A Treatment Approach to Malocclusions Under the Consideration of Craniofacial Dynamics Sadao SatoPreface Orthodontics had been established for two decades now. My involvement in the field of orthodontics is not only limited t6 clinical orthodontics. In fact, from the very start I had been fascinated with bone biochemistry. [realized that the only possible rescarch field that will likely conduct a dynamic bone research is the specialized field of orthodontics. This is so since consideration of the bone cells, phosphoric acid calcium crystallization, collagen and other bone proteins is of great relevance during the initial stage of treatment The bone tissue used to be regarded as a very static tissue where the adaptational activity is low. However, with the development of molecular biology, results showed that the bone is a very active tissue with a high adaptational capacity to the environment. This renders tooth movement is possible, However, clespite its high adaptational capacity to the environment, we are still faced with the problem of abnormal growth, During the 70°s, research studies reveal the importance of environmental factors in the growth of craniofacial skeleton, The adaptational capacity of the bones to the environment was seen to be the possible key After nearly a decade of clinical orthodontic, treated patients, including my own, started coming back for re-treatment. These patients, unfortunately, had recurrence of malocclusion and I wondered what went wrong with the treatment. Surprisingly, most of these patients had open bite tendencies. So I concluded that this is not simply relapse but rather a recurrence of malocclusion, Besides, these changes usually appeared after the termination of the pubertal growth stage. If the relapse of malocclusion is attributed to hereditary factors, why then did the changes not appear during the active growth period? This question looms in our minds. ‘The answer to this question appeared after examining the cephalometric Tadiogram and oral cavity, which showed that there was a problem of posterior discrepancy and vertical dimension of the posterior teeth. However, even though the problem has already been identified, we were lost with respect to the proper approach for the management of these problems. With the timely lecture of Dr. Young H. Kim, Thad a chance encounter with the MEAW treatment. Afterwards, I had the intuition that this could be it. The day following that lecture of Dr. Kim, I could vividly remember that Ihad started bending MEAW in the treatment room. In this book, a new approach to the treatment of malocclusion was presented based on the experiments done on most of the patients who had recurrence of malocclusion, the researches of Dr. Kim and his clinical experience that gave rise to the idea of MEAW technique, and my concept and method as well. Dr. Sadao Sato Associate Professor Department of Orthodontics Kanagawa Dental College September 1991Editor’s Note Marubranshu, the pupil of Dekaruto by chance saw a dog while walking with a friend along the street and says, “this is a machine named dog” and left. The dog upon seeing Marubranshu wagged its tail and ran away. The rest is a joke. The teacher, Dekaruto recognized the importance of intracerebral process and attributes it to the humanlike response of mental activity. The anatomist, Prof, Yoro, made further studies on this matter and affirmed that it is the result of the peripheral nervous system’s domination over the central nervous system. The concept that the stimulation of the central nervous system comes from the peripheral nervous system was introduced for the first time, This correlates with the established and dominating structural concept of “Periphery as the Center”. For instance in a cultural society, development does not necessarily mean progress from an uncivilized to a civilized society but rather they co-exist. This also goes with the importance of stimulation of the periphery to the central nervous system, The founder of structuralism, Louie Strauss, also insisted that the world consists of people with a mental culture of equality. Prof. Yoro tried to correlate this equality in the realm of nerves, but it turned out to be the opposite. In recent years, the author of this book, Dr. Sato, started re-treating his patients with open bite and mandibular protrusion, He investigated the cause of the relapse and determined the mechanism behind it. One reason is that itis related to the cranial base growth due to the enormous effect of the vomer to the growth and position of the maxilla. This makes is necessary to manage the occlusal condition, too. Another aspect is the discrepancy that causes supra-eruption of the molars resulting to the displacement of the mandible, and stimulating the remaining growth capacity, thus expanding the mandibular ramus. Dr. Sato had excellently explained the remarkable mandibular growth during the pubertal growth spurt. The concept on the primary ‘guidance of jaw morphology claims that mandibular protrusion develops when the mandible enlarges. However there is the new explanation which states that there are changes in jaw morphology caused by abnormal occiusal function, Dr. Sato was fortunate to have met Dr. Kim who authored the treatment using a multi-loop appliance where this concept was based With the data that has captivated the development of orthodontics, the existing treatment approaches based on the established philosophy proves to be inadequate. There are still numerous patients who still cannot help but rely on surgical operations These are the patients whom Dr, Sato intends to help, It is indeed my great fortune to be part of that endeavor by making me the editor of this book. Prof. Yoshii. Suzuki Professor Department of Orthodontics Kanagawa Dental College September 1991FOREWORD On this occasion of Dr. Sadao Sato’s publication, 1 sincerely compliment his superb production, In such a short period of time, he has published in the JOURNAL OF ORTHODONTIC PRACTICE seventeen monthly articles covering the theory of the craniofacial disharmony, the diagnosis and the treatment modality for dificult malocctusions. Certainly, these articles deserve a compilation so that many orthodontists can learn from them. The history of orthodontics, especially during the past three decades, has evolved through numerous, so-called philosophies, concepts and techniques. Among them, the techniques utilizing the edgewise principles have proven to be the everlasting method of treating malocclusions. However, under the concept of the edgewise principles, there are varieties of Diomechanical approaches. In a broad sense, there are two categories. The first approach is to customize the individual arch form and meet the demands of the individual requirement. And the other is to utilize highly commercialized and prefabricated archwires on all paticnts. The unfortunate part of the latter is that there are no two individuals who are exactly alike. And, therefore, a prefabricated product cannot be suitable to all patients. There are too many variations among individuals. Accordingly, the treatment must follow the customized concept to provide an utmost functional occlusion to the patient Whatever the treatment modality one may choose to follow, the importance of correct diagnosis cannot be overemphasized. ‘The dentition behaves according to the facial pattern. This very fact is often overlooked by many, and when a desired occlusion is not attainable, a surgical remedy is too frequently sought, ‘To treat complicated malocclusions, | have introduced the Multiloop Edgewise Archwire Technique over two decades ago, and Dr. Sato has revolutionized the concept. Now many orthodontists in Japan are utilizing the technique to obtain the utmost result of orthodontic treatment. With this diligent search for satisfactory answers to the orthodontic problems, he has produced an immense amount of information regarding many varieties of difficult malocelusions, and he has demonstrated superb treatment results utilizing the MEAW therapy. He even modified the mechanism to appropriately to mobilize the posterior teeth to quickly eliminate the crowded conditions. It seems that his imagination is endless and his never-ending effort will someday lead us to an even better understanding malocelusions. Young H. Kim, D.DS, DM.D.MS. Founder, President of + MEAW Technique and Research Foundation June, 1991 Boston, MA, USAFOREWORD Most people don't like CHANGE. We all have our comfort zones and most of us dare not do anything new. Approximately more than a quarter of a century ago, Dr. Young Kim introduced this strange-looking archwire with so many loops in it known as the Multiloop Edgewise Archwire (MEAW), originally designed for the treatment of open bite cases. Several years later, as he introduced this technique in different parts of the world, it has not only gained such great following but most significantly, a number of modifications and improvisations have evolved. And this | attribute to the endless pursuit of Professor Sadao Sato for clinical excellence, He has developed a new orthodontic treatment approach for various types of malocclusions such as skeletal Class [Il, mandibular lateral displacement, crowding, Class II (including high angle cases) and even TMS dysfunction cases. This treatment approach is not just based on techniques but more importantly based on the Dynamics of Craniofacial Skeleton Orthodontists have long been treating malocclusions as if it were a static entity; treating merely the symptoms and not the cause of malocclusion. This book will be an eye- opener for many for it clearly explains the developmental process of malocclusions and how to formulate the proper treatment objectives and provide the utmost functional occlusion to our patients. Whenever there is a paradigm shifl, there are always two groups formed: a group who will adapt to the change and a group who decides to be left behind. May this textbook revolutionize our orthodontic treatment methods and benefit not just ourselves but most of all, our patients as we make clinical excellence a common trait, Cynthia Protacio-Quismundo , DMD,FAPO President, MEAW Study Club of the Philippines Manila, Philippines February, 2001TABLE OF CONTENTS PART 1: THEORIES & PRINCIPLES Chapter 1. Dynamic Mechanism of the Craniofacial Skeleton esse tive Morphological Characteristics of the Craniofacial Skeleton in Skeletal Malocclusion...... 12 Dymamic Mechanism of Craniofacial Skeleton 4 The Dynamic Mectranism of the Neufocranial Base... 15, ‘The Dynamic System of Skeletal Sutures and Articulations 16 ‘The Importance of the Temporal Bone in the Dynamic ‘Mechanism of the Cranial Skeletal System 0 ‘The Growth of the Maxilla based on its Dynamic Mechanism v The Growth of the Maxilla According to the Flexion- Extension of the Cranial Base 19 Lateral Rotation of the Maxilla 2 Chapter 2. The Dynamic Mechanism of Craniofacial ‘Skeleton and Mandibular Growth Relationship of Heredity with the Growl of Craniofacial Skeleton 2B ‘The importance of Functional Environmental Factors . 23 Mandibular Movement and Growth 25 Relationship of Vertical Dimension with Mandibular Growti 1 Occlusal Function and Growth 28 Developmental Mechanism of Growth Abnormality... 30 Chapter 3. The Role of Posterior Di Development of Skeletal Malocetw 3 Discrepancy and Malocclusion 3 The Meaning of Posterior Discrepancy 34 Feedback Regulatory Mechanism in the Development ‘of Skeletal Maloeclusion 38 Feedbacks Regulatory Mechanism in the Development ‘of Mandibular Mesiocclusion 38 Dental Compensation ~The erroneous concept of Dental ‘Compensation 4 Feedback Regulatory Mechanism in Mandibular Distocelusion 4B Chapter 4. Occlusal Plane and Functional Occlusion ... 44 ‘Orthodontics and Functional Ocelusion 44 Dynamic Mechanism of the Maxillofacial Skeieion and Ocelasion 4s Functional Occlusion and Occlusal Piane 50 Molar Interference and Posterior Discrepancy 31 ‘Occlusal Plane and Mandibntae Position 31 Chapter 5. The Characteristics of Malocclusion and the Morphological Types of the Craniofacial Skeleton .. 36 Occlusal Plane and Denture Frame Morphology 56 ‘The Basis of Harmonious Denture Frame Morphology - 56 Occlusal Plane of an Individual with Normal Occlusion : 59 Effect of the Changes of Occlusal Plane on the Denture Frame 39 Orthodontic Approach to Denture Frame 61 Denture Frame Analysis 61 FH-MP, a PP-MP “ OP-MP a OP-MP/PP-ME.. 66 AB-MP 6 AUP 66 Ars 67 AIA” o Denture Frame of the Upper and Lower Anterior Teeth ‘and the Measurement of the Relationship of Tipping, and Position of the Molar or Tooth Material 68 ‘Types of Craniofacial Skeleton and Malocclusion ...... 69 Hyperdivergent-Mesio.ocelusion Type 9 iypodiversent- Mesio-Ovelusion Type © Hyperdivergent-Disto-Ocelusion Type 8 Hypodlivergent-Disto-Occlusion Type im Chapter 6, Diagnosis of Malocelusion .... 2 Dental Examination of Anterior Guidance n Relationship of the Occlusal Paue and Incisal Path Inclination 73 Examination of Mandibular Position 8 Reference Position (RP) 9 Ingereuspal Position (ICP) » ‘Therapeutic Reference Position (TRP) Mandibular Position as the Treatment Objective .. 79 ‘Therapeutic End Position (TEP) 3 Examination of Posterior Support 8 Examination of Posterior Guidance 3 Characteristies 85 Quality a5 Quantity 85 Symmetry 86 Tnelination 86 Reproducibility 86 Retrat Stability 86 Clicking or Noise 86 Ligament Situation 86 Muscle Problem 7 Chapter 7. Diagnosis af Discrepancy .. Discrepancy and Malocclusion Disadvantages of 4 General Consileration of DiserepaneyOcclusal Problems Caused By Discrepancy 9 Crowding and Mesial Tipping of Molars coe 89 Procrusion of Tet 90 Impacted Tooth and Difficulty of Eruption... 90 ‘Supraeruption of Teeth... B Clinical Examination of Posterior Discrepancy 94 Chapter 8, Orthodontic Treatment and Tooth Extraction 101 Imponance of Tooth Extraction in Orthodontic ‘Treatment 101 Disadvantages of Premolar Extraction 102 Advantages of Malar Extraction in Orthodontic Treatment 104 Extraction of 1* Molar 105 Extraction of 2 Molar 106 Extraction of 3 Molar 106 Early Extraction of Lower 3° Molar Toot Gem (Germectomy} 110 Chapter 9. Objective of Orthodontic Treatment and Its Guiding Principles mM Te Objective of Orthodontic Treament a ‘Treatment Objectives Based on the Dynamics of the ‘Craniofaciat Skeleton ui Flexion Position - Low Angle ML Flexion Poition - High Angle .... 113 Extension Position - Low Angle 13 Extension Position - High Angle n3 Reconsiruction of Occlusal Plane 4 Relationship of Vertical Dimension with Mandibular Position ug Relationship of Ocelusal Support with TM! no Relapse and Loss of Occlusal Support 120 PART 2: CLINICAL Chapter 1.The Use of MOAW, MEAW and DAW in ‘Occlusal Reconstruction. Modified Otet Archwire (MOAW) Muliloop Edgewise Archwite(MEAW). Double Archwire (DAW) Chopter 2, Occlusal Reconstruction in Skeletal Clas IHL Maloeclusion . : Treatment Objective Skeletal Clee Ill Maloeshsion 136 ‘Treatment Procedure for Skeletal Class HIE Malocelusion 136 Clinical Case #1 141 Clinical Case #2 M48 Chapter 3, Ocelusal Reconstruction in Open Bite so. 153 ‘Similarity in the Development of Skeletal Class I) and ‘Open Bite Malocelusions 153 ‘Treatment Onjective in Open Bite 137 CCinical Case #1 138 Clinical Case #2 164 Chapter 4, Occlusal Reconstruction in Skeletal Class 1H ‘Open Bite. 168 Treatment Plan for Skeletal Class Il Open Bite 168, eal Case #1 i 1 Clinical Case #2. 8 Clinical Case #3 183 Chapter 5, Occlusal Recoastruction of Mandibular Lateral Diacement (MLD), 19 ‘The Developmental Process of Skeletal MLD 190 Occlusal Reonstryetion of MLD... won 194 Clinial Case #1 196 Clinical Case #2 203 Chapter 6, Occlusal Reconstruction of Crowding Treatment Plan for Crowding ‘Treatment Procedare for Crowding Clinical Case #1 Clinical Case #2 Clinical Case #3 Chapter 7. Occlusal Reconstruction of Mandibular Distocelusion +230 Teeatment Objective for Mandibular Distocelusion 234 Effectivess of the Deuble Archwire (DAW), 231 Clinical Case #1 234 Clinical Case #2 239 Chapter 8. Occlusal Reconstruction of Malocehusion with Associated TMJ Disorder « ‘The Relationship of Premolar Extraction with TMI Arthrosis 246 Lingual Tipping of Maxillary Anterior 246 246 Load to the TM) due to Loss of Occlusal Support 247 Incerference in the Molar Area Due w Posterior Discrepancy 27 ‘Treatment Objective in Malocelusions with TMI Arthrosis.... 247 Clinical Case #1 249 Chinicak,Case 42 237 APPENDIX. 265 {(, Molat Supraeruption in Posterior Discrepancy/2. Relation ship of Cranial Base Movornent ard Palatal Plane Tipping)’. Relationship of Maxillaskeletal inorphology and Occlusal Plane! 4. How to Make & DAW, Recoastruction of Occlusal Plane Showing Sudden Tipping/6, Adjunctive Appliance for Dental ‘Archi Expansion) BIBLIOGRAPHY 2m INDEX 215-278 SUMMARY ABOUT THE AUTHOR 280PART 1: THEORIES AND PRINCIPLES 1. Dynamic Mechanism of the Craniofacial Skeleton 4 2.The Dynami Mechanism of Craniofacial Skeleton and Mandibular Growth 2 3. The Role of Posterior Discrepancy in the Development of Skeletal Malacclusion 33 4, Occlusal Plane and Functional Occlusion 44 5. The Characteristics of Malocciusion and the Morphological Types of Craniofacial Skeleton 56 6 Diagnosis of Malocclusion 2 7. Diagnosis of Discrepancy 88 8, Orthodontic Treatment and Tooth Extraction 101 8. Objective of Orthodontic Treatment and its Guiding Principles at1. THE DYNAMIC MECHANISM OF THE CRANIOFACIAL SKELETON Introduction Dental medicine revolves around the study of occlusion. The basis of occlusion is not simply the interdigitation of the aligned teeth in both the upper and lower jaws, but a combination of their positional relationship and the functional movement of the mandible, This is controlled by a complicated system of functional elements, i.e. the masticatory muscles, neuromuscular system, ‘TMJ function etc., which serve as a basis of dental treatment. Orthodontics, a branch of dental medicine, constructs an occlusion by correcting malaligned teeth. in Prosthodontics, re- contouring of tooth crowns, as the primary measure in bite construction, is an important approach in improving malocclusion. Therefore, in clinical practice, especially in orthodontics, it is very necessary to fully understand the physiology of occtusal function and the biology of tooth movement. However, these important topics are not sufficiently tackled so far in orthodontics Looking at its history, the development of orthodontics tends to focus more on orthodontic, appliances and their improvement. With technology, as the focal point of therapeutic advancement, the treatment effects on malocclusion has certainly improved and its ation has expanded. Nevertheless, numerous contradictions have come about as a result of mere technological advancement. The orthodontic approach seems to have been isolated from the basics of dental medicine (i.e. physiology of occlusal function, biology of tooth movement etc.), enclosing itself in a specialized field. ‘The orthodontic advancement in the pastfailed to give attention to the causes of malocclusion and mechanism of its development. ‘The introduction of cephalometric radiography for orthodontic diagnosis has certainly played a significant role in understanding malocclusion. However, it does not clearly show the cause of malocclusion, It only localizes the site of skeletal malocclusion and shows the degree of displacement, The elimination of the cause is an indispensable factor in the radical treatment method and with this, stable results can be obtained. With the current orthodontics, it is simply the identification and the treatment of the symptoms, and not the cause. Moreover, the current orthodontic therapy has insufficient therapeutic objectives. To improve the facial profile as a treatment objective, orthodontics can obtain results as if it were a section of cosmetic orthopedic surgery. Of course, in managing the maxillofacial area, the relevance in the improvement of facial profile must not be neglected, but this cannot be the ultimate treatment objective in orthodontics. As mentioned earlier, occlusal construction is one of the effective approaches in orthodontic therapy. However as a treatment objective, the basic guideline and an established therapeutic technique as to which type of occlusion has to be managed is still non- existent. And the time