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INDIAN DENTAL ACADEMY Leader in continuing dental education

Melvin moss 1997 • FMH R 1 • FMH R 2 • FMH R 3 • FMH R 4

Craniofacial growth •

Genomic P

• Craniofacial growthgenetically predetermined • Orthodontic calvinismwendell w •

Functional P Emphasis on functional factors Plasticity of craniofacial growth Concentration – not on skeletal tissues

Origin of the concept Functional cranial component Skeletal unit

Functional matrices

Macroskeletal Microskeletal



eg-endocranial surface Of calvaria

eg-teeth and muscles

eg neural mass

eg-coronoid, angular

Classic statement – 1981 • The functional matrix hypothesis claims that the origin , growth & maintenance of all skeletal tissues and organs are always secondary , compensatory and obligatory responses to temporally and operationally prior events or processes that occur in specifically related non-skeletal tissues, organs or functioning spaces

Why revisited FMH?? Constraints in the initial version... • Methodological • Hierarchical

Why revisited FMH?? Measurement techniques – eg – roentgenographic cephalometry Method specific – not structurally detailed

FEM – quantitative aspect of localized cephalic growth kinematics

Why revisited FMH?? • Hierarchical constraints

Downwards –cellular, subcellular or molecular upwards – multicellular processes “suspended” or “sandwiched” b/w two levels

Why revisited FMH?? • How epigenetic stimuli are transduced into signals by bone cells??

• How individual bone cell signal brings about a multicellular process??

Why revisited FMH?? Fundamental point • PFM – mechanical loading • Growth of SU – biologic process

How are they related??

Anatomic and conceptual basis • Epigenetic primacy

• PFM considered only cellular and molecular processes brings about the triad of active skeletal adaptation. Deposition Resorption maintenance

Anatomic and conceptual basis • The developmental origin of all cranial skeletal elements and all their subsequent changes in size, shape and location, as well as their maintenance in being, are always , without exception , secondary, compensatory and mechanically obligatory responses to the temporally and operationally prior demands of their related cephalic non-skeletal cells, tissues, organs and operational volumes.

FMH R1 • All vital cells – irritability Mechanosensation


Mechanotransduction Intracellular signal

Osseous mechanotransduction Loading static

dynamic deformation

Extracellular matrix Bone cells threshold

triad of bone cell adaptation

Osseous mechanotransduction Unique in 4 ways 1. Mechanosensory cells are cytologically specialized but bone cells are not 2. 1 stimulus – 3 adaptational responses 3. Osseous signal transmission is Aneural 4. Adaptational processes are independent

Osseous mechanotransduction • Important point mechanotransduction translates the informational content of PFM stimulus to skeletal unit cell signal

Hierarchically downward

Mechanotransductive Processes Ionic processes • Transport of ions through bone cell plasma membrane Stretch activated channels loading Ca++

Intracellular signal

Mechanotransductive Processes Electrical processes Electromechanical


Voltage activated Ion channels

Streaming potential

Transmembrane ion flow

Electric field strength exogenous electrical fields endogenous electrical fields (muscle activity)

Mechanotransductive Processes Mechanical processes • Macromolecular lever capable of transmitting information from strained matrix to bone cell nuclear membrane Organic matrix

………… ………… …………

Nuclear membrane


………… ………… …………

Macromolecular collagen Transmembrane integrin Cytoskeletal actin


Loading Dynamic


Mechanosensing Mechanoreception (Input) Mechanotransduction Ionic / electrical S –Achannels


Mechanical Electrokinetic

Field strength

Macromolecular lever

Skeletal unit cell signal CCN Response (output)

Deposition Resorption Maintainance

Bone as CCN • PFM stimulus


Intracellular signal

Intercellular communication

Bone adaptation

Multicellular level

Bone as CCN • All bone cells are interconnected – Gap Junctions • Exception - osteoclasts

Connexin 43

Plasma membrane of canalicular processes meet

Bone as CCN Gap jnc’ connects1. Osteons to interstitial regions 2. Superficial osteocytes – periosteal & endosteal osteoblasts 3. Laterally connected 4. Periosteal osteoblasts – preosteoblastic cells(interconnected)

Bone as CCN •

Important points

1. 2. 3. 4. 5.

Extensive communication CCN acts as a syncytium Gap jns acts as electrical synapses Permits bidirectional signal traffic No role of secondary messengers

Bone as CCN • Network theory Cells are arranged in 3 layers Initial input layer Final output layer Intermediate / hidden layer

Bone as CCN • Network theory Initial layer cells (loading);stimuli “Weighted”input

summation threshold

Intracellular signal (mechanotransduction) Hidden layer cells (adj. Osteocytes) Final layer cells (osteoblasts)


Bone as CCN

“The output determines the site, rate, direction, magnitude and duration of specific adaptive response i.e deposition, resorption or maintenance of the skeletal tissue�.

