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We only treat what we are educated to see. The more we see, the better the treatment we render our patients Arnett and Bergman AJODO 1993
Terms of reference
Frankfort plane Zero meridian True vertical (plumb line) Mandibular plane Maxillary plane Horizontal(Transverse) 1/5ths Vertical 1/3rds Midline(s) Dentoalveolar compensation
Frankfort Plane
Zero Meridian
True Vertical
Mandibular plane
Me Go
Constructed Gonion Go Lower border
Horizontal 1/5ths
Rule of 1/5ths Divided into equal fifths Each the width of an eye Alar base = intercanthal Mouth = medial iris margins
Vertical 1/3rds
Equal thirds
Trichion to glabella Glabella to subnasale Subnasale to s.t. Menton
Lower third
Subnasale to stomion 1/3rd Stomion to s.t. Menton 3/2rds
Midline
Facial midline
Philtrum, glabella
Maxillary dental midline Mandibular dental midline Relation to each other Displacement
A functional movement ICP to RCP
Deviation
A dynamic movement
Dentoalveolar compensation
A mechanism where the position of the teeth has altered in an attempt to maintain a normal inter-arch relationship
Aetiology
95% Complex interaction
Genetic Environmental influence
5% Specific cause
In-utero disturbances Syndromes Trauma Growth disturbances
Importance
Greater genetic component: worse prognosis Mode of treatment
Interceptive Camouflage Orthognathic
Skeletal pattern
Antero-Posterior Vertical Transverse
1. 2. 3. 4. 5. 6. 7. 8. 9.
Nasomaxillary complex Maxillary alveolus Maxillary incisors Mandibular incisors Mandibular alveolus Ramus Body Symphysis Spheno-ethmoidal synchondrosis 10. Anterior cranial base 11. Spheno-occipital synchondrosis 12. Posterior cranial base
CLINICAL ASSESSMENT
A B
Kettles Method
Zero Meridian
Profile contour
Straight Convex
II
Max excess Mand def combination
Upper facial plane; Glabella to Subnasale Lower facial plane; Subnasale to Pogonion
Concave
III
Max def Mand excess combination
Crossbites
Displacement? Skeletal versus dental? Age?
RADIOGRAPHIC ASSESSMENT
ANB
Class I Class II Class III ANB 2-4 ANB > 4 ANB < 2
Eastman Correction
ANB assumes
SN is reliable Points A and B reflect basal bone Variation in position of Nasion affects SNA, SNB and therefore ANB
Wits Analysis
Compares maxilla and mandible to occlusal plane Drop perpendicular lines from points A and B Measure AO to BO Male -1mm Female 0mm
Ballard Conversion
Rotate the upper incisors to 109 Rotate lower incisors to 120 MMPA Residual OJ reflects underlying skeletal pattern
MMPA
MMPA
Ratio of posterior to anterior face heights Average value 27 +/- 4
LAFH
Max plane to Me x 100 MxPl to Me + MxPl to N Average value 55%
Jarabak ratio
Posterior face height(S Go) X 100 Anterior face height(N Me) < 59% 59-63% vertical growth neutral growth
> 63%
horizontal growth
TREATMENT
Treatment planning
Facial concerns Dentoalveolar compensation Influence of soft tissues Mechanics
Compensation High/low angle
Growth
Expected future growth Influence it?
Skeletal Class I
Treatable Be aware of vertical and transverse problems Eliminate any unfavourable soft tissue influences Soft tissue profile Dentoalveolar assessment
Degree of crowding Incisor protrusion
A-Pog line (Raleigh Williams) Aesthetic not for stability(Houston and Edler) Lower labial segment position (Mills)
Skeletal Class II
Where is the problem?
Prominent maxilla Retrognathic mandible Combination
Skeletal Class II
Mild, treatable Moderate
Growth modification Camouflage Associated vertical or transverse problems?
Severe
Usually orthodontic/surgical treatment
Common xl patterns
Finish to Class I molars
Upper 4s Lower 5s
Skeletal III
Mild, treatable especially if simple interceptive treatment GROWTH BEWARE. Can be very unpredictable Refer early for growth monitoring Treat once growth has slowed Treat upper only? Degree of dentoalveolar compensation
Compensated Class III
Proclined upper incisors retroclined lower incisors both
VME
Transverse problems
Displacement?
Eliminate
Tx options
Grinding premature contact in deciduous dentition Asymmetric XLs URA QH RME SARPE Functional Headgear Fixed Orthognathic surgery
Growth
Growth rotations;
reflection of differential growth between anterior and posterior face heights(Bjork 1955, 1969)
Backward
Type I Type II
Forward
Type I Type II Type III
Summary
Camouflage Too old for successful growth modification Mild/Moderate Class II Mild Class III Good alignment Average vertical proportions Avoid camouflage Still potential for growth modification Severe Class II or Class III Significant vertical discrepancy Severe crowding and protrusion Adults better managed with orthognathic surgery