has come to re-evaluate orthodontic therapy. Since the Angle’s expansion arch appliance, various improvements have been imroduced in the evolution of the current full bracket system, From a mechanical standpoint it is believed to be an adequate accomplishment. However, why are there still a number of patients who are difficult to treat? Why does malocclusion recur post treatment? Does this mean that serious errors were committed in the development of ‘occlusal treatment? As numerous improvementsare being made, the current treatment approach has become too complicated. This is perhaps, due to the unpredictable results obtained by symptomatic treatment based on a. less accurate diagnosis (ic. only the identification of symptoms). Orthodontic occlusal construction is one of the important measures in occlusal therapy and should be widely used in dental medicine. However, this does not reconcile with the concerns of present orthodontics as the contradiction is evident from its new standpoint Hence, new treatment objectives and techniques need to be introduced. In this book, the dynamic mechanism of the bones of the maxillofacial skeleton and the mechanism of the development of malocclusion will be clearly discussed. On this basis, the diagnosis, treatment objective, and treatment techniques for orthodontic occlusal construction, will also be explained. Distinctive Morphological Characteristics of the Craniofacial Skeleton in Skeletal Malocclusion Most malocclusions are simply the manifestations of an abnormality in the alveolar bone and dentition as well as growth abnormality of a bone associated with a disproportion of the skeletal morphology . The latter type, classified as skeletal malocclusion is considered to be an extremely difficult orthodontic case . Even though the diagnosis of malocclusion is confined only to the teeth and alveolar structures, the absence of skeletal discrepancy cannot be confirmed. It is because the functional abnormality of occlusion extremely affects the maxillofacial skeleton and the entire skeletal system due to the dynamic iz mecha ism of skeletal and neuromuscular systems. This only means that skeletal discrepancy can be considered to invariably co-exist with malocclusion. And it is basically important to understand the skeletal characteristics of each malocclusion and the mechanism of its development in correcting a malocclusion, Since Downs, cephalometric radiogram was used in case analysis to find out the static symmetry or asymmetry of the maxillofacial skeleton. This in turn, led to the diagnosis of malocclusion. However, with this type of analysis, alone, itis difficult to recognize the development of the skeletal characteristics, and the changes that would occur from then on. Besides, ironic the findings maybe, the most important thing in orthodontic diagnosis is that all the bones of the maxillofacial skeleton can be dynamically captured from the static cephalometric radiogram. Figure 1 shows the cephalometric radiogram of the facial profile of the skeletal Class III and skeletal Class Il malocclusions. Chart | also shows the morphological characteristics of the same malocclusions. Though both patients of Figure L are 22 years old, they have a remarkable morphological difference as shown in their respective typical characteristics. How did these skeletal morphological differences develop remarkably? The mechanism in the development of malocclusion and the diagnosis of orthodontic malocclusion are considered to be extremely important in making an occlusal construction plan. There seems to be a problem when these morphological characteristics are simply presumed as growth abnormality or individual differences. It is because these characteristics resulted actually from the adaptation to physiological and functional demands during theprocess of growth and development. Figure 2 is an illustration that shows the interaction of the bones that comprises the maxillofacial skeleton, The maxillofacial skeleton hhas a complicated bone interaction and consists, of their respective movements, During the growth period of an individual, the mobility of each bone is extensive especially that the interosseous suture is mostly open. According to Hooper (1985), the movement of the bones that constitute the face and the neurocranium depends on the mutual articulating action of a bone and the adjacent bone 1, Dynamic Mechanism ofthe Craiofsial Skeleton igure 1. Morpologial characterises of skeletal mandiFular mesiocehsion a skeletal manditular istoccusion ofthe maxillofeal skeleton as shown fn he cephalometric racogrem, 2. skeletal mandibular mesloccasion bskelea! mandihulardisoectusion| Bodh are 22 yeas old. Observe net only the maxilla, mandibular positon, ‘morphology, but also the neurocranial base which corstitues the ethno Tame, sphenoid bone, the location and size ofthe expt bone, morphology ofthe mally sas ae prerygopataine fess, Vora dimension, exclusal Plane, and the characteristics of the whole maxillofacial skeleton, There is remarkable diference especially in the vertical dimension wih the vertical length of he maxiloacial skeleton. The skeletal growth pater inthe growth roces leads this direction heeause ofthe fupedonal demands (Fig. 3). The most important articulation in the skull, excluding the TMJ, is the sphenobasilar articulation because it has a dynamic movement. There is no concrescence in this attachment from the carly stage of growth until its maturity thus its articulating action persists. Looking at this BSkeletal Mandibular Skeletal Mandibular Mesiocelusion Distocelusion Anterior cranial base length short long Posterior cranial base length short long Cranial angle (NSBa) small large Anterior cranial angle (NSP) Posterior cranial angle (PSBa) small large Morphology of pterygopalatine fossa straight curve Floor of maxillary sinus low high Floor of nasal cavity deformed flat Palatal plane (PP) anterior tipping posterior tipping Anteroposterior dm, of maxilla (A’-P) short long Ht, from OP to PP long short Occlusal plane flat posteriorsudden tipping Anteroposterior dm, of mandible (Co-Gn) ong, short ‘Axis of maxillary anterior teeth labial tipping - Axis of mandibular anterior teeth lingual tipping labial tipping Chart 1. Characteristics of skeletal mandibular mesiooclusion and skeletal mandibular dso from a cross-sectional angle, there is no concrescence in the articular surface between the sphenoid and occipital bone where these interact. Evident in Figure 2, the movement of the sphenoid bon, which is located at the center of the skull also affects the other bones comprising the maxillofacial skeleton, making up the whole dynamic mechanism. Dynamic Mechanism of Craniofacial Skeleton The dynamic mechanism of the craniofacial skeleton can be discussed in detail under the ‘osteopathic field where cranial bone correction is mainly managed. According to the cranial concept in osteopathy, the articulating action of 4 juston ofthe maxillofacial skeleton the cranial sutures in the maxillofacial skeleton depends on the primary respiratory mechanism (includes the resting phase of respiration, heart rate, fluctuation of cerebrospinal fluid) and functions according to the rythmic impulse of the intracranium. An abnormal interactive movement between these bones will develop, in case that during the developmental period, the harmony of the movement of these bones is not preserved. A change in the growth pattern may result. Another cranial bone function is its important influence on occlusion and mastication. Mastication comprises the mandibular movement, Which is regulated by the neuromuscular system. ‘Needless to say, that the mandible is connectedapts me —~ hietie ee os &f wy aren Figure 2. Group of bones tat comprises the manitucal skelewn. Arcalaions are formed though a stue a cartilage, between a bone and the adjacent bose, dynamically relating 19 each otter. A bane ‘communicates withthe aljacent bone, and the later bone willommanicate tothe next one creating the whole dyramic mechanism, This dysamic ‘mechartm has a great inluence on the grow pattern of an ivi uri the pros peri, which brings abet the morphological eatres ofthe maxillofacial skeleton. (nthe ilusteation, infcior nasal conch, lacrimal bone, and hyoid bone were exclu) to the skull through the TMJ, which shows that it has the most important function among the cranial bones. In addition, it plays an important role in occlusion and has a great influence on the functional movement of the skull, Moreover, thefluctuation transmitted from the mandible through the temporal bone has an influence on the movement of the skull, Now, let us further 1, Dynamic Mestanism of the Craniofacial Skeleon Toupee Oe Ei boi a CRBNOm™ | Sneoid bond Frou bone / es vy LPN G7 ROM \ ty hy ee OF Figure 3. Correlation ofthe bones comprising the neurocra a. neurceranil base observe from the ventral viewsagit the neuroerarial bas, the communication of eins Doe, spend bone and oecpitl bone trough an articulation, the sphenotemporl artic nd the oceipitotemporal artiewation ar lated betwen the rexpestive sutures the temporal spend, and occipital bones. discuss the movement of the cranial bones. ‘The Dynamic Mechanism of the Neurocranial Base In understanding the function of cranial bones, itis imperative to touch on the concept of dynamic mechanism of the neurocranial base which are the Cranial Concept (Hooper, 1986) and Cranial Motion (Blum, 1958, 1987). Needless to say that the neurocranial base consists of a series of connected bones which are the frontal, ethmoid, sphenoid, and occipital bones (Figure 3). A suture lies between each bone to connect 15them and the part where a biodynamic force is obtained and a sudden growth is seen is the so- called articulation. In the neurocranial base, the ethmosphenoidal, intersphenoidal and sphenobasilar articulations can be found. Among, these, intersphenoidal articulation fuses and becomes one at birth, but there is no conerescence on the sphenoethmoidal articulation until 7-8 y.o. Also, sphenobasilar articulation fuses at about 18-20 years old and the articulation persists and the aspect of a dynamic mechanism is shown here. In other words, the developing articulation functions to mediate the difference in the growth condition of the neurocranium with the craniofacial skeleton after birth. In addition, it copes with the changing mechanical force from the craniofacial skeleton through its articulating, action after birth, and preserves the harmony of the whole craniofacial base through the rotation of the cranial base and intraosseous tissue movement (Figure 4) ‘The Dynamic System of Skeletal Sutures and Articulations The articulating action of skeletal sutures is explained by numerous researchers like Blum (1985), McElhaney et. al. (1970), Wood (1971). The movement of the skeletal suture usually corresponds to the biodynamic force and primary respiration, and regulates the movement of the connecting bones through its articulating action. ‘This means that the skeletal sutures function as a hinge -of the connecting bones (Markens & Oudhof, 1980). ‘The cranial bones are very dynamic bones usually interacting with the skeletal sutures. The cranial base slides repetitively, consistently coping 16 Figure 4, Movements of the Occipital and Sphenoid Bones b "The * represents the rotating center he sphenoid apc occipital move- Flexion Extensiona Dyess tite rete with the dynamics of respiration, heart function, and the pressure of the cerebrospinal fluid (Retzlaff, 1972, 1975, 1977, 1983) Moreover, the functional force originating from the occlusal function through the action of masticatory muscles is transmitted to the temporal bone through the TMJ, which influences the group of bones that consists the cranial base, a dynamic movement that constantly occurs.Among the skeletal sutures, the parts that have a very important articulating action are the occipitomastoid region, the suture between the pyramidal base of the temporal bone, and the sphenobasilar articulation (Hooper 1986, Blum 1987) According to Hooper, the fashion of the neurocranial movement is classified into two types as shown in Figure 4, which is flexion and extension. ‘The sphenobasilar articulation is the most fundamental articulating suture among the cranial bones and it is where the movement of flexion-extension occurs. Among the functions of the maxillofacial skeleton, mastication, the most important biodynamical function, is transmitted to the entire craniofacial skeleton as a masticatory force, causing an effect on the dynamic movement of the cranial base. The Importance of the Temporal Bone in the Dynamic Mechanism of the Cranial Skeletal System In the dynamic mechanism of the cranial skeleton, the temporal bone holds the most important role among the maxillofacial bones due to.the following reasons. Looking at its anatomical position, the temporal bone is located between the sphenoid, occipital and the parietal bone (Figure 3). In the external part forms the zygomatotemporal process attached to the zygomatic arch. The zygomatic process forms the hollow space called mandibular fossa, forming the mandibular and maxillary joints. A muscular mechanical force is obtained with the unity of the functions of the forceful masticatory muscles (masseter muscle, temporal muscle). In addition, the temporal bone usually functions through the influence of mechanical force related to mandibular movement, mastication etc. The temporal bone affects the rotating movement of the sphenotemporal articulation, which is formed between the temporal and sphenoid bones, and the temporo-occipital articulation, which is formed between the temporal and occipital bones. The temporal bone itself, rotates in the petrotemporal axis of the pyramidical part. The results obtained with the occlusion in recent orthodontics or prosthetic construction bite is that the whole facial bone is secondarily affected once themandibular movement is transmitted to the temporal bone The Growth of the Maxilla based on its Dynamic Mechanism As mentioned earlier, the maxillofacial skeleton is always understood as a complex of extremely dynamic bones, This dynamic mechanism has a surprising effect on skeletal growth. The importance of the dynamic aspect of the maxilla in orthodontics will now be the focus of the discussion The maxilla, where the maxillary sinus is located, has 4 external processes, which are the frontal, zygomatic, palatal, and alveolar processes. The alveolar process accommodates 7every tooth in the maxilla forming the upper dental arch creating an occlusion with the lower dental arch. The frontal process and zygomatic process. forms a joint with the frontal, nasal and zygomatic ones, etc., respectively. On the other hand, the palatal process forms a joint with the palatal process of the opposite side. This attachment site of the palatal process is the median palatal suture, a protuberance along the surface of the nasal cavity, forming the nasal crest. The inferior border of the vomer attaches to the nasal crest, forming a joint. Moreover, the vomer is formed between the neurocranial base and the maxilla as a support (Figure 5), and transmits the important movement of cranial base to the maxilla. Once the superior surface of the vomer is exposed (vomer wing), & joint is formed between the inferior surface and rostrum of the sphenoid bone. Based on this structure, it is easy to understand that the movement of the sphenoid bone is transmitted to the palatine bone and maxilla through the vomer. Also, the inferior border of vomer transmits the growth pressure of the nasal septum and movement of the ethmoid bone, which is connected to the ethmoid perpendicular plate and the nasal septum cartilage, to the maxilla. However, the movement of the sphenoid bone is indirectly transmitted to the mandible because the anterior border of the median layer of the sphenopterygoid process is connected to the vertical process of the palatine bone. As described above, the maxilla moves anteroinferiorly when the movement of the ethmoid, sphenoid and occipital bones etc. is exhibited, consequently inducing a growth in the suture part of the maxilla 18 Figure §, Movementof the neuocraial tas andthe prowth direction of ttemaxila 3 The moverent of every bone of the neuroeranial base is coming from the vor rans fo the maxi Anteronferior movement of the naxilla allows moderate exension of Ue “pheoid bone, activating fresh steogeresis ofthe mixlary tuberosity ine poxerior border, expanding the ociptofontal dlameter ofthe rani:______. yamic techn of the Cranial Skeleton Figure 6 Relationship inthe growth direction ofthe a. When the eceptal ase movements ene lla athe sphenn-ceipal bone lesion extension the mila pushed anteroinferiorly duet he sphenopterygid process and vom rotation When the cranial base movements flexion, the manila is strong psi inferiorly: thus the acypttronal size of the manlla has a minimal increas. The Growth of the Maxilla According to the Flexion-Extension of the Cranial Base The rotating movement of the neurocranial base is at the spheno-occipital articulation. The rotating axes of the sphenoid and occipital bones are the anterior of sella turcica and the posterior of major occipital foramen respectively (Figure 4). The rotating movement of the sphenoid bone is transmitted to the mandible through the vomer, which results to the anteroinferior pushing of the maxilla (Figure 5). The vomer has a direct effect Totating axes of the sphenoid and occipital bones are the anterior of sella turcica and the posterior of major occipital foramen respectively (Figure 4). The rotating movement of the sphenoid bone 19Three types of maxillary movement (Precious et al., 1987) 4, Translation with the frontal bone ‘Figure 7 An llstration ofthe growth patterns ofthe maxilla, oe 2, Vertical elongation 3, Anterior rotation, which both advances and elongates the inferior part of the maxilla “The growth per ofthe maxilla lassi ino tree and each growth pattern closely related wo the development of malechsion. is transmitted to the mandible through the vomer, ‘which results to the anteroinferior pushing of the maxilla (Figure 5). The vomner has a direct effect on the rotation of the sphenoid since the sphenoid and vomer are communicating with the rostrum of the inferior surface of sphenoid and the wing of vomer. In addition, the rotating movement of the sphenoid bore is indirectly transmitted to the maxilla because the inferior border of vomer is connected to the maxillopalatine process and the nasal crest of the palatine horizontal plate (Figure 6). This is how the movement of cranial bones affects the maxilla especially when the pushing direction of maxilla changes related to the rotating 20 direction of the neurocranial base, for which this would indicate the growth of the maxilla. For example, when the rotation of the sphenoid bone is flexion, this would influence the rotating force of the wing of vomer, which is posteroinferior, preventing the pushing of the maxilla anteriorly, instead it will move inferiorly. On the contrary, when the rotation of the sphenoid bone is extension, the rotation of the vomer would be anterior, and the maxilla will be strongly pushed anteriorly. In the pushing movement of the maxilla, it gives enough space in the posterior part of the upper teeth, allowing the growth of the posterior border of the maxillary tuberosity (Ross, Enlow).