Bone as CCN Attributes of CCN 1. Developmentally – untrained, self- organized, epigenetically regulated 2. Operationally – stable, dynamic system – oscillatory behaviour 3. Structurally – non modular, i.e variation in organization permits discrete processing of signals

Bone as CCN Important points 1. Information is not stored discretely in CCN 2. CCN shows oscillations 3. Phenotypically similar osteoblasts – open gap jns 4. Dissimilar osteoblasts – sharp histological discontinuities

Bone as CCN Attributes of strain 1. Dynamic loadings – better response 2. Frequency – osteocytes are tuned to the frequencies of muscle function 3. Magnitude of the strain

Bone as CCN • conclusion New version – explanatory chain extending from the epigenetic event of skeletal muscle contraction, hierarchically downward , through the cellular and molecular levels to the bone cell genome and then upwards again through histologic levels to the event of gross bone form adaptational changes.

FMH R3 & FMH R4 The controversy • • • • •

Genetic Vs epigenetic Dichotomy How to solve dichotomy???? Dialectic analysis…. A method of examining and discussing ideas in order to find the truth

The controversy • Dialectic analysis Thesis Antithesis Resolving synthesis

Genomic thesis • The plan of growth – written down in nucleic acid message Jacob.F (Logic Of Life) • Within the fertilized egg, all information is present for growth Kessler and Melton • Genes make us, body and mind Dawkins ( The selfish gene)

Biologic bases for genomic thesis • Only 10% of genome is related to ontogenesis Housekeeping Genes

Structural Genes

• Regulate metabolic and resp activity of all cells • Regulate specific activity of special cell (neurons, osteoblasts)

Biologic bases for genomic thesis • Defect in the gene

Disorders….. Marfans syndrome O Imperfecta Achondroplasia

Physical analogy – construction of building

Genomic thesis in orofacial biology • Classic article on prenatal craniofacial dev Johnston. MC & Bronsky. PT Craniofacial development Initial regulatory homeobox gene activity

Subsequent activity of 2 mol. groups

Growth factor families

steroid/thyroid Retinoic acid Super family

Orthodontic implication of genomic thesis • Defect in the regulatory activity of genes or gene expression governing the size of the teeth and jaws

Malocclusion and dentofacial deformities

The other side of the coin • FMH supports the concept of epigenetic primacy • Epigenetic processes and mechanisms has the capability of regulating the genomic activity Epigenetic antithesis • Odontogenic eg. Of genomic / epigenetic dichotomy

The other side of the coin Mechanical forces Epigenetic signals

Dental papilla cells

Control of genetic expression of differential tooth form

To solve dichotomy… • Epigenetics • Hierarchy • Emergence • Causation

Epigenetics • All the extrinsic factors impinging on the vital structures – mechanical loadings / electrical signals


All intrinsic events occuring in the cell and between the cell

Hierarchy • Levels of organization • Sub atomic atom organism


molecule tissue

Genomic thesis Epigenetic antithesis

subcellular cell

Emergence • Appearance of attributes at each successive higher level • Changes in attributes – cannot be predicted Osteocytes and bone tissue Emergence is not genomically controlled

Causation • How the attributes of a given biologic structural level cause (control, regulate and determine) the attributes of next higher level

Genomic thesis Epigenetic antithesis Coronoid and temporalis

Classification of causation  Material (what is acted upon?) Intrinsic ;prior causes  Formal (by what rules?)  Efficient (what was the immediate preceding event?) Extrinsic ; proximate  Final (why?)

Resolving synthesis Materials


Cellular/intercell Genomic code ular materials “laws” “rules”

Efficient Epigentic factors

sufficient Morphogenesis


Conclusion • Morphogenesis is regulated by both genomic and epigenetic processes, mechanisms • Both are necessary causes, neither alone are sufficient causes. • Their integrated activities provide the necessary and sufficient causes for growth and development

References • Moss, Primary role of functional matrix in facial growth- Am J Orthod, 1969 June:(20-31) • James Scott, The doctrine of functional matrices- Am J Orthod, 1969 July:(56) • Moss, The capsular matrix- Am J Orthod, 1969 nov:(56) • Moss, Twenty years of functional cranial analysis- Am J Orthod, 1972 may:(61) • Moss, Genetics, epigenetics and causation- Am J Orthod, 1981oct: (366-75) • Moss, Functional matrix hypothesis revisited- Am J Orthod Dentofac Orthop, 1997 july-oct. • Lysle E.Johnston Jr - Factors affecting the growth of the midface – The functional matrix hypothesis : Reflections in a jaundiced eye • David S. Carlson – craniofacial biology as normal science


