition - William Proffit • Handbook of Orthodontics 4 th Edition -Robert E. Moyers • Facial Growth and Facial Orthopedics -Van der Linden • Pediatric Dentistry 3 rd Edition - Pinkham Thank you Leader in continuing dental education

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