—_.vT77_———— & Pymumic techni ofthe CranioficitSteteton Figure 8. Anilustation of the maxillary lateral tation 8 External rotation b. Internal rotation. Tai ype of Intra eoaton has great effect on the eng and wid ofthe maxillary teh Scott (1960) considered that maxillary growth is due to maxillary movement, which is dependent on the growth of the nasal septum cartilage and secondarily due to the growth of the skeletal suture. However, it is extremely difficult to explain the pushing movement of the maxilla due to the growth of the nasal septum cartilage alone, which is communicating with the perpendicular plate of sphenoid and anterior border of vomer. ‘When the growth of the nasal septum cartilage has an effect on the pushing movement of the maxilla, looking from its anatomical position, it affects the movement of the maxilla towards the superior, inferior and vertical direction. In terms of the protrusive movement of the maxilla, it is absolutely difficult to explain this movement of the maxilla without the influence of the rotating movement of the sphenoid. At this point, Very necessary to touch on an important matter that is quite significant in the field of orthodontics, And this is the flexion of the neurocranial base which is becoming a very relevant phenomenon in the development of skeletal reversed occlusion. The posterior cranial base length of a patient with a skeletal reversed occlusion is short, the cranial angle is small, and the anterior maxillary growth is poor. This is due to the neurocranial base flexion position, In the prolonged flexion position of the neurocranial base, the anteroposterior growth of the sphenobasilar articulation and the extension of the sphenoid and occipital bones is inhibited resulting (0 a short posterior cranial base length and small cranial angle. Additionally, the inhibition of the maxillary tuberosity growth related to the anterior movement of the maxilla aggravates the posterior discrepancy and this has a serious effect (on the occlusal system (Appendix 2). According to Precious et. al. (1987), maxillary growth has basically three patterns as 21growth patterns is possible These patterns, looking from the dynamic mechanism of the skull, resulted from the anterior rotation of the vomer due to the elongation of the maxilla resulting to the protrusive maxillary movement with frontomaxillary suture as the fulcrum In this case of mazullary rotation, the anterosuperior tipping of the palatal surface becomes strong, and the Jabial tipping becomes visible in the anterior teeth, of themaxilla Moreover, the occipito-frontal Gtameter of the maaulla increases because of an extensive growth of its posterior part creating an eruption space for the molars. ‘On the other hand, inferior movement of the maxilla 1s due to the posteroinferior rotation of the vomer telated to the flexion of the cranial base In this case, the anteromnferior tipping in the palatal surface is visible, and there is not much, room for the tooth to gain space because the occipitofrontal diameter of the maxilla does not, increase In other words, thts reveals discrepancy. Lateral Rotation of the Maxilla Maxillary movement 15 mot only anteromferior, but 1 also laterally rotates. AS shown in Figure 8, the lateral rotations of the maxilla are anternal and external. In the internal rotation, the incisive bone 1s pushed anteriorly because the length and width of the dental arch are increased and decreased respectively (Figure 9). This also makes the palate deep and this can bbe generally interpreted as Class 1] Division 1 maloceiusion. On the other hand, external rotation of the maxilla decreases the length and increases the width of the dental arch, creating a shallow palate, These characteristics are eviclent ina patient with skeletal reversed occlusion. The development ‘of numerous malocelusions 1s completely related to this dynamic mechanism of the maxilla 22 FFagure9 The corrlayon ofthe morphology with te Inteal route of the mle 2 legratrottonb Ester rctaon~ he characterises ad morpblegy lott ental arc eerved in malay prerasion apd evesed oLsion ‘dv (os ype oF madary mavernent2. THE DYNAMIC MECHANISM OF CRANIOFACIAL SKELETON AND MANDIBULAR GROWTH Relationship of Heredity with the Growth of Craniofacial Skeleton Before even considering the discussion of craniofacial growth, it is important to be historically acquainted with the concepts related to the regions of its growth. The basic skeletal research related to the concept of this growth region started in 1940, and was revised ten years later (Carlson, 1985) With the old concept, the growth of the craniofacial skeleton was believed to be related to heredity (Charles, 1925), and not due to environmental factors, as seen from numerous cranial bone research studies (Figure 1) Therefore, artificial alteration of the growth pattern of the craniofacial skeleton was considered impossible then, Sicher (1947) is perhaps the first researcher to present a clear concept of the mechanism of craniofacial growth. The sutural dominance theory, which he authored , states that the growth of the craniofacial skeleton is in the growth of the skeletal sutures where the growth center is the cartilage Jocated in the neurocranial base, nasal septum, and the mandibular condyle ete. This growth is thought to be due to heredity and very less attributed to environmental factors. However, Scott (1953) believed that the growth of skeletal sutures is not controlled by heredity alone, but rather, itis greatly influenced by environmental factors, though there was a strong concept that the cartilage or periosteal growth is clearly influenced by hereditary factors. ‘This matter was subsequently mentioned by Courtesy et. al. (1968). Nevertheless, Scott, like Sicher, believed that the craniofacial cartilage is the primary growth center, especially the nasal septum cartilage, which has a major role in the anteroinferior growth of the maxilla, Actually, this type of concept raised a serious question then, It is because the growth of the nasal septum cartilage horizontally and vertically expands the middle third of the face, thereby regulating the craniofacial growth. Though this is influenced by heredity, chiefly between gestation to several years after birth, it is becoming apparent that the growth of the tooth and alveolar part, muscle function etc., is influenced by environmental factors. The Importance of Functional Environmental Factors In the 1950's, research studies, using animal subjects, have increased which elucidated the ‘mechanism of craniofacial growth. After 1960, a number of theories were presented based on the results of these research studies. The Moss (1962) functional matrix theory, in particular, is the one that has the most relevant concept. The influence of this concept to the 231940 1950 1970 1980 1990 (Genes Frederica, Neuse Mader conte merous crnvet ‘ne rescue, stakes Pesos ‘Skeletal sone Corelanon of | ‘igure 1 Tramsiton of he craniofacial skeletal growth theories rea » ) | J i | | | Sa Mintivtar conse ‘The mailofocilselets| posenor higher deer tapi | "Theol concept ofthe craniofacial growth as gradually changed, and te importance of funcional environmental factor was recognized, (Vistas in “ortnodoatis, Carson) development of clinical orthodontics and to researchers is immeasurable. ‘A very good example of the cranial bone growth is explained in the functional matrix theory, The growth in the cranial suture is not only due to the external expansion of the suture. ‘This could also be due to the capacity of the brain to expand, creating a translation in the spatial 24 position of the cranial bones, consequently proliferating the connective tissue, creating a transformation, resulting to the expansion of the whole cranium. This is not only attributed to the relationship of the skull and brain, but also due to the orbital and ocular relationship, or the maxilla and maxillary sinus relationship ete. Moss, in thesae ee ret functional matrix theory, generalized that the organs, cavity, sinuses etc, affect skeletal growth The basic concept of functional matrix theory is that, the Jocal functional environmental factors have extensive roles in the growth of the craniofacial skeleton. The paradigm shift in relation to craniofacial growth spontaneously changed the mandibular growth concept. Among the bones of the craniofacial skeleton, it is the mandibular growth that has the most serious concern for orthodontists. Mandibular Movement and Growth Among the bones of the maxillofacial skeleton, the mandible is the only bone that has the voluntary and the most extensive movement In order to understand the movement of this bone, it is necessary to comprehend the occlusal function and neuromuscular system. An articulation (TMJ) is formed between the mandible and the temporomandibular fossa, and its movement has a great influence on occlusion. ‘The relationship of mandibular movement with occlusal function or mandibular position will be examined especially the relationship of the changes of occlusal system with mandibular growth. As mentioned earlier, the studies in the 1950°s showed that environmental factors have a greater influence than hereditary factors in the growth of skeletal sutures and periosteum etc. according to Moss. This gave Moss the opportunity to determine whether this is closely related to skeletal growth and function through the functional matrix theory. In the 1960’s, several researchers of craniofacial growth accepted the functional matrix 2 Dynamic Mechanism of Craniofacial Sklcto znd manibular growth interests were diverted to mandibular growth, its function and functional relationship. Petrovic, Carlson, McNamara, Woodside et. al., are just few of the various researchers who reported, using functional appliance on animals as clinical subjects. This studies showed the possibility that the growth pattern of the mandible can be changed since its growth is related to its function, Petrovie (1975) comprehensively studied the factors affecting the growth of the craniofacial skeleton, As a result, he reported on the cybernetic model of mandibular growth with the concept of Moss as his basis. The most important point in the cybernetic model is that occlusal function is an important factor in mandibular growth, The anteroinferior displacement of the maxilla directs the mandibular growth adaptation, In the cybernetic model, the functional factor that regulates mandibular growth is “occlusal function”. It is important since it serves as a functional matrix The cybernetic model of Petrovic can be simplified into the manner shown in Figure 2. The most important local factor in the control of mandibular growth is the occlusal surface and spatial position of the maxilla the maxillary dental arch, The occlusal movement of the mandible, which is in the occlusal surface, is dependent on the action of the central nervous system and masticatory muscles. The anteroinferior growth of the’ maxilla functionally shifts the mandible, making the TMJ adjust to the new mandibular position; which leads to mandibular remodelling or growth, Hormones also influence the growth of the mandible and mandibular condyle ‘The most important point in this concept is that mandibular growth is not only controlled by the endocrine system and its growth potential but 25a ee ee ‘Temporal bone Vy. eenittens igure 3, Relationship of the mandible, temporal an sphenoi! tae observes fromthe frmml view: ‘The functional dsplacerment of the mandible afees the newrocranial base ough the rotation ofthe temporal one. Trough ths system, the dyamic ‘mechanism of oclusal funciona facial skeleton i closely related also, the position of the occlusal surface of the maxillary teeth (functional occlusal plane) to which the mandible is functionally related with. For instance, in a patient where the maxilla vertically descends, the functional occlusal surface will change (0 an inferior position Consequently, the mandible will move inferiorly and elongate vertically. ‘The adaptation to the new mandibular position, is not simply due to mandibular growth and TMJ remodelling. But it is also affected by the functional force from the mandible to the 2 Dynamic Mechanism of Craniofical Skeleton and manila growth temporal bone through the joint cavity, masseter muscle, changes in the traction force from the temporal muscles to the temporal bone, movement or rotation of the temporal bone (Figure 3) In addition, the tension of the medial and lateral pterygoid process, which is related to the positional change of the mandible, affects the rotation of the sphenoid bone. As mentioned earlier, the sphenoid bone movement changes the maxillary movement and vert’cal position through the vomer. A change in the mandibular position due to occlusion controls the harmony of the whole craniofacial skeleton. ‘The occlusal function and the craniofacial skeleton are closely related, creating a whole dynamic mechanism, The balance of this dynamic mechanism has a great influence on the growth of the maxillofacial skeleton in actively-growing infants. Therefore, orthodontic occlusal treatment is not simply the alteration of the occlusion but the consideration of craniofacial dynamic ‘mechanism, Relationship of Vertical Dimension with Mandibular Growth Schudy (1964) mentioned, as stated below, the relationship of the vertical growth of craniofacial skeleton and mandibular rotation. The increase in the vertical dimension of the craniofacial skeleton, as shown in Figure 4, is due to the increase of nasion (1), inferior movement of the mandible (II), increase of the vertical dimension of the maxillary teeth (II), and mandibular teeth (IV). When the harmony of these and the vertical increase of the mandibular condyle (A) is maintained, mandibular rotation will not occur.Vertical Growth T+ +Ul+V=HAa (Schudy , 1964) nension with igure 4. Rettonship of an increase in vertcal smandihularcondslar growth Veruca) growit of nasion ), ventical diptacement of maxilla (1, increase in the vertical diameter of the maxillary teeth (II), and mandibular molars (1), de close rlaonship ofthe increase in vertical dimension ofthe mandible wih the growth the muelular coy e(A) ‘A alanosl growl ofthese structures will result to harmonious relationship of the skeletal patern(Sehucy, 1968) 28 However, the increase of I, Il, III changes the vertical position of the maxillary occlusal plane leading to the adaptation of the mandible, allowing the growth of the mandibular condyle. As shown in Figure 5, a lesser increase in vertical dimension than the growth of the mandibular condyle, results to the forward rotation of the mandible presenting an open bite condition on the molar region. But this usually leads to the posterosuperior rotation of the mandible because of the disocclusion between the upper and lower molars. This type of mandibular adaptation to docelusion gives a load to the mandibular condyle where its growth will be regulated. On the contrary, when this load is excessive to the TMJ adaptation capacity, the load becomes strongly abnormal for the temporal bone, articular disc, and masticatory muscles, causing TMJ arthrosis. On the other hand, a better increase of vertical dimension than the growth of the mandibular condyle results to the backward rotation of the mandible, presenting an open bite condition of the anterior teeth creating a fulerum in the molars, which in this case, causes an abnormal load on the TMI As mentioned earlier, the increase in vertical dimension and mandibular growth are closely related, When there is an increase or decrease in vertical dimension, the mandible adapts through functional displacement. Hence, it is important to develop and maintain their harmonious growth. Occlusal Function and Growth Research studies of the craniofacial skeletal growth before the 1940's showed that alterationa H+lleV A Figure. Reatiorship of the increase in vertical dimension with mandbularcondsla gr Lesser increase ofthe vertical dimension than Ube mandibular conlye grow results othe forward eka ofthe mandible. b. An increase ofthe vertical dimension more than the mandibular condyle results othe ackwared rotation of the mandible. Sehnaly, 1964) of its growth pattern could not be artificially changed, ‘Then, with the advent of the functional matrix theory and cybernetic model, alteration of the growth pattern has proven to be not at all impossible. In fact, research studies by McNamara, Graber, Harvold, Bass et. al., in the 1970's revealed that the amount of mandibular growth changes due to cell proliferation in the mandibular condyle is related to the changes in occlusal function, This suggests that itis possible to alter the craniofacial growth pattern, The history of growth research studies is said to have unveiled the importance of functional environmental factors in growth. The most important point thatshould be considered is the morphology of the craniofacial skeleton, observed from the cephalometric radiogram. Itis not solely influenced by hereditary factors, but by functional environmental factors as well. ‘The growth of the craniofacial skeleton at the pubertal period, which is the final stage of occlusion, and the post pubertal period is influenced more importantly by occlusal function rather than the inherent genetic factors. Even if a craniofacial growth abnormality is suspected, behind it isan underlying functional cause. Thus, improving the occlusal function, which is the 29etiologic factor, will prevent the growth abnormality. It is important to note that even if it is possible to alter the growth pattern, the improvernent of the function has to be attained first. Herein lies the importance of orthodontic management of occlusion in children during the period of growth. In orthodontic diagnosis, possible occlusal function abnormality can be detected at an early stage, and the corresponding measures may be applied. A patient shown in Figure 6 is an 11-year- old boy who came to the hospital with a chief compiaint of reverse occlusion, During the pretreatment orthodontic diagnosis, evident were the ff: a deficient anteroposterior length of the maxilla, excessive mandibular length, and an insu‘ficient vertical dimension of the maxilla If this growth pattern progresses, it would result toa skeletal malocclusion The growth pattern changed after the maxillary 2" molars and the mandibular 3rd molars were extracted. The reconstruction of occlusal plane and the attainment of a functional occlusion were the orthodontic treatment objectives. Length of active treatment was about one and a half years, A retainer was used for about a year, and then orthodontic treatment terminated, Figure 6b shows the 2-year post-treatment progress of the cephalometric radiogram at the age of 16. There has been a significant change in the skeletal morphology as seen in Figure 6c which shows the superimposition of the pre and post treatment cephalometric tracings On the other hand, Figure 6d shows the skeletal morphology of the same patient at the age of 16 had he not undergone orthodontic 30 treatment ‘As mentioned earlier, the method of orthodontic case analysis and diagnosis in the current static skeletal analysis merely focuses on localizing the skeletal abnormality or the degree of skeletal displacement. But the functional abnormality that causes skeletal displacement is ot clear. Developmental Mechanism of Growth Abnormal Research studies of the craniofacial skeletal growth play an important role in the field of orthodontics. In the occlusal management of an orthodontic patient, the important elements in craniofacial growth are certainly the maxilla and mandible, The sudden growth of the mandible after treatment may render the efforts of the orthodontist and the surgeon wasted. Various orthodontists are puzzled with the thought that growth phenomenon is nothing but abnormatity, What then is the mechanism of this type of growth abnormality? To ascertain this, itis very important to conduct an accurate occlusal reconstruction As mentioned earlier, environmental factors have an extremely great influence on the craniofacial skeleton at birth, and especially on the function of the occlusal system, The abnormalities of occlusal function easily displace the mandible. In fact, various malocclusions show a displacement of the mandible from the central position. Moreover, this displacement in malocclusion increases with age. ‘As understood in the cybernetic model of Petrovic, mandibular displacement, mediated by the neuromuscular system, guides the mandibular condylar growth, A persistent mandibularlechanstn of Craniofacial Skeleton and mandibular growthdisplacement consequently results to the skeletal morphological displacement. According to Mos: the latent growth potential of the cartilage is extremely low, Mandibular elongation is explained as a secondary or compensatory growth and is achieved through the functional displacement of the mandible, which is related to the protrusive movernent of the maxitla that is so, it could be interpreted that the abnormality in the mandibular growth is actually an abnormal adaptation to occlusal function in the normal skeletal pattern. Moreover, the increase in the incidence of abnormality of te ‘TMJ post puberty creates an