• Conventional orthodontic therapy

100 g for canine retraction

Lag phase

• Current project – • Translation can occur without lag phase • Low force magnitude • Translation can occur at velocities that are clinically significant

• • • •

7 subjects 84 day study 18 g and 60 g Compressive stresses on distal aspect of canine was 4 kPa and 13 kPa • M/F ratio – 9-13 • Tooth movement in 3 linear and 3 rotational dimensions was measured • Dental casts – at 14 day interval

Subjects and method • 7 Healthy patients from the graduate orthodontic clinic at the university of nebraska medical center • 2 males and 5 females (12y 3m to 16 y 3m) • Good oral hygiene • Maxillary 1st premolars extracted • NSAIDs avoided

Subjects and method • Each subject was scheduled for 9 appt • Day 0 , 1 , 3 and then after every 14 day for a total of 84 day • • • •

One week before day 0 – orthodontic appliance Chlorhexidine mouth wash Oral hygiene evaluated Impressions made

Subjects and method • Maximum posterior anchorage was required • Nance app or combination of nance/ transpalatal arch • Upper 2nd molars involved • Segments were made of 19 x 25 ss

Subjects and method • • • • •

Canine retraction 17x25 or 16x22 ss Vertical height – 9-13 mm Cres – 0.24(Lr) Activation of loop – NiTi closed coil spring

Subjects and method • 2 retraction forces • Distributed randomly to Rt and Lt canines • Force (spring)= k(ΔL) • Spring attachment

Subjects and method • Between appointments – canines moved • Springs adjusted or changed to maintain the desired force magnitude • The forces and countermoment delivered were measured with 2 calibrated clinical instruments

Subjects and method • Orthometer , ortho measurements

Battery operated 2 probes Transducer Electronic display

Subjects and method • •

The compressive stresses applied were 4kpa and 13 kpa These values were chosen for 3 reasons

1. 2 stresses were different enough to bring different rates of tooth movement 2. Both stresses were of low magnitude 3. Pilot work demonstrated sufficiency for canine retraction

Subjects and method • To produce the desired compressive stresses Distal root surface area Root morphology

Subjects and method • Impressions were made at each appt.

Posterior anchorage segment was stable

3 axis measuring microscope

Subjects and method • Results

2.41 mm

Canines retracted at low stresses Canines retracted at high stresses


Subjects and method

Subjects and method

Crown moving more lingual than the root

Distal in

• Conclusion • Effective canine retraction can be brought about, without a detectable lag phase and with minimal unwanted linear or angular tooth movements • Continuous stresses of 13 kpa (60g force) produced distal tooth velocity of 1.27mm/ month • 4kpa – 0.87mm/month • Segmental retraction showed controlled and determinate tooth movement

Optimum force magnitude for orthodontic tooth movement : A systemic literature review Yijin Ren Jaap C. Maltha Angle Orthod 2003

Materials and methods • Meta analysis of force magnitude • • • •

Medline was searched from 1966 – 2001 Over 400 articles collected Animal studies Human trials

Materials and methods • • • • • • • •

Exclusion criteria No quantification of orthodontic force magnitude No quantification of rate of tooth movement No control group or split mouth design Number of experimental sites </= 5 Use of extaoral or functional app Observation period </= 1 week Medication or surgical intervention.

Materials and methods • 161 articles on animal studies - 17 • 305 articles on human studies – 12 • Articles tabulated



Conclusion â&#x20AC;˘ It is not possible to perform a meta analysis of the relation between force magnitude and rate of tooth movement from current literature â&#x20AC;˘ No evidence based force level could be recommended for optimal efficiency in clinical orthodontics â&#x20AC;˘ Well controlled clinical studies with standardized set up are required for better understanding on optimal forces.