abnormal occlusal function making the mandibular condyle adapt, through an immense growth, This growth, however, diminishes the growth potential of the mandibular condyle, Either way, the cause of the abnormal grow(h is assumed to be essentially the functional factor of the stomatognathic system In the field of orthodontics, it was long believed that growth and development which is genetically predetermined is the main etiologic factor of malocclusion, Orthodontists have long blamed growth and abnormal growth to be the cause of skeletal malocclusion. This is the reason why unsuccessful response to orthodontic treatment, or when the expected growth does not match with the skeletal changes, or relapsed cases, even after treatment ete, are attributed to abaormal growth which is believed to be genetically predetermined. The convenient explanation for orthodontists is that all are due to growth Assuming that growth development is really the cause of the development of malocclusion, improving malocclusion alone is not possible. And with this growth concept in mind, in the long tun, we cannot help but view orthodontic 32 treatment as futile ‘That growth is the culprit ofall, as mentioned a while ago, is incorrect. Rather, the abnormal growth pattern is the result of mandibular adaptation related to occlusal function abnormality. Therefore, early orthodontic management has a very important implication in the harmony of craniofacial skeletal growth. This viewpoint is important in reconsidering the developmental process of skeletal malocclusion. ‘The orthodontic management does not only involve tooth alignment especially in occlusal guidance but more importantly, it is the consideration of the harmony of the craniofacial skeleton and the management of the entire growth. In order to do that, itis important to understand the relationship of occlusal function and the craniofacial skeleton, and the development of specific skeletal growth abnormality. This concept is based on the dynamic mechanism of craniofacial skeleton and the developmental mechanism of skeletal malocclusion3. THE ROLE OF POSTERIOR DISCREPANCY IN THE DEVELOPMENT OF SKELETAL MALOCCLUSION Discrepancy and Malocclusi Discrepancy means the disharmony between the size of the jaw and the size of the teeth, commonly known as tooth-to-denture base discrepancy. In discrepancy, the tooth size is usually too large or too small for the size of the jaw. This discrepancy problem is usually encountered in orthodontic treatment. The reason for the emergence of the concept on discrepancy is attributed to the importance of tooth extraction mainly in orthodontic occlusal construction. The advocacy of non-extraction in the occlusal construction of Angle has been renowned but was opposed by the tooth extraction concept of Case and of course by his successors like Tweed, Steiner, Begg et. al, , who asserted the importance of tooth extraction in orthodontic treatment. This became the basis for the concept of discrepancy Moreover, Tweed noticed that bimaxillary protrusion results from treating cases without extraction and in fact, considered discrepancy as the cause of anterior tipping of the teeth and presented the Tweed analysis in measuring the labial inclination of the lower anterior teeth in measuring discrepancy. This has been accepted as the basis of the measurement of the extent of discrepancy even at present ‘The total discrepancy is computed by adding the required space and the arch length discrepancy for the correction of the labial inclination of the anterior teeth to its ideal position, In this analysis, discrepancy is usually presented as an insufficient space in the anteroposterior relationship of the dental arch, and the problem of whether to extract or not in this standpoint is included in the orthodontic treatment. However, this concept of Tweed and Steiner on discrepancy has some problem points. Firstly, the discrepancy in the values obtained from the measurements of arch length and the tooth crown width are too much emphasized which becomes their basis in determining the need for extraction. ‘This is an alarming situation, In other words, the anteroposterior dimension receives so much attention. How about the three-dimensional difference (discrepancy) of tooth support, dynamic skeletal growth changes, and the growth of skeleton during tooth eruption? Secondly, Tweed views discrepancy as the disharmony of the size of the teeth mesial to the first molars and the size of the anterior part of the alveolar base, However, based on the real definition, discrepancy means the relationship of the size of the entire jaw and the entire teeth, and not just the anteior part of the jaw. ‘Thus it is not a limited phenomenon. The functional occlusion 33and abnormal growth is rather a vertical problem, than a horizontal one. Since anterior diserepaney is considered to be prevalent in the analysis of discrepancy, the importance of posterior discrepancy is not recognized. Posterior discrepancy is actually more important than anterior discrepancy because it is related (0 the relapse of crowding in the lower anterior teeth and impaction of 3" molar (Richardson). In fact, various patients show an impacted 3" molar as seen in their x-rays after treatment. Thirdly, the method in caiculating the discrepaney considers the mandibular dental arch as the focus and not the maxillary arch. It has been demonstrated in the cybernetic model of Petrovic, that discrepancy in the maxillary arch is more important since symptoms manifest from any problem in this area rather than the mandibular arch. Discrepancy is a concept involving the jaw and the biological environmental factors of the teeth, and the mutual relationship of the jaw with the tooth development, This means that the failure of this mutual relationship implies discrepancy, and it is important for the orthodontist to determine as to whether the harmony of this mutual relationship is preserved or not. ‘The method of Tweed and Steiner in treating Class II patients, can be applied but with several precautions. For instance, Tweed calculates the total discrepancy by converting the labial tipping of the mandibular anterior teeth into discrepancy, and adding the arch length discrepancy. However, in most patients, discrepancy tends to have a pushing action of the occlusal surface towards the lateral side, because the teeth are pushed anteriorly or laterally and simultaneously 34 vertically (Sato, 1987), (Figure 1). In this type of patient, the inclination of the occlusal plane and the labial tipping of the anterior teeth are closely related. This means that the extent of labial tipping of the anterior teeth is a manifestation of discrepancy. However, precaution is needed in reconstructing the occlusal plane, that is, the labial tipping of the anterior teeth has to be eliminated ata certain degree. In most cases, the labially tipped anterior teeth show a mesial tipping of the premolar and molar, and consequently, the labial tipping of the anterior teeth is improved when aligning the entire dental arch, (Sato, 1989) (Figure 2) As mentioned earlier, the objective in computing for the total amount of discrepancy is, to determine whether to extract or not. If the manner by which to compute the total amount of discrepancy is, as advocated by Tweed & Steiner, ‘most of the patients will have an extracted space. ‘Then if there is space left after extraction, an excessive lingual tipping of the anterior teeth or mesial tipping of the molar may result, and attaining a functional occlusion becomes difficult, prolonging the treatment period. In addition, labial tipping is not always a symptom caused by discrepancy. This is influenced by the rotation of the maxilla and mandible. Therefore, a prudent consideration is important in the currently used tooth extraction standards. ‘The Meaning of Posterior Discrepancy ‘Tweed and Steiner presented discrepancy as the “difference in the size of the tooth and the size of the alveolar base” anterior to the first molar, On the other hand, as mentioned earlier,4 Daselapnem ot Skeletal Maloctuson and Dasssgpsediscrepancy should be understood as the difference in the size of the entire jaw and the size of the teeth. However, itis not easy to get the difference between the size of the entire jaw and the total width of the tooth crown. It is because usualls the patients suitable to be the subjects are from the mixed dentition c the permanent demtition periods and the second and third molars have not yet erupted. But the diagnosis of the existence of discrepancy in those patients is important in the Tweed and Steiner method, The important thing to note is that, once there is an anterior discrepaney (in the anterior part of the first molar), then itis most likely that there is also a discrepancy between the entire jaw and the entire dentition. It is important to include the posterior part in determining the amount of discrepancy, because the discrepancy that has an. enormous influence on occlusal function is posterior rather than the anterior ‘The discrepancy in the posterior part of the first molar is called posterior discrepancy. This is usually due to the vertical pushing action or the“squeezing out” of the teeth thereby producing an occlusal interference to the posterior region. leading to the functional displacement of the mandible and eventually (o abnormal growth, And most skeletal malocclusions are due to these causes. In the relationship of posterior discrepancy with skeletal malocclusion, the most important thing to understand here is on how does posterior discrepancy affects the dentition Diserspany is the basic cause of malocclusio + parting various conditions to the occlusal sy: em. In the concept of discrepancy so far, Ux. symptoms manifested are crowding, protrusios, displacement mainly the vertical and 36 Figure 2 lmpewversen of abil peping ofthe ateror ee de 19.008 ‘peng and cool of he oecsa plane 1 fn climinating posterior discrepancy, tooth uprising improves the Jablltgping of €asterior teeth since the uprighing ofthe postesine teeth ie ist Inthe presence of psterior discrepancy the eatmeot objective is usally fo flaten he ecu pane hus maprovemont of the aterioe png can teschieven posterior displacement. Hlowever, the most severe symptom that affects occlusal function and maxillofacial growth is the vertical pushing of the tooth. When this occurs in the molar area, it certainly has an effect on the occlusal function. In the supracruption of the molar, the phestomenon in the vertical pushing8 drretopenc or tetera tatoctusior ana Discrepancy of the tooth is basically caused by discrepaney especially the posterior discrepancy. ‘The conditions, which have great effect to posterior discrepancy, are eruption, expansion, formation of the tooth germ of the 1°, 2" and 3° molar, expansion and easy pushing of the molar due to eruption. This creates an occlusal interference in the posterior part of the dentition resulting to a disturbance in occlusal function (Figure 1d). Supraeruption due to the pushing phenomenon would result (0 the change of the occlusal plane, causing disharmony to the maxilloskeletal morphology. This pushing movement of the tooth due to posterior discrepancy is the major cause of occlusal function disturbance, causing a dysfunction in the mandibular movement, which displaces the mandible, leading to an abnormal growth of the mandibular condyle. Cephalometric analysis, as the main diagnostic tool in orthodontics has rapidly progressed. This confirms the degree of skeletal displacement and its local site. However, itis still inaccurate because it doesn’t reveal the cause of the malocclusion. Due to the effort of orthodontists to understand more accurately and more detail the morphology of craniofacial skeleton, a complicated method has evolved consequently defeating the original purpose. ‘The etiology of skeletal malocclusion is related to posterior discrepaney and this is important in analyzing the morphological characteristics in the cephalometric analysis (Appendix 1). Posterior discrepancy, is an important factor inthe developmental process of malocclusion. However, it is more important to consider the original characteristic pattern of the patients. How does posterior discrepancy develop? ‘This matter is explained in the theory of evolution (Inoue, 1986) which is the relationship of the ja size reduction with the tooth size reduction. But the concept that discrepancy is a part of the growth, process of an individual after birth cannot be accepted. Certainly, the explanation of the evolution theory of discrepancy is interesting However, the dietary change associated with jaw reduction, leading to the reduction of the tooth, size originally, keeps the harmony, but as to why it is that the reduction of the jaw precedes the reduction of the tooth size, remains a question. It is important to consider the crowding of the tooth germ during the developmental period (Daie, 1969) in obiaining sufficient space for the tooth eruption. In the series of processes for eruption, the acquired factors have no influence on discrepancy As already mentioned, when there is growth in the maxillary tuberosity due to the forward pushing or rotation of the maxilla, it allows sufficient space for tooth eruption in the anteroposterior diameter of the dental arch. In case of minimal maxillary pushing related to the rotation of the sphenoid, space for tooth eruption becomes insufficient because the growth in the posterior part of the maxilla results to posterior discrepancy Posterior discrepancy changes the occlusal plane due to the pushing action of the teeth, creating an acclusal interference in the posterior part of the dentition. To prevent the interference, the mandible, in response, rotates associated with a protrusive displacement related to the neuromuscular system. Persistent protrusive displacement of the mandible changes the rotation of the temporal bone and since the mandibular condyle is not fused to the joint cavity it leads to a7a secondary growth and decreases the functional pressure to the temporal bone through the joint cavity, promoting a flexion of the neurocranial base. These series of processes eventually minimize the protrusive rotation of the maxilla and because it enhances its vertical descent, the more severe the posterior discrepancy becomes. With the acquired causes, the development of posterior discrepancy is closely related to the ‘dynamic mechanism of the craniofacial skeleton. Feedback Regulatory Mechanism in the Development of Skeletal Malocclusion ‘There are several cases, erroneous concepts about the developmental process of skeletal maloclussion. The worst one is that malloclusion is related to the abnormal growth of the maxilla ‘or mandible. The maxillofacial skeleton is composed of numerous bones with complicated morphology, mutually relating and influencing each other, creating the entire craniofacial skeleton (Figure 3.) With its complicated structure, it is too simple to understand that mandibular protrusion is a growth abnormality of the mandible and that maxillary protrusion is a growth abnormality of the maxilla. From the above standpoint, feedback regulatory mechanism is the developmental mechanism of malocclusion from the mutual relationship of all the bone tissues of the craniofacial skeleton. “The craniofacial skeleton is not composed of static bones, It always shows a dynamic movement. The functional pressure originating from the mandibular function like mastication, swallowing, pronunciation, ete., is transmitted, 38 in an orderly manner, to the temporal bone - neurocranial base (ethmoid, sphenoid, occipital bones) - vomer ~ maxilla, creating a cycle. The maxillary position displaces the position of the occhisal surface of the upper dentition because again, this has an influence on mandibular function, and this cycle is an unceasing chain of reactions, The special characteristics of the skeletal morphology of skeletal malocclusion are formed due to this vicious cycle, Figure 4 and 6 show the characteristics of the skeletal system in mandibular mesiocclusion and distocclusion and the illustration of their respective feedback regulation. In the orthodontic management of malocclusion, the objective is to have harmony established from the feedback regulatory mechanism by inhibiting this vicious circle through management of the occlusal system. Feedback Regulatory Mechanism in the Development of Mandibular Mesiocclusion Ina patient showing harmony of the skeletal growth, as shown in Figure 3, the neurocranial base displays an appropriate movement based on respiration, swallowing, pronunciation, mastication etc. causing the protrusive movement of the maxilla, The mandible functionally displaces anteroinferiorly in response to the displacement of the maxillary occlusal plane, consequently feading to the growth of the mandibular condyle, stimulating the rotation of the temporal bone in response to mandibular function like mastication etc. The temporal bone rotation and the flexion-extension of the neurocranial base is regulated by this mechanism, feedback regulatory cycle.TT $§ 5 Doveterment of Stra Matoctuson ant Discrepancy In the severe case of posterior discrepancy as shown in Figure 4, since the occlusal plane is flat due to a supraeruption of the molar, and the mandible adapts to this by tts rotation associated with a protrusive displacement, The mandibular isplacement secondarily decreases the functional pressure applied to the temporal bone, externally rotating it. In addition, it leads to the flexion of the neurocranial base resulting to a decrease mm the anterior pushing of the maxilla In this type of patient, the posterior discrepancy 1s more and more aggravated because the growth in the posterior border of the maxillary tuberosity 1s inhibited leading to an excessive eruption of the molar, creating the vicious circle, thereby manifesting the skeletal conditions. This 1s amandibular feedback regulation and once this vicious circle 1s imtiated, this system cannot be easily inactivated For that reason, the persistent protrusive rotation of the mandible increases the angle of the mandible because of the lingual tipping of the mandibular anterior teeth and mandibular symphysis. This leads to bone deposition in the posterior border of the mandible, making the mandibutar length longer than the average The flexion of the neurocrantal base inhibits the elongation of the posterior crantal base length and shortens the cranial base angle Inaddition, the downward growth of the body Of the maxilla results because of the inhibition of the anterior pushing of the maxilla. This decreases the anteroposterior diameter of the basal bone, thereby aggravating the posterior discrepancy causing the crowding of the molar. Thus, the treatment objective in orthodontic occlusal management 1s to terminate thts vicious circle Figure 3. The movement of de Bones ofthe cram base and maillary promt mcelation co 4 spedcrate ratio ofthe shenox hone regalates the anteroueror growth ofthe maulla These a wluenee the growth ofthe manticFigure 4 The develo 4023 Development of Skeletal Malacelston and Discrepancy DENTAL COMPENSATION The erroncous concept of dental compensation- The term dental compensation came from the concept that the teeth compensate for the function of the jaws through compensatory adaptation when there is disharmony of the skeletal relationship of the upper and lower jaw ‘Taking the skeletal reversed occlusion as an example, anteroposterior pressure an the maxilla and mandible causes labial upping of the maxillary antenor teeth or hngual tipping of the mandibular anterior teeth and the teeth respond by compensation. This concept believes in the adaptation of the tunetion of the occlusal s io the growth abnormality of the jaw The functional adaptation in response to the pre- existing growth abnormality can be illustrated a diagram Pages Den conpenton dag develometa press However, this growth concept clearly eee comradicts the concept that belreves in the tntluence of environmental factors in the skeletal growth and above ail the enormous influence of assocyated with the functional displacement This occlusal function to the cramofacial skeletal may fesull (0 the Lingual upping of the anterior growth Unless the alteration of the occlusal teeth of the mandible Actually in patients with system ts prioritized, skeletal growth ts interpreted these changes, lingual tippmg of the mand:bular as the secondary compensation anterior teeth 1s not observed in the superimposed The changes 1n the inclination of the anterior tracings of the mandible when observing an teeth of both the mandible and maxilla in the anteroposterior change, In this phenomenon, the) dental compensation is not the result of tooth degree of lingual tipping of the mandibular Tipping but rather it 1s the adaptation of the skeletal anterior teeth 1s described as the process of system functional reaction of the mandible related to the Dental compensation is actually the abnormality of occlusal function of that patient. functional adaptation of the mandible. As sh Similarly, the mesial movement of the molar mm Figure 5, in the skeletal reversed occlusién, associated with a vertical descent to the occlusal the occlusal plane of the maxilla flattens, and the surface ts the cause of the tabral tipping of the mandible adapts to this through protrusive rotation maxillary anterior teeth. al‘Scan tppmng.of eels plane, al station of the mail ye Mate Soca, see of fanvtenalpremre fo he si candje u ae ital ie meee ous condyle Figue 6, Feedback epulstory mechanism te developmental proces sll mandibular distsces$15. Developmen of setetat Maloctusion and Discrepancy Feedback Regulatory Mechanism in Mandibular Distocclusion When the rotation of the neurocranial base is extension, the sphenoidal rotation will forcefully push the maxilla protrusively through the vomer In this case, even if the occlusal plane is tipped superiorly and the body of maxilla is moved inferiorly, the spatial position does not change much (Figures 6 and 7a). In the case where there is a slight change in the occlusal plane, there is no need for the mandible to functionally adapt through protrusive rotation or protrusive displacement. This is because it usually takes the mandible to be in a retruded position, inhibiting the mandibular growth, thereby increasing the functional pressure to the temporal bone. Naturally, since temporal bone rotation and the neurocranial base extension is intensified, anterior pushing of the maxilla increases, associated with its forceful rotation induces the growth of maxillary tuberosity, preparing a sufficient space for molar eruption, In the above mechanism, since posterior discrepancy is eliminated in maxillary protrusion, the occlusal plane does not present a significant change. In mandibular distocelusion, there are several patients having an excellent vertical growth of the ramus of mandible but shows a posterioi tipping of the palatal plane (PP). This means that the frontomaxillary suture is the axis in the 9 enc ca eee ite palen protrusive rotation of the body of maxilla. This ofthe ods plane aimoar docs ot cane: type of patient is shown in Figure 7 where the By Mien fe manila aterinfrorty displaces, cctael plane dees mandibular growth, due to its adaptation to a fatkat i ict gov flea of mnie da maxillary rotation, tips the occlusal plane in the ma rusapinee meee] pa ae molar area. 4B4. OCCLUSAL PLANE AND FUNCTIONAL OCCLUSION ‘Orthodontics and Functional Occlusion Attainment of a functional occlusion is the ultimate objective of orthodontic occlusal construction. In fact, this is the basic therapeutic objective of dental medicine in general. The same is true with regards to the treatment objective of operative dentistry and prosthetics. However, it is important to determine whether the attainment of functional occlusion through orthodontic approach and prosthetics are considered to be in the same level. Special consideration is important in orthodontic therapy because most of the patients, being treated are at the growth period. The dynamic alteration of an individual's occlusion during the growth period is considered important in harmonizing the craniofacial skeleton through occlusal treatment. Functional occlusion has totally been disregarded not until recently with the development of orthodontics (Roth, 1979). The basic concept of prosthetic occlusal construction, which apparently is a different method applied to orthodontic occlusal construction needs to be re- evaluated Functional occlusion affects mandibular movement through the neuromuscular system. Mandibular movement is guided by the mutual function of the teeth and TMJ with a minimal efficiency load. Generally, regulation of mandibular movement through the teeth is called anterior guidance and mandibular movement through the ‘TMI is called posterior guidance (Figure 1). This can also be classified into two: anterior occlusion induced by the anterior teeth and vertical dimension support through the molar (posterior 44 support). Each of these efficiently contributes to the preservation of harmony. However, when there is a defect of the mandibular guidance in the anterior teeth, it produces interference in the molars, producing an excessive load leading to the destruction of the periodontal tissue. In addition, when there is a problem with the posterior support, the task is shifted to the anterior teeth and the TMJ. From this functional perspective, malocclusion is a result of the disturbance of the harmony Malocclusion can basically be classified according to the causes of functional malocclusion. As shown in Figure 2, it is Jassified into: premature contact, cuspal interference, occlusal interference, and loss of occlusal support. In orthodontics, it is necessary to recognize the causes Anterior Guidance Posterior Guidance ii poser fidiece guidance Figure 1. Postetlor and anterior guidance in she functional movernent of che manileof functional malocelusion Premature contact in a narrow sense means the cuspal contact in the reference position (central position) of the mandible however, ina broad sense, comprised in a concept, cuspal contact is not only in the central position but could also be in the intercuspal position or the eccentric position. ‘This means that the mandible has the tendency to position itself in the effort to avoid the interference. In this regard, cuspal interference is ey e occlusal contact in the central position of th mandible, which induces sliding of the mandibular condyle causing a discrepancy of the centric mandibular position and maximum intercuspal position. Primarily, the normal movement of the mandible, as shown in Figure 3, is both the smooth rotation and sliding movement of the mandibular condyle, However, cuspal interference is a cuspal contact where the rotation of the mandibular condyle is specially prevented. On the other hand, occlusal interference is the cuspal contact where the sliding movement of the mandible is inhibited. For example, the cuspal contact is on the balancing side during a, lateral movement of the mandible. And finally, the loss of occlusal support disharmonizes the relationship of mandibular growth and the increase of vertical dimension, resulting to an insufficient vertical dimension. All of these abnormalities interfere with the movement of the jaw related o the function of, the neuromuscular system and has an effect on the mandibular position either by displacement or avoidance. It has also an indirect effect on the growth of the mandibular condyle. Moreover, the loss of occlusal support emanates from tooth 4, Occlusal Plane and Functional Oselusion position, tooth axis, and tooth rotation ete. When the appropriate position and volume of the centric stop in central occlusion is not established, that occlusion becomes very unstable resulting in an insufficient posterior support. The objective of orthodontic occlusal reconstruction is to eliminate the aforementioned causes, and establish an intereference-free occlusion based on the functional mandibular movement. The concrete objectives of orthodontic occlusal reconstruction is presented in Table 1 ‘The most important thing in these objectives is the attainment of occlusal harmony through a functional movement of the mandible. However, this is not at all easy. It is important to secure the stability of occlusion post-treatment especially in the elimination of cuspal interference and occlusal interference in the molar. This point has to be given careful attention Dynamic Mechanism of the Maxillofacial Skeleton and Occlusion As mentioned earlier, the maxillofacial skeleton possesses a very dynamic mechanism The regulatory mechanism of this skeleton is related to its growth as well as to the development of skeletal malocclusion The mandible basically has a rotating and sliding movement, and the cause of malocclusion is the interference on this movement. The movement of the mandible, is the most important factor in ensuring the harmony of the craniofacial skeleton. Mastication, swallowing and speech are the normal functions of the occlusal system. In case there is an abnormality of the occlusal system, this has an effect on the whole ay46 1 Premae cance 2. Cuspal interfere cosa inte 4. Loss of te vestioal support of occusion ‘anlamenl cases of fonctional maloecision » CCucpat conte of she mancibnlar and mastery tecth nthe reference position of te mantle An nterneyal or eooenti> position Contac of ds nantes 4 ‘nnbiing condyla cotati [Disteaston: Eéfece om the figs cwvity muscles of the TMS) marie teeth ni and oral Contst ofthe mate and assy ‘nbibting condy las rotation Toes the ntscular avoidance movement) Las af vrtical dimension scion: Tond on TRU: ate oralcts Pane st tint Occasion Objectives of Orthodontic Occlusal Reconstruction. 1, Eliminate the cuspal premature contact in all mandibular positions. 2. Eliminate cuspal interference that inhibits mandibular condyle rotation. 3. Fliminate the cuspal contact that interferes with the sliding movement of the mandibular condyle. 4. Obtain a sufficient centric stop to stabilize the mandibular position 5. Obtain a posterior support that does not apply load to the anterior teeth and TMJ hart 1 Figure 3. The fonctional manblar movement associated with the Figure 4, The rebitionship of the fictional movement of the mansile ‘movement ofthe mandiulsr ene an the amie mechanisn ofthe rani skeleton 47craniofacial skeleton, From this viewpoint, we basically classified malocclusion into the 2 static conditions, maxillary protrusion and reversed occlusion. As mentioned earlier, itis necessary to reconsider the basic cause of malocclusion and the harmony of the maxillofacial skeleton (Figure 4). ‘The balance of the maxillofacial skeleton is usually regulated through its dynamic mechanism. it has a great effect especially on the occlusal function, The occlusal function works due to mandibular movement through the neuromuscular system, The teeth and TMI control the movement of the mandible, that is why it is important to understand first the relationship of occlusion and the basic movement of the mandible, Mandibular movement in an edentulous maxilla allows the mandible to freely move extensively with the TMJ as the main pivot point (Figure Sa). In this case, the mandible can freely move to a certain extent considering the muscles and ligaments ‘The movement of the jaw is regulated by the range of maximum capacity of the muscular function due to the contraction of masticatory muscles like the lateral pterygoid muscles, digastric muscles, etc. Similarly, the lateral pterygoid muscles and TMJ ligament regulate the range of the protrusive movement of the mandible, and the extent of movement can be determined. However, in the vertical movement of the mandible, itonly closes uatil the upper and lower jaw collides. The TMJ can rotate up to this extent, and it can freely carry out its sliding movement, regulated by the articular surfaces and dise. Given, this condition, TMJ arthrosis can easily develop. ‘To understand the relationship of the TMJ and occlusal condition, though this is a purely hypothetical example, (Figure 5b) shows the 48 presence of only the anterior teeth in the maxilla, In this case, a class III cantilever is formed in the contact position of the maxillary and mandibular anterior teeth because the anterior teeth regulate the vertical length of the mandibular movement, ‘This guides the mandible posterosuperiorly, resulting to a compression of the mandibular condyle with the temporal bone joint cavity. Consider, on the other hand, the presence of only the molar in the jaw (Figure $c). The closing movement of the mandible is regulated through the sudden contact of the molar. in this ease, the mandible as a fulcrum of the molar, rotates protrusively, and due to the action of a class J cantilever, it results to the inferior pulling of the mandibular condyle from the articulating fossa. This is how the teeth regulate the height of the mandible and at the same time its influence on the rotation of the mandibular condyle and its sliding movement. Therefore, when the teeth are complete, the arrangement of these teeth is important in close harmony with the movement of the mandibular condyle (Figures d). Therefore, it is ideal that the jaw has a complete set of teeth. © _ The movement of the mandible is the most nportant among the craniofacial skeleton Therefore, any abnormal movement of the mandible greatly affects the movement of the TMJ and the whole craniofacial skeleton. Especially in the growth period, this matter directly affects the growth pattern. In the case of a poor adaptational capacity of the cranial skeletal system, the load on the TMJ can be quite extensive. ‘Though Figure 5 shows an extreme xample, this phenomenon is not rare at all, Even if the maxillary and mandibular teeth are complete, the same thing can happen when there is an infraeruption or supraeruption of the molarsIn fact, when identifying the mandibular condyle displacement through the mandibular position indicator (MPI, footnote), there is usually the absence of compressive force to the mandibular condyle of a patient with skeletal reversed malocclusion during the growth period, And in patients with deep overbite, the compression force is applied to the condyle when the patients clenches strongly Viewed from this perspective, recognition of the relationship of vertical dimension and craniofacial skeleton is extremely important, This reiterates the importance of the relationship of its dynamic mechanism with the occlusal plane manifested by the height and tipping of the occlusal part. Functional Occlusion and Occlusal Plane It is important to consider the numerous factors that affect the ocetusal function in attaining an orthodontic functional occlusion. This is especially true with respect to the most important factors affecting the relationship of the occlusal plane and mandibular movement. During mandibular movement, except the tooth contact related to mandibular guidance all the other teeth especially the molars are disoccluded. Though this becomes the point where mandibular movement creates a harmonized functional occlusion, this is determined by the incisal guidance and horizontal condylar inclincation, cuspal angle and occlusal plane angle (Figure 6). The incisal guidance angle and the horizontal condylar inclination have their respective Noms Mandar positon diane (PO, MPT edi SAM System a conic MPI (CMPD This an detect be handiblardsplacevent between the reference position (Pad the ICP ofthe marci 50. independent mandibular guidance path. The incisal guidance is in the axis of the maxillary anterior teeth and the morphology of the lingual surface, That is why in orthodontic treatment procedure, this could be controlled easily On the other hand, horizontal condylar inclination is determined through the joint cavity and the anatomical morphology of the articular eminence of an individual and extensive artificial changes are not possible. Usually, the incisal guidance angle coincides With the horizontal condylar inclination or when the angle is somewhat extensive, these two are mutually in harmony. However, it is important to recognize the fact that the interference of the tooth is also affected by the angle of the occlusal plane. In other words, even if the incisal guidance angle and the horizontal condylar inclination keep a certain relationship, the interference in the molar easily develops if there is a sudden tipping of the occlusal plane. On the contrary, if the occlusal plane is flat, disocelusion of the molar is excessive and the sliding movement of the mandibular condyle during a masticatory movement is extensive thus the masticatory efficiency diminishes. ‘The most basie task in the construction of functional occlusion in orthodontics is the management of the occlusal plane. After establishing an occlusal plane where the denture frame and horizontal condylar inclination is harmonized, positioning the axial inclination of the anterior teeth into its proper occlusal plane can be done first. In a patient where the occlusal plane is flattened due (0 posterior discrepaney, the most, effective weatment procedure is to correct the occlusal plane into its proper inclination.—. $$ 4 oes Pane ane Fret Octusion Figure 6, tacsa guidance in mandiblar movement, the relationship of horizontal condylarinclintkn ad ccs plane 2 When the occlusal plane inclination is im harmony withthe incisal ‘guidance and horizontal condyle incineaton . molar is moderately Aspocladed dating mandibular movement. 1. When mereis tipping ofthe cecil pane teas rete interference ‘the molar tepion due to mandibular movement When the occlusal panes it, the Uepreeo he dsocetion of molars, uring mandala mavemere is excessive. Molar Interference and Posterior Discrepancy To climinate the occlusal interference in the molar area, attainment of a functional occlusion is indispensable. To do this orthodontic procedure, it is important to determine first the degree of molar interference, It is usually difficult to determine the eruption of the tooth in an obstructive position during jaw movement, When the tooth erupts in a position that interferes with jaw movement, that tooth must have erupted there because of typical environmental factors. Therefore, treatment of posterior discrepancy has to be settled first in order to eliminate molar interference Molar interference results mostly from the vertical pushing of the teeth brought about by posterior discrepancy. Therefore, posterior discrepancy has to be managed first in order to eliminate molar interference. ‘The “squeezing out” phenomenon of the tooth in posterior discrepancy, as mentioned earlier, flattens the occlusal plane, affects the growth of the individual during the growth period and creates an occlusal interference in the molar region ‘Therefore, treatment of posterior discrepancy and reconstruction of the occlusal plane are important in attaining a functional occlusion. Occlusal Plane and Mandibular Position As explained in the cybernetic model of Petrovic, the maxillary occlusal plane spatial position is an important element in the regulation of mandibular growth. Moreover, mandibular growth is not only regulated by the maxillary occlusal plane position but more so, the effect of the occlusal plane tip and the vertical dimension 51Figure 7. Skeletal growth pattern ofa patient with mandibular mesioctuson Ta cael leet ine fom te ecianmaxilay inal margin 1 he distal surface ofthe Ist moar of the axl. Te ous plan ine mola ertinie ie inistng the chronsepesl age fh pes wih presenting est yearfelemsnay shen, ‘The de represen he mesure point worked on every year of the mandibular position. Therefore, this suggests that these elements regulate mandibular growth. In order to understand the relationship of the dynamic mechanism of the craniofacial skeleton with occlusal plane and mandibular position, here are several examples Figure 7 is the growth and skeletal pattern of a patient with mandibular mesiocclusion. In 52 this type of patient, the growth associated with the increase of anteroposterior diameter of the maxilla is not apparent and the vertical descent of the body of the maxilla is excessive, The descent of the maxillary molars with increase in age consequently leads to the flattening of the occlusal plane. In response to this, the mandible anteriorlyFigure 8, Skeletal growth pater of patient with mansalar distcctsion ‘Tre accusal plane i the line fm the median malar igcisal mars wee dst sunfae ofthe Ist molar ofthe maxilla The occlusal plane in the molar ot with he igure indicating dh histrical age of he parle as 1 represents the first year of elementary schoo, The dot represen the measurement pots to be worked an every year rotates associated with protrusive displacement resulting to anteroposterior length expansion ‘When the vertical descent of the P and AB points is excessive, the cranial base angle (NSBa) and the posterior cranial base angle (PSBa) has a tendency to decrease, and the mandibulofacial function affects the dynamic mechanism of the neurocranial base. Figure 8 shows the skeletal growth pattern of mandibular distocclusion. Compared with mandibular mesiocclusion, the degree of protrusive displacement of the maxilla is excessive and shows a somewhat increasing tip though the occlusal plane has not changed much, In response to this, the mandible rotates retrusively ‘and because of that, it anteriorly adapts, and the chance of the mandibular condyle to grow is slim. 33 een ce‘The insufficient increase of vertical dimension functionally prevents the protrusive movement of themaxilla. In these patients, decrease of the cranial angle is not apparent, but the difference in the dynamic mechanism is obvious in cases of mandibular mesiocetusion, In these patients, the vertical dimension and the inclination of the occlusal plane leads to the functional displacement of the mandible, which are the definite factors in either mandibular distocctusion or mesiocclusion, Moreover, these also affect the dynamic mechanism of the maxillofacial skeleton, regulation of the growth pattern, and could serve as, the control of the skeletal system. ‘The lateral displacement of the mandible is shown in Figure 9, The right side of the patient's mandible was displaced from the age of 7 10 15 Based on the superimposition of the frontal view of the cephalometric radiograms, the lefi side of the occlusal plane (occlusal plane is represented as EE and 66) suddenly descends, and in response to this, the mandible displaces to the right side ‘There is a discrepancy during the eruption of the teeth in both the left and right side of the mandible in this type of patient because usually tooth eruption in the non-displaced side is late. In the case of the patient in Figure 9, the Lst molar of the left side erupted at the age of 7 and the Ist molar of the right side erupted at the age of L1. Moreover, the 2nd molar of the right side erupted at age 12 but the 2nd molar of the Ieft side rupted at age 15, about 2-3 year gap. This means that there is a growth difference in the feft and right side of the mandible, The posterior discrepancy is excessive on the side where the growth is late, and tooth eruption is also delayed, resulting to the flattening of the occlusal plane due to the squeezing out of the teeth. 4-Osclasal Plane and Functional Occasion ‘The mandible is consequently displaced to the lateral side as result of its functional adaptation to the displacement of the maxillary occlusal plane. Tn fact as shown in Figure 9, the mandibular condyle of the left side moved inferiorly, while the mandibular condyle of the right side moved superolaterally. In response to this, the lft temporal bone moves externally, eventually resulting 10 displacement. Ina patient with lateral displacement of the mandible, more often than not, the molar of the non-displaced side erupts extensively and displays a flat occlusal plane when looking at the facial profile (Sato et al, 1990). When carefully examining the cephalometric radiogram of this patient, there is a clear difference in the thickness of the lateral bone cortex of the temporal bones. The cortical bone of the displaced side of the mandible is thicker while the non- displaced side is extremely thin, This shows the difference of functional pressure on the lateral bones due to the lateral displacement of the ‘mandible, In addition, the functional displacement of the mandible brought about by the changes in the inclination of the occlusal plane affects the whole maxillofacial skeleton, There is also a difference in the horizontal condylar inclination of both right and left as seen from the sliding movement of the mandibular condyle and usually, when compared to the non- displaced side, the horizontal condylar inclination of the displaced side is larger This displacement seen in about 70 % of patients show some sort of TMJ arthrosis in the displaced side of the TMJ (Fushima et al, 1989). Keeping this in mind, management of the the occlusal plane, mandibular position, as well as the harmony of the maxillofacial skeleton are of ‘utmost importance. 555. THE CHARACTERISTICS OF MALOCCLUSION AND THE MORPHOLOGICAL TYPES OF THE CRANIOFACIAL SKELETON Occlusal Plane and DentureFrame Morphology The special orthodontic procedure in doing an occlusal reconstruction, needless to say, is the alteration of tooth position, Alteration of the tooth Position results not only to the alteration of the occlusion, but also brings about changes in the mandibular position. This change cause a great effect inthe morphology of the denture frame. Therefore, in orthodontic treatment, it is important to understand not only the occlusion but also the effect of changes with the skeletal morphology specifically the position of the mandible in response to the occlusal changes Occlusion means the contact of the upper and lower teeth but in the actual orthodontic, ‘occlusal construction, itis the contact of the upper and lower tech and at the same time the continuity of the occlusal surface representing the occlusal plane. There are (wo concepts in the foundation of occlusion and spatial position of the occlusal plane. These are the static viewpoint and functional viewpoint From the static viewpoint, if the anteroposterior tipping of the occfusal plane is parallel with the maxillary and mandibular base, the occlusion is stable because the pressure applied to the occlusal surface during mastication is vertically applied to the tooth axis (Figure 1) However, the occlusal plane is not always paralle] 56 with the maxillary and mandibular base. Therefore, it is our goal to establish an ideal occlusal plane for each patient, In determining the occlusal plane, various structures of the face and oral cavity function as indices. The method being used is based from the mutual relationship of the indices to the occlusal plane. ‘The occlusal plane indices are the Frankfort plane, Camper plane, oculo-axial plane, nose hamular notch line. However, neither of these indices has a direct relationship with the basic morphology of the denture frame because of the extensive distance from the occlusal area. In establishing the occlusal plane, it is important to consider the basic dental frame morphology of each patient. Attain a functional and stable occlusion first by considering the appropriate tipping of the occlusal plane, position of occlusion, and the proper contact of the upper teeth with the lower teeth. The Basis of Harmonious Denture Frame ‘Morphology Denture frame is the skeletal frame that accommodates the dentition. However, this skeletal part participates in the movement of the mandible and that movement has to be always given consideration. Which means that mandibular position is easily displaced when tooth contact changes. Because of this, it is importantto consider whether the mandibular position is correct or not in doing ocelusal construction The problem on the relationship of the occlusal plane position with the mandibular position starts there. So we must not only determine the fixed changes of the occlusal plane in cach individual, but recognize as well the extreme instability of the occlusal plane, The effect of discrepancy is extensive especially the effect of the mofars on the occlusal plane. This, could possibly lead (0 a serious condition called skeletal malocclusion, Figure 2 shows the exacerbation of skeletal symptoms in reversed occlusion and the changes of denture frame in an open bite condition (Chapter 4, Figure 7, p.52) In these patients, the occlusal plane changes due to the eruption of either the second or third molar. Because of that, the morphology of the denture frame changes extensively due to the displacement of mandibular position. tn patient with a normal occlusion, occlusal changes is very insignificant since the harmony of the denture frame is maintained, ‘The sudden change of occlusal plane in a patient with skeletal reversed malocclusion is due to the vertical pushing phenomenon of the molar, producing a squeezing out effect on the occlusal function, In effect, a fulcrum is formed in the molar part, produces an interference on occlusion, thus in tura affect the functional movement of the mandible, As a result, the occlusal system adapts by the prottusive rotation of the mandible, and the protrusive displacement of the mandible through the neuromuscular function. This mandibular displacement induces the growth of the mandibular condyle. This functional malocclusion will consequently become a skeletal malocclusion as presented in Figure 2, wherein 5, Characters of Maloccusion and Types of Avail Skeleton Figare 1. Relationthp of denture arte morphology and oclusal plane 4. nib sane cence, he ceca) planes most stable when its parle wath ae ase! bone ofthe upper 2nd Lower jaws bo. However, wen the sal bone of dhe jae in each vidual is not aways partie, the cesta plane ips the morphology of the denture frame shows a condition of extreme disharmony. This is how the occlusal function of the denture frame morphology is closely related to the growth pattern. Denture fraine analysis, which will be discussed later, identifies the harmony of the denture frame as the basis of the effect of the 5758functional occlusion of each patient relative to the degree of the changes. Occlusal Piane of an Indi Occlusion. dual with Normal ‘As mentioned earlier, the occlusal plane position and the angle of the mandibulofacial skeleton are important factors in the regulation ofthe functional movement of the mandible. Even litde change in the occlusal plane affects the functional movement and displacement of the mandible, Therefore, stability of the occlusal plane especially the mandible is an indispensable factor in acquiring a stable mandibular position. But as expected, the maintenance of the stability of the developmental process of the occlusal plane or the process of orthodontic treatment is still a big problem “The occlusal plane of a patient with a normal occlusion (Figure 3) shows that the OP-MP is, consistently close to 13.5, showing insigniticant changes. Of course the increment of the vertical diameter through the vertical growth of the alveolar part equally pushes the occlusal plane upwards, that the occlusal plane tipping does not really change. With the balanced increase in the vertical dimension and growth of the mandibular condyle there is no displacement of the mandible resulting to a well-balanced growth of the maxillofacial skeleton. In comparison to this, the patient that has a possible malocclusion has a very unstable occlusal plane, and the OP-MP consequently increases especially with the supraeruption of the molars. These changes have serious effects in terms of the occlusal function because this could affect the mandibular position. 5. Characteristics of Malocctusion an Types of Anillofcal Skeleton Effect of the Changes of Occlusal Plane on the Denture Frame ‘The maxillofacial denture frame morphology has a vertical and anteroposterior positional relationship with the maxilla and mandible. The mandibular position is regulated especially by the neuromuscular system which in turn controls the morphology of the denture frame. The mandible rotites almost near the center of the TMJ and because of this, the vertical position becomes the contact position of the teeth. In other words, the closing movement of the mandible is limited to the nearly overlapping position of the occlusal plane with the upper and lower jaw and the spatial position in the maxilla and mandible are important elements in determining the mandibular position. ‘What about the anteroposterior position of the mandible? The terminal position of the mandible is dependent on the TMI, But to acertain degree, it can freely choose its position. In other words, the vertical position of the mandible is, primarily determined by the spatial position of the teeth, Anteroposteriorly, it can locate its appropriate place during the free mandibular movement. As a result, the mandible is in an appropriate contact position for the upper and lower teeth. In other words, it has rested on the obtained position of maximum contact area ‘The vertical and anteroposterior position of the mandible is not 2lways determined by the spatial position of the upper and lower teeth. If the spatial position of the teeth is inappropriate, the mandible looks for the most suitable position resulting to the displacement of the mandible. When the occlusal plane of the maxilla and mandible changes, the mandible adapts with the changes resulting to displacement. In a patient 39DENTURE FRAME ANALYSIS FH-MP PP-MP oP-MP OP-MP/PP.MP AB-MP 1-AB (mm) T-AB(°) 1-AB (mm) Intermolar() Tooth material 80} al 4 i 8 i go 2 i 67 8 9 0M 12 13:14 $78 9 OH 213 14 ‘Age (years) Age years) ame aralyss ihe denne teme alysis ao vse age ava patient with pom xcuskntavdng congenitally bse tint mole 60with normal occlusion, tipping of the occlusal plane is comparatively stable in the growth process. In this patient, the mandibular position is also stable, and the balance of the denture frame is maintained. However, in a patient where there is occlusal plane deviation, te mandibular position extensively changes, associated with the changes in the denture frame. AS mentioned earlier, the occlusal plane is extremely important in the harmony of the maxillofacial skeleton. The deviation of the occlusal plane does not only affect the occlusal function extensively but it also changes the growth, pattern, thus results to the lost of harmony in the denture frame, and extensive effect on the facial profile. Therefore, the most important point in the orthodontic occlusal management is in the treatment of the occlusal plane. in addition, the treatment objective in orthodontics is mainly on the improvement of the occlusal plane, attaining, 2 functional occlusion Orthadontic Approach to Denture Frame In the revent years, orthopedic approach is becoming popular for skeletal disharmony, The anterior growth of the maxilla is controlled through the maxillary protrusive traction appliance or the maxillary extraoral appliance. On the other hand, the chin cap appliance inhibits the growth of the mandible. These methods are appropriate in directly managing skeletal discrepancy However, the cause of the skeletal displacement is actually the abnormality of occlusal function? A direct sketetal approach disregards the root cause, and instead, uses an indiscreet treatment method, which is to improve the symptoms only. In the previously mentioned 5, Characteristics of Malocetuson and Types of Aiiloicial Skeleton patient with reversed occlusion, obtaining the harmony of the denture frame is through improving the occlusal plane. After which attainment of a stable functional occlusion can be done. Denture Frame Anal ‘The shape of the skeleton that supports the ‘maxilla and the mandible has a direct relationship to occlusion. This skeleton is called denture frame (Figure 4). Since the denture frame is a basic skeleton that supports the upper and lower molar elated t he eruption ofthe Pel csiducus molars, together with supeaerupion Similarly, 93comparatively easy to determine through the presence of abnormality like tooth displacement and tipping, symptoms like tooth supraeruption is extremely difficult to determine by a mere clinical or oral examination, Examination of tooth clongation is a combination of determining the dynamic harmony of the maxillofacial skeleton and occlusal function. Clinical examination of posterior discrepancy In the examination of posterior discrepancy, it is important to determine the characteristics of the craniofacial skeleton first. Its dynamic features are closely related to discrepancy, The flexion-extension movement of movement of the bones that comprises the cranial base has influence on the growth of the maxilla, which would eventually regulate its anteroposterior and lateral growth, ‘As a general tendency, flexion of the craniofacial skeleton intensifies with posterior discrepancy. In addition to this, flexion of the skeleton with high angle, shows an enormous effect on the jaw function. Figure 5 shows 2 subjects with an abnormal type of craniofacial skeleton, Subject A, with a maxillary protrusion (mandibular distocclusion) shows anterosuperior tipping of the palatal plane. Looking at the position of the root apex of the upper 1* molar and tipping of the occlusal plane, there is infraeruption of teeth, and due to this, there could be inhibition of the forward adaptation of the mandible. Since there is extension of the craniofacial skeleton, the maxilla anteriorly rotates, because of a comparatively good growth of the dentition in the posterior part, where there is a slight tipping of the occlusal plane in the 1*, 2, 94 and 3° molar In this connection, the maxillofacial skeleton of subject b is in flexion position because the distance from the neurocranial base to the palatal plane is long and the palatal plane is almost in parallel with the FH plane, leading to 2 less anteroposterior growth of the maailla. The alignment of the 1", 2" and 3 molar shows a sudden tipping and the tooth germ, during its development, has positioned above the molar. Because of this, supraeruption of the 1* molar is determined from the position of its root apex and the maxillary sinus base. Through this, the maxillary occlusal plane flattens Figure 6 shows a patient where an orthodontic treatment started from age 4 t0 14 and improvement of reversed malocclusion was difficult, In the occlusal findings at the age of 4, with overjet of 0.5mm, it did not show serious problems especially, skeletal problems, Occlusal improvement was not thought to be that difficult However, the occlusal plane flattened due to the pushing of the Ist and 2" deciduous temporary molars related to the eruption of the 1* permanent molar. At the age of 9, there was a vertical movement of the 1’, 2”, and 3 molars as these teeth bunched up causing the further flattening of the occlusal pane. At age 14, the flattening of the occlusal plane due to discrepancy affected the growth of the mandible, Overbite improvement was difficult then, which led to the extraction of the upper 2"! and lower 3° molars In the successive panoramic radiograph of this patient, molar crowding was apparent (Figure 7). When looking at the relationship especially of the 1 and 2 molars from age 9 to age 12, the effect of posterior discrepancy is easily7, Diagnosis of Discrepancy Figure 5. Aljgnmeat ofthe molars observed fr i the digetion A patiem having a tendency of milo sctepaney, which makes the understood Figure 8 shows a patient with molar crowding due to posterior discrepancy. Posterior discrepancy is not determined through the mere alignment because posterior discrepancy could possibly Icad to mesial tipping and vertical elongation of the molars. Therefore, in the diagnosis of discrepancy, understanding the various symptoms shown here is important Below is the list of cardinal symptoms observed in the dental arch due to posterior discrepancy (Figure 9) he eplalomerie rim 4 “Inapaven showing a vndeney for extension ofthe munllofacal helene ad pon of he 1,2 and 3! molar shows alight upping a acl plane, al evi an inferior dotacement of the maxilla, osctusal plan Mans because of the nz in posterior men of temo eth es vertical asset wth he ern ofthe 2am 3 lat teth oho soe Petrie reationf the maxilla, witha sudden iping of he och plane, 1, Mesial movement of the premolar and molars; 2. Excessive supraeruption of the molars; 3. Impacted molars especially the 3" molar; 4. Buccoversion of the molars (molar crowding); and more. In addition, below are the characteristic symptoms of posterior discrepancy, which are important points to give attention to in the diagnosis of posterior discrepancy 1. Flatteniing of the occlusal plane in the 95Figure. Sucesive cehalograms ofa pater showing posterior discrepancy fentition, the L* and ‘mors are cron Primary densition period (8y.0,), reversed xchsion in primary Py eto oe” mua eruion 6 0), the elatonsp ofthe and 2% primary melas sre aggre earn para (9... toeah germ of the 3 agar is see and prowusve displacement ofthe mane is oberves- ai ero pesca cit'y.0), octal lane lates an the anterior tet overt has not improved, ost mined dentition J ance te latenngnpct ote sha plane was shown upper 2* moar an lower 3“melar were eas posterior discrepancy ed toabort 96,7, Diagnosis of Discrepancy Figure 7. Successive panoramic radiographs of te patent in Figure 6 The numbers show the chronologic age ofthe patent. Pay acon oe supaerupin of he mola teeth, This extensive posterior dscrepaney inthe primary denn reversed ochision is nbtcoreved a ‘weliminat the discrepancy at an early age because these skeletal sympoms hive specially at age9 in response tothe crowding ofthe ly, Faber is impor tat tbere are measures aken ‘he eneney to exacerbateFigure 8. Panocamic radiograph of potent with posterior discrepancy 42 Mesial tipping ofthe lower left 2" molar bb Presence ofthe 3° molar jst above the upper 2 molar isl lock ofthe upper 3" molar on the 2* melars, 4. Crowding of te molars eruption of the 1*, 2% and 3° molar teeth (Fig. 10) 2, PP-OP decreases because of the fattening @) of occlusal plane associated with the elongation of the molars. In addition, there is a tendency for the OP-MP to increase in a patient where the functional adaptation of the mandible is poor. 3, Inapatient where the maxillofacial skeletor is in flexion position, the posterior discrepancy is extensive. The infraversion of the floor of the maxillary sinus is common with this type of discrepancy because of the inferior displacement of the maxilla. In the radiographic findings, the maxillary sinus floor is observed far above the 98 palatal plane and the root apex of the 1* molar is usually far below the palatal plane. 4, Inpatient with mild posterior discrepancy excessive mesial tipping of the 1* molar and its mesial movement are absent however, mesial tipping of the 1* molar results when the posterior discrepancy becomes more extensive. Therefore, the effect of posterior discrepancy can be determined by finding the distance from A'-6 and ‘A’-P” (Chapter 5). 5, Problems in the upper 2" and 3 molar eruption are common (Figure 8) 6. Observed from the study cast, the clinical crown length of the molar of a patient with severe‘Buaninatin of Paster Desegpey 1 Angle of Is, 2nd, & 3rd moles in elaon the OP isi 2 OP-PP ange is low 3 Infraversom af the bass of rly sis 4 Mesal tppmg of de Mi. M3 5; Clinical row Teng is 1a, Figure 10 lems 1 observe during a clinical exami discrepancy on of posteriee posterior discrepancy is usually long. On the contrary, with deep overbite etc., clinical crown length is short ina patient with insufficient vertical dimension As mentioned earlier, discrepancy is considered as the basic cause of the development of malocclusion. Due to an abnormal bite, discrepancy is possibly related to occlusal diseases like the dysfunction of the jaw, TMJ abnormality, and abnormal muscle activity, unknown causes of numerous complaints, which are the dysfunctions of the stomatognathie system. If this is the way discrepancy is understood, then this should be a problem not only in the orthodontic field but the general dental service. Nevertheless, discrepancy is closely related to the dynamic system of the maxillofacial 100 skeleton that manifests various symptoms. ‘The orthodontists, especially in the treatment of young, patients, must give careful attention in checking the relationship of discrepancy and malocclusion. Inthe clinical examination of discrepancy , analysis of the general discrepancy and the diagnostic tools, as mentioned earlier, are important in making the general diagnosis8& ORTHODONTIC TREATMENT AND TOOTH EXTRACTION Importance of tooth extraction in orthodontic treatment The problem of tooth extraction in orthodontic treatment has a long history. The most prominent is the dispute between the group of Angle, who advocates non-extraction and the group of Case, who advocates the need for toxtt, extraction. ‘The tooth extraction dispute in the period 1910-1920 which was the start of modern orthodontics, has come to an end with the emergence of the alveolar base theory (Lundstrom, 1925), self criticism of Strang and ‘Tweed, the students of Angle, the establishment of treatment system due to tooth extraction (Tweed, Steiner, Holdaway), and the advocacy of the attrition occlusion theory of Begg The basis for tooth extraction in orthodontic treatment is the discrepancy of the tooth width and the size of the jaw. This is the concept of discrepancy The symptoms of malocclusion due to discrepancy are anterior teeth crowding and anterior protrusion of the jaw. Therefore, the initial measures generally used in these malocclusions are tooth extractions, the expansion of the dental arch, or the distal movement of the molars, However, among these measures, elimination ‘of discrepancy by extraction was mostly used because expansion of the dental arch and the distal ‘movement of the molar require space. With this, extraction especially of the 1* premolar suddenly became the trend in osthodontics. Even in the treatment system of malocclusion, improvement of ocelusion is done through the use of the extracted premolar space, discounting the dynamic adaptation of the mandible and maxillofacial skeleton, in exchange for the alveolar bone of the adjacent teeth thus referring to a static condition, On the other hand, problem points came about with the extraction of premolars before the year 1960, and instead of the premolars, extraction of the molars was admonished in the treatment of malocclusion, Extraction of the premolars as 2 means to eliminate discrepancy does not always, climinate the total jaw discrepancy. In fact most of the patients previously treated with premolar extraction. still has fo be subjected to 3% molar extraction. This means that extraction of the premolar is not really useful in the elimination of posterior discrepanc: Extraction in orthodontic treatment, is done to eliminate discrepancy, which is the cause of malocclusion. However, in the choice of the appropriate tooth to be extracted, continuation of ‘occlusal improvement from a technical point and the condition of the teeth in both jaws must be considered 101Disadvantages of Premolar Extraction 1, Overretraction of the anterior teeth results to the so-called dished-in face ‘This allows the lingual upping of the anterior teeth, thus disrupting the correct mandibular guidance, 2, Basy loss of posterior support due to the mesial movement of the molar related to premoiar extraction, adding load to the TMJ, which becomes the cause of TMJ arthrosis (Figure 1) 3. It leaves space in the extracted part, destroying the parallelism with the adjacent tooth. 4, Destroys the continuity of the dentition, and allows molar rotation and mesial tipping due to thie mesial movement of the molar, making it difficult for the orthodontist to attain a functional occasion (Figure 2a) of the oral cavity. ‘The tongue space narrows due to the decrease in dental arch length, harmfully affecting all functions 6. Even if anterior discrepancy has been eliminated, posterior discrepancy is still present, leading to the possible relapse of malocclusion. 7 It takes a longer time to close the extracted space and the attainment of a functional occlusion, ani Premolar extraction as a trend for orthodontic treatment, has not stitred doubts. The problem of extraction 1m orthodonuc treatment, based on the above-mentioned points, merits reconsideration Disadvantages of Premolar Extraction ‘Treatment procedures, therapeutic results, and post-treatment stability are important factors when considering tooth extraction for orthodontic treatment Until now, premolar extraction is the 102 now, premolar extraction ts the trend in orthodontic treatment ‘One of the most important things to consider in the smprovement of occlusion 1n orthodontic, ircatinent 1s the possible loss of posterior support ‘This casily develops especially when the premolar is extracted Phystologic occlusion is primarily @ bite wherein the intercuspation (ICP) of the upper and lower teeth and applies no excessive load to the TMJ Occlusal force as shown in Figure 1a is distributed to the entire maxillofacial skeletonthrough the alveolar bone and zygomatic bone. However, when there is loss of posterior support due to tooth loss or insufficient vertical dimension etc., this results to the manifestation of various symptoms seen in TMJ arthrosis because all the load during closure is concentrated in the TMJ (Figure 1b). ‘The growth and development of an individual preserves the harmony and the growth of the ‘mandibular condyle due to the physiological tooth eruption and vertical growth of the alvcolar bone. Extraction of the premolar at this period becomes, a factor that disturbs its harmony. In addition, the protrusive movement of the posterior teeth after premolar extraction is a negative element in ‘maintaining the vertical dimension which must be adequately considered. In the field of dentistry, the trend has come to effectively eliminate the causes of TMJ arthrosis considering that the patients with malocclusion is already predisposed to TMJ arthrosis, It is important for orthodontists to sufficiently recognize that it is their duty to ‘manage the physiological function of the TMJ through occlusion. Therefore, improvement of crowding, choice of treatment mechanics, and also a condition of negative load to the TMJ must be considered in deciding the tooth to be extracted. ‘Advantages of molar extraction in orthodontic treatment Tooth extraction in orthodontic therapy actually eliminates the cause of malocclusion, which is discrepancy. As mentioned earlier, premolar extraction that has been done in the past until now does not always eliminate the 104 ‘Figure 3. Mesial tipping ofthe molars after premolar extraction "The weatment was ot idea! in ether of dese patients hough there ‘waa peevios otodoatc eatment with extastionof he 1 prema Snltectuse ofthe lack of posterior supert,dhemolars showed anexteme mesial pine. 2 {7y.0, completed the 3-year onthodentic weatment 1.28701, completed in less han 10 years of erhodontis estes. {C 2by 0. completed in 7-& yeas of orthodonie wean5 oirtrntonte teat ant rect Extraction Advantages of molar extraction 1, Eliminates the supraeruption and mesial tipping of the molars due to posterior discrepancy. thus removing one the causes of the abnormal growth of the jaw. 2. Eliminates the cuspal interference, occlusal interference that usually occur in the molar area, thus restoring the function of the mandible back to normal 3. Lesser load to the TMJ because of less postcrior support loss, and also, stabilizes the occlusion after treatment. 4. Ata ns an occlusion based on the harmony and dynamic mechanism of the craniofacial skeleton. 5. Avoids inconvenient adverse effect seen in premolar extraction, easily achieving a functional occlusion 6. Shortens treatment period. ‘cnart2 discrepancy, which is the cause of malocclusion. Looking from the dynamic mechanism of the craniofacial skeletn, malocclusion prevents the functional movement of the mandible, and sittce harmony of the craniofacial skeleton is disturbed, consideration of these points is important in the choice of tooth for extraction. In cases of occlusal interference, where the function of the mandible is inhibited, it is important to eliminate the posterior discrepancy first in the occlusal treatment because of the possible supracruption of the molar related to the influence of maxillofacial growth, extensive mesial tipping of the molar due to anterior discrepancy, and various causes of malocclusion due to posterior discrepancy From this viewpoint, the choice of molar extraction instead of premolar extraction is increasing, The list of the advantages of molar extraction is found in chart 2. In the extraction of the molars, the problem lies as to which molar is to be extracted, In deciding which tooth is for extraction, the attitude of the patient, degree of crowding, shape and size of teeth and its formation are the factors that must be considered. Here are the general considerations: Extraction of the I molar ‘The 1° molar, being the biggest tooth among the permanent tecth has an enormous occlusal loading force Therefore, this is very important in the bite relationship of the upper and lower jaw in order to obtain a centric stop and posterior support. Because of this, extraction of the [* molar 105is comparatively low. There is another reason to exempt the 1* molar from extraction, It is because of the relationship of the upper 1* molar tooth and the base of the maxillary sinus, Normally, the base of the maxillary sinus extends up to the area of the mesial root. Extraction of the I! molar lowers the base of the maxillary sinus, thus the parallelism of the tooth root will not be obtained because the cortical bone of the maxillary sinus base disrupts the root movement of the 2"! premolar. However, extraction of the I molar tooth is not rare when considering the accompanying factors like the degree of crowding, elongation, dental caries etc. Extraction of 2" molar ‘The 2 molar, especially the upper 2" molar, has the highest extraction incidence. Extraction, of the 2" molar eliminates posterior discrepancy and at the same time easily corrects the mesial tipping of the "molar, reconstruction of occlusal plane, and improvement of anterior crowding. Italso eliminates the occlusal interference in the molar area indirectly alleviating the load to the masticating muscles and TMJ. The eruption of the 3 molar, the formation of its crown, and the direction of eruption are considerations for occlusal reconstruction in 2" molar extraction cases. However, itis important to note that there is more mesial tipping of the 3 molar with the extraction of the lower 2” molar. Figure 4 shows the eruption of the 3“ molar after the extraction of the upper 2" molar. Extraction of the 2® molar before the age of 15 allows a good eruptive direction of the 3* molar 106 and morphology of the tooth root. Eruption is also earlier. At the age of 16, most of the teeth had already erupted Nevertheless, when the extraction of the 2 molar is beyond age 15, the 3% molar will show mesial tipping and rotation. From this point, age factor is a consideration in the extraction of the 2" molar. Extraction of the 3 molar Extraction of the upper 3 molar is usually difficult because this is located in the posterosuperior part of the maxillary tberosity. ‘This is one reason why the 2" molar is the frequent choice for extraction, The 3° molar, due to posterior discrepancy frequently causes impaction, difficulty of ruption, associated with infection, swelling, pain, dental caries, periodontitis ete., and the chances of its extraction is extremely high, However, inspite of the effect of the lower 3" molar to the lower anterior teeth, already identified by the oral surgeon Thoma, until now, Jower 3" molar extraction from the viewpoint of orthodontics is comparatively low. This is because orthodontists hardly know the effect of the 3 molar to the dentition and the occlusal system, The series of research studies on the relationship of the lower 3" molars and lower anterior crowding (Richardson, 1970, 1979, 1982, 1985) showed no clear evidence yet. There are also problems on the relationship of the lower 3 molar and crowding of the anterior teeth associated with crossbite but actually, that is usually left untouched after orthodontic treatment. As repetitively mentioned in this book, posterior discrepancy in the 3% molars may'lead to skeletal malocclusion due to its influence on8, Orthodontic Treatment and Tooth Extraction Figure 4. Panoramic radiograph showing the proses ofthe 3 mor ezupton ale upper 2 8°14, age of extraction, de molar descended nea thelist 178, age of extraction, te 3 molar descended rom ih dist molar extraction plane ofthe I“ mola, and eropted maining its parallel relationship with the I molar al plane of the 1 molar ad erepted through mes png 107Figure s. Suscessve panoranicradiogam af the developmental process of toth germ ofthe 3 molar a 7'y 0. toot germuf the 3° mari nt yet visible 1b By... appearance of 7 molar tooth germ © 10.0, begining of te calito af the 3% molar tooth crown 4. 13 yo), the 3"molar appears tobe impacted in the posterior pat due tothe alveolar socket growth ara the lateral molar 108 ‘movement inthe oclusal surface of the 2°[igure 6. Abortion of the 3 mola tooth germ igermectomy) {} Imsion on he distal put of the [* mar, removal ofthe oot germ using a cure afer detaching the mucoperosteum, by Suturing ater extraction ©) Panoramic radiograph of de extracted 3+" molar 1b) Extracted veoth gers 109occlusal interference, TMJ arthrosis, and to the growth and development as well. Therefore, the lower 3" molar is the most suitable tooth for extraction in orthodontic treatment. Extraction of the 3% molar, which is located in the most posterior part of the dentition, also favors the construction of the functional occlusion compared to the extraction of a tooth in between the dentition, because it does not affect the hasic morphology of the whole dentition. Early extraction of the lower 3“ molar tooth. germ (Germectomy) As what had been discussed so far, crowding in the 3 molar area, which causes posterior discrepancy aggravates the crowding in the anterior part, and creates occlusal interference in the molar area, This consequently affects the functional movement of the mandible and the TMJ. In addition, this has also an effect on the growth of the maxillofacial skeleton due to the flattening of the occlusal plane, making it difficult for orthodontists to manage. Extraction of the tooth germ ata young age can be considered for elimination of posterior discrepancy, improving the function at an early stage. Many researchers and clinicians have investigated the diagnostic technique, and usefulness in the early extraction of the tooth germ of the lower 3rd molar (R.M. Ricketts, 1980). ‘The formation of the tooth germ in the lower 3 molar occurs in the mesial wall of the retromolar triangle (Atkinson, 1951). In its early stage of growth, when it is about to form a tooth germ, it remains embedded due to the additional growth of the bone surface. In the process of tooth germ formation, the 110 more formed the tooth germ becomes, the more difficult it is to extract. And since extraction, an invasive operation like this becomes extensive, early extraction (germectomy) is advantageous (Figure 6). The advantages of germectomy are the following: the amount of bone removed is small, period of operation is short, and it is a less invasive surgery ‘This suggests that early tooth germ extraction is an effective method in eliminating posterior discrepancy9. OBJECTIVE OF ORTHODONTIC TREATMENT AND ITS GUIDING PRINCIPLES The Objective of Orthodontic Treatment Needless to say, the objective in orthodontic treatment is the improvement of malocclusion and the attainment of a normal occlusion. But then, the meaning of the “mal” in malocclusion and the condition of the “normal” in normal occlusion is so far not clear. ft is because most of the orthodontists believe that in general, orthodontic treatment is the mere restoration of tooth alignment rather than improving the occlusion. However, when the causes of malocclusion are the premature contact of the teeth, cuspal terference, occlusal interference, and loss of occlusal support, (Chapter 6, Diagnosis of Malocclusion), the objective in the orthodontic treatment should be to eliminate these causes and to attain the harmony of the maxillofacial dynamic ‘mechanism and the ocelusion that has no untoward effect on the TMJ function and mandibular movement. In order to achieve these goals, itis necessary to understand some basic concepts and principles These are the relationship of the occtusal plane and the maxillofacial dynamic mechanism, relationship of the mandibular position and the vertical dimension, and the relationship of the ‘ovejusal support and TMJ. It is important to know how to consider this concept and how co specifically approach the knowledge on this interrelationship in determining the objective in orthodontic treatment. ‘Treatment Objectives based on the Dynamics of the Craniofacial Skeleton ‘The basic movement of the neurocranial base is classified into flexion and extension. Since these movements are closely related to occlusal function, it is important to adequately consider them in orthodontic treatment, It is difficult to simply classify a complicated dynamic mechanism of the maxillofacial skeleton of an individual, The following are the classification of adaptation and relationship of the mandible to occlusion and their respective treatment objectives: 1, Flexion position - Low angle ‘There is a functional reversed malocclusion in these patients, In the functional reversed malocclusion, there is insufficient vertical growth of the upper face, and because of this, vertical dimension in the maxillary molar area is insufficient, creating a discrepancy in its relationship to the vertical growth of the mandibular condyle. Normally, though there is less problems in the anteroposterior growth of the maxilla, it usually manifests a symptom of deep reversed occlusion due to the hyperprotrusion of the mandible (Figure ia). Now, the treatment objective in this type of patient is to inhibit the functional excessive rotation of the mandible by increasing the upper face length and the vertical dimension. (Figure Ib, tc). This increases the distance between the jaws, and establishes a new occlusal support. The istimuli coming ftom the mastication and the various functions of the oral cavity is transmitted to the sphenoid and ethmoid bone through the tmaxifla and temporal bones, secondarily restoring, the harmony of the craniofacial bones. 2. Flexion position ~ High angle Skeletal reversed occlusion and skeletal open bite are observed in these types of patients Usually, these types of patients have a deficient anteroposterior growth of the maxilla, and the molar elongation due to posterior discrepancy flatiens the occlusal plane. The mandible adapts {o the elongation of the molar through anterior rotation, resulting to protrusive displacement. Therefore in these cases, the objective of orthodontic treatment is first, to eliminate posterior discrepancy, and to restore the various functions of the oral cavity in accordance to the reconstruction of the sudden tipping in the occlusal plane. ‘The chin cap appliance and the maxillary protraction appliance (facemask) are frequently used in the treatment of skeletal reversed occlusion bout these devices, though usually used for symptomatic treatment, are not always effective in restoring occlusion and the functional harmony of the maxillofacial skeleton. In achieving the above objective, it is important to have a combination of treatment of these devices (and methods) and other (devices) For example, the use of chin cap appliance in a patient with mandibular protrusion and a progressive flattening of the occlusal plane intensify the protrusiverotatioa, solely promoting, the vicious cycle. In this type of patient, posterior discrepancy and the elongation of the molar teeth have to be prevented first before considering the use of the chin cap appliance 9, Objective of Orchotontic Treatmene sn is Guiding Principles 3. Extension position - Low angle In a low angle patient, the growth capacity of the mandibular condyle is towards the vertical direction, Because of this, there is a tendency for the lack of vertical dimension in the molar area due (0 vertical growth of the maxillary alveolar part and tooth eruption. Since the occlusal support is lacking, it allows the protrusive rotation of the ‘maxilla and mandible, and the cranial base adapts through the extension position. Thus, the occlusal condition becomes a deep overbite. The treatment objective with this type of patient is naturally, the inhibition of the vicious cycle by increasing the vertical dimension, which inhibits the protcusive rotation of the maxilla and mandible. With the objective of increasing the vertical dimension using the orthognathic appliance and a bite raising plate, careful attention is needed here because this creates no occlusion the molar area, increasing the protrusive rotation of the maxilla where the danger of promoting the vicious cycle is possible. This point has to be sufficiently considered and must choose a positive measure to increase the vertical dimension, 4, Extension position - High angle When the cranial base is in the extension position, the maxilla usually grows due to its protrusive rotation and protrusive displacement. In this case, increment in the vertical dimension is usually low due to the growth of alveolar part and tooth eruption. In this condition, the occlusal plane of the maxilla, especially the functional occlusal plane, always show a sudden tipping, Besides, the spatial position of the occlusal plane does not change due to growth. As a result, the mandible usually adapts in a retruded position resulting to mandibular distocclusion withholding, 113Figure2. Patent with TM) arheosis post otuodrtic treatment due vo presnlarexrsction a. Pre-treatment . Supetinpesivon of cephalometric tseings pre and post tweatment(Sorigin, SN reference plane) the chance for anterior growth. ‘The treatment objective in this type of patient therefore is to flatten the maxillary occlusal plane, thus allowing the mandible to adapt anteriorly This secondarily leads to mandibular growth. However, this is also related to the growth capacity of the individual. It is important to accomplish this with prudence since this does not always lead to the adaptation of the mandible. Reconstruction of occlusal plane ‘The occlusal plane is the most important functional plane to be considered in the progression of orthodontic treatment, The 14 mandible in response to this functional plane normally performs its functional movement like mastication, etc. When the occlusal plane does not adapt, the mandible suddenly adapts forcibly, leading to an abnormal growth and TMJ dysfunction, Figure 2 and 3 show the changes of ‘maxillofacial skeleton due to the reconstruction of the altered occlusal plane. The patient in Figure 2 has an improved occlusion through the extraction of the premolar. However, the occlusal plane, compared to the pre-treatment, is in a sudden tipping. In addition, there was excessive lingual tipping in the maxillary anterior teeth. There was insufficient vertical dimension observed and thea ee 9. Objective of Orthodontic Treatment and its Gung Principles Figure 3. patent wh had undergone orchodonic etme through the extraction ofthe 2 molar a Pee neument 5 Ceplatemene superimposition of pre and post scatment¢S origin SN plane mandible has retruded. Because of these, the Patient experienced TMJ arthrosis post treatment So the patient came back for check up with a complaint of trismus. During the examination of ‘TMI, there was an anteromedial displacement of the articular disc due to loss of occlusal support (Chapter 6, Figure 10 shows the apparent reciprocal click of this patient seen in the trace of the condylar path movement through the axiogeaph). ‘On the other hand, the patient in Figure 3 is the result of continuous treatment through extraction of the upper and lower 2" molars, showing the transition of the flattening of occlusal plane afier treatment. The changes of occlusal plane leads to the adaptation of the mandible eee through protrusive rotation related to growth, and the dynamic function of the craniofacial skeleton resulting to the harmony of occlusion and skeleton. Reconstruction of the occlusal plane and bite is accomplished by attaining a stable ocelusion that has a less load to the TMI In the reconstruction of occlusal plane, especially in individuals still with growth capacity, treatment must be continued while the mandible protrusively adapts. However, the sudden tipping of the occlusal plane usually intensifies which makes the mandible lose its opportunity to adapt ‘Through orthodontic treatment, there is no decrease of vertical dimension, but rather an increase vertical dimension of the molars, There 1s anterior rotation of the mandible and adaptation MSFigure Pate ih mapaibulrdisioclusio showing x sulden ping fhe oecsa plane We toe extraction ofthe 1 premolag at g.Pre-trsament + Cemalusupermpesition of pre aml post teatment (Sorin, SN plane sandard) to an anterior position and because of these, there is a lesser load to the TMJ. Increase of vertical dimension was not observed, thus with the sudden tipping of the occlusal plane, the mandible shows a tendency for retrusive rotation, aggravating the AB relationship Figure 4 is @ high angle Class II patient, showing sudden tipping of the occlusal plane, where there is an extensive difference in the AB relationship because of the retrusive rotation of the mandible, Moreover, the mandibular ramus length is short. Treatment was done in this patient through extraction of the 1% premolar but, the result as shown in Figure 4, compared to pre- treatment. shows a more sudden tipping of the occlusal plane, and a retrusive rotation of the mandible aggravating the AB relationship Figure 5 shows a class II patient with a sudden tipping of the occlusal plane but was treated through molar supraeruption to flasten the occlusal plane. However, the flattening of the ‘occlusal plane induced the mandible for pro'rusive rotation and to adapt to the protruded position. In these types of patients, the most important points in the orthodontic occlusal reconstruction are the adjustment of the occlusal plane and the adaptation tion of the mandible to it.', Objective if Othedontie Trestment and its Ging PrinciplesFigure 6 Musraton of he lateral displacement che ruadbte 1 When there a diteence inthe verti dimension on uh ses te anc ble sptaces toe Inver sale ofthe aclusion Wi ta placement bec dlimenion on both sides drt the growih por, esl 19834 fen ate wens effect na the growth ot the mambuly eon re Ina nny ta she displaced sulle of the TMS un. pats wo has passed the proth perio 1 Ua patent ida lateral dplaeon oft mandible, the dlyectve of othoduatc reatmcmr sto pre the aference a vertical densi of both yes by avdemessna ofthe mins en the nesploced sue at sapraeraption of he molags on Ue dsplaced side Relationship of the Vertical Dimension with the Mandibular position It has already been mentioned that mandibular position is affected especially by the tupping and postion of the ecclusal plane ‘The crease of the vertical dimension results to mandibuJar adaptation through protrusive rotation and prottusive position leading to the correction of the AB 1elationship That also means that vertical dimension and mandibular position are closely related fo cach other In an orthodontic 118 occlusal reconstruction, we often consider the horizontal relationship of the upper and lower dental arch as the basis of choosing the tooth 10 be extracted and the system of treatment However, this matter should be considered sufficiently because the mandibular position changes due to the angle of occlusal plane and vertical dimension, and this should be included mm the treatment plan ‘The patient shown in Figure 51s an example of ay increased dimension of the maxillary molars Increase of vertical dimension an this patientusually Icads to the anterior rotation of the maxilla, which secondarily leads to adaptational growth of the mandible. This normally happens in the body. In the normal growth process of the mandible, the development of the alveolar socket due to growth and tooth eruption normally increases the vertical dimension. Together with Unis, the mandibular condyle also increases maintaining the harmony of the vertical dimension. Therefore, this treatment approach, does not disturb the harmony of this physiological harmony. Moreover, when there is a discrepancy due to the vicious circle, the treatment plan should be, to restore the harmony of vertical dimension and TMI Now in considering the relationship of the vertical dimension and mandibular position, examine not only the anteroposterior displacement of the mandible but the lateral displacement as well. Ifthe vertical dimension on one side is high, and low on the other side, the mandible has a tendeney to adapt to the lower side through later displacement igure 6). Continuation of this condition for a long period of time results to a change of the skeleton to an asymmetrical shape because of the excessive growth on one side of the condyle path and lesser on the other side. When there is a discrepancy in the midline of the upper and lower dentition, most orthodontists use a midline elastic to align the tooth fo the median line. However, this is incorrect most of the time. In this case, suspect for jaw displacement. So first, examine the difference of the vertical dimension of both sides, which could reveal a lateral displacement. Increasing the vertical dimension on the lesser side can be done after, leading to the correction of the jaw displacement. This condition usually occurs in 9. Objective of Onhadontic Teeutment and is Guiding Principles the carly growth period of infants. Correction in the difference of the left and right occlusal plane at an early stage is important because this will provide a normal growth of the jaw, thus preventing jaw deformity. ‘The Relationship of Occlusal Support with ™SJ ‘The main function of a joint to the whole skeleton is t0 connect bones and maintain their mutual function. Therefore, when a non- physiological or intolerable force is applied to the elbow or knee, it causes a damage to that joint. The TMJ is different from those joints for three reasons: Firstly, the TMJ does not only rotate but also slides condylar path even with a {ateral movement of more than 19 mm, making it a special joint. Secondly, the unusual movement of this joint, which happens to be connected to the adjacent structures, has an effect om them ‘Thereby its movement should maintain the mutual relationship. Lastly, the movement of TMS, in response to occlusal force, contradicts the lateral pressure applied, maintaining the mutual relationship with the adjacent structures. The abnormal bite, as a complicated force or mandibular displacement, greatly affects the TMI. ‘Therefore, the occlusion must not be in a condition that applies foad to the TMI In normal conditions, there is no excessive load to the TMI during the intercuspation of the upper and lower teeth thus preserving the function of the TMJ, Because of that, the centric stop shout work to maintain the support to the vertical dimension during an orthodontic occlusal construction (Figure 7). With this, the importance of considering the relationship of the occlusal 119plane and vertical dimension with the mandibular position in attaining the objective of orthodonti treatment is recognized. Relapse and Loss of Occlusal Support In the process of occlusal reconstruction, prevention of relapse is important in orthodontic treatment (dynamic treatment), The orthodontist’s attention to the prevention of the destruction of the attained occlusion is really very difficult In preventing relapse, it is important to understand how this happens. This is considered to be an adaptation of the body to the new environment. That adaptation causes an inconvenient condition, which is relapse, to both the patient and the orthodontist. Relapse is classified into two: one is the jaw relapse and the other is dental relapse The relationship of occlusal support to relapse is mainly in the jaw but this is closely related to dental relapse as well. Loss of occlusal support alters the stability of the vertical dimension, The patient in Figure 8 shows an supraeruption of the molars post treatment associated with the protrusive displacement of the mandible, Despite the 1" premolar extraction due to discrepancy, a pushing effect of the molars, occlusal interference in the molar and displacement of the mandibular position were still visible (Sato, 1988). The recurrence of skeletal reversed occlusion and skeletal open bite condition post treatment is usually related to the problem ‘on occlusal support, Relapse of crowding in the lower anterior tecth is relatively high. ‘This relapse is usually considered to have resulted from the pressure coming from the posterior teeth, which are the 120 Figure 7. The relationship of ocluslsupport and TM Vertical dimension and clus plane tipping mamta the dstanoe btwn the jn, ana est imporaey stabs he mandibular position. ‘Theis importa nthe maintenance ofthe ene oF TMI par to which the teatmen plan in selecting te wood fr exsaction an reconstruction ‘ofthe oxclisl planes bes molars (Richardson). But why is it that this is usually considered as a horizontal problem? Nevertheless, patients with the recurrence of crowding in the lower anterior teeth even with the available space after 1* premolar extraction are usually encountered in the daily practice. This means that recurrence of crowding in the lower anterior teeth is not only caused by a horizontal space problem. This is due to the decrease of vertical dimension and the protrusive rotation of the mandible in response to the increase of vertical dimension in the molars when there is relapse of mandibular position (Figure 9) Either condition aggravates the overbite, leading to crowding as a compensation to the overlapping of the maxillary anterior teeth In doing an orthodontic occlusal9. Objective Ortodontte Treatment and is Guiding Principles “wo were Figure’. patient sewing a skelealretrogression post orioontic realm 2. Pre-tealment 8 Post-triment © yx pene treatment : ae AL dp &. Sujerinpston of cepalonsrctracins post othe eatment and I yar Orton treatm was dene to tis pacer huh he 1 prema exeraton but suprienipion ofthe molars du wo poxerior dcrepancy is eberved, mating the cecal upp unsaleoease the Matern heels pane. The mali “ nips 1 meri poston leaing toa secondary srw, reconstruction, managing the problem of vertical orthodontic treatment must be attained through dimension is more important than the horizontal the knowledge of the aforementioned points relationship of the upper and lower dentition. ‘The problem of vertical dimension is related to the growth and position of the mandible, function and disease of the TMJ, and stability and relapse of the occlusion post treatment. The objective of 121122PART 2: CLINICAL The Use of MOAW, MBAW andl DAW in Occlusal Reconstruction , Occlusal Reconstruction in Skeletal Class Il Malocclusion Occlusal Reconstruction in Open Bite Occlusal Reconstruction in Skeletal Class [11 Open Bite Occlusal Reconstruction of Mandibular Lateral Displacement (MLD) Occlusal Reconstruction of Crowding : 7. Occlusal Reconstruction of Mandibular Distoeclusion 8. Occlusal Reconstruction of Malocclusion with Assuciated TMJ Disorder Asn 125 135, 153 168 190 a2 230 246J. THE USE OF MOAW, MEAW, AND DAW IN OCCLUSAL RECONSTRUCTION Maloccluston is mainly caused by the disharmony or discordance of the dynamie system of the craniofacial skeleton, When this system. activates the vicious eyele, it may possibly aggravate the malocclusion. ‘Thus, the basic objective of orthodontic treatment is to restore its harmony through the control of the vertical dimension. To other words, the restoration of the harmony of the craniofacial skeleton chrough poclusal Geatment is a daily responsibility of an orthodontist The devices that have been used for the improvement of vertical dimension are the bite raising plates and activator ete. however, these ale comparatively passive deviees, since they cannot correct the vertical dimension by quadrant The modified offset archwire (MOAW) multiloop edgewise archwire (MEAW) and double archwire (DAW), are good appliances in controlling the vertical dimension. Modified Offset Archwire (MOAW) MOAW, as shown in Figure 1, is basically an offset arch wire consisting of a horizontal loop and 2 combination loop. Usually MOAW is made from .016x.022 rectangular wire. The method of bending will be mentioned in the section of MEAW. The horizontal loop is located ‘a the mesial part of the canine, in order to eliminate the crowding. This archwire also serves asa hook for the vertical elastic which is usually used inal conto of the molars withthe use ofthe MOAW jon of force system ofthe eral elastic an MOAW in the upper and lower dentin. The purpose of the tip tuck bendof MOAW. as shawa inFig?, isocontol the mol. bb MOAW using #-