Implant as absolute orthodontic anchors Dr. Chetan V. Jayade

Implants â&#x20AC;˘ Preserving anchorage in total is a major problem â&#x20AC;˘ Conventional orthodontics

IOA Anchor loss

EOA Patient compliance

Implants • Treatment options start getting limited or the end results compromised • Pioneering studies by Dr. Branemarke on Osseo integrated implants • Implants – Absolute anchors Indirect anchorage True stationary anchorage True skeletal anchorage

Implants • Definition • Implants are alloplastic devices which are surgically inserted into or onto the jaw bones

• Osseo integration – an intimate structural contact at the implant surface and adjacent vital bone devoid of any intervening fibrous tissue

Implants • Types Screw type Plate type

• Parts Head Body

Implants â&#x20AC;˘ Classification â&#x20AC;˘ Depending on the location of the implant

Subperiosteal Transosseous Endosseous





Implants â&#x20AC;˘ Based on configuration design Root form implant Blade / Plate implant â&#x20AC;˘ Based on surface structure Threaded or Non Threaded Porous or Non Porous

Implants • Based on the composition SS Ti Co - Cr – Mo Ceramic Miscellaneous – Vitreous carbon and composites

Implants â&#x20AC;˘ Early reports of implant usage â&#x20AC;˘ Grainesforth and Highely (1945)

Vitallium screws in Ramal area Immediately loaded For canine retraction

Implants â&#x20AC;˘ Linkow (1970) â&#x20AC;˘ Conducted a human trial to retract the anterior segment using molar implant

Implants • Orthopedic changes Maxillary protraction Maxillary expansion

• Shapiro and kokich (1984) used ankylosed teeth as pseudoimpant • Intentional ankylosis of deciduous canines

Implants â&#x20AC;˘ Smalley et al (1988) Insertion of titanium implants into maxilla, zygoma, orbital and occipital bones of monkeys 12-16mm widening of sutures with 5-7mm increase in overjet

Implants • Andrew , Parr et al (1997) • Conducted experiments on nasal expansion using endosseous Ti screws • Sample – 3 groups • 1 N and 3 N force force applied • 5.2 mm and 6.8 mm expansion

Implants • Orthodontic changes • Creekmore (1983) • Unloading period of 10 days • Within 1 yr – 6 mm of intrusion and 25ºof lingual root torque

Implants • Southard (1995) compared the efficacy of Ti implants with that of teeth in dogs • Unloading period of 3 months • Intrusive force of 50 – 60 g

Implants â&#x20AC;˘ Eugene Roberts: use of retromolar implants for space closure Size of implant: 3.8mm width and 6.9mm length

Implants â&#x20AC;˘

Drawbacks of Retromolar implants

1. 2. 3. 4. â&#x20AC;˘

Bulky Long waiting period Anatomic limitations Expensive Since 1995 , around 10 implant systems have evolved

Implants • Onplants • Block and Hoffman in 1995

3mm height

Unloading period 3-4 months

Implants • Osseous implants • Placed in dense bones – zygoma, body or ramus, mid palatal area Skeletal anchorage system Orthosystem implant Graz implant supported system Zygoma anchor system

Implants • Skeletal anchorage system (SAS) • Developed by Umemori and Sugawara • Ti miniplates stabilized using screws (2 - 2.5 mm in dia) • Design – L type T type

Implants Placement

Unloading period of 3 â&#x20AC;&#x201C; 4 weeks

Implants • • • • •

Orthosystem implant Developed by wehrbein Ti screw (3.3mm dia) 4mm or 6mm length 8 weeks of waiting period • Surface treatment

Implants • Graz implant supported system • Karcher and Byloff • Modified Ti miniplate

Implants • Zygoma anchor system • Hugo De Clerck and Geerinckx (2002) • Curved Ti miniplate with provision of 3 screws • Lower end projects outward and has a vertical slot • Placed in zygomaticomax buttress area

Implants Osseous implants • Advantage • Molar intrusion

• Limitation • Involves complex surgical procedure • Removal - difficult

Implants â&#x20AC;˘ Interdental implants â&#x20AC;˘ Rely on mechanical retention rather than Osseo integration â&#x20AC;˘ Simple to place under LA

Mini implant Aarhus implant Micro implant anchorage

Implants • Mini implant • Ryuzo kanomi (1997)

6 – 7 mm in lenth 1.2 mm dia

Implants â&#x20AC;˘ Aarhus implant â&#x20AC;˘ Birte melson

Implants • Microimplant anchorage (MIA) • Dev by a team of korean orthodontists • Maxillary implants are longer • Ti implants • Drill – 0.2 mm smaller than the implant size

Implants • Newer interdental implant system • Spider screws • OMAS

Implants • Stability of the implant • Miyawaki et al analyzed the stability of screw and plate implant • Sample – 51 patients • 134 screw implants(1,1.5, 2.3 mm dia) • 17 miniplate

Implants • Results • 1mm dia – high failure rate • 1.5 and 2.3mm dia – success rate of 84%and 86%respectively • Miniplates – showed best stability • Peri implant hygiene major criteria for success

Thank you Leader in continuing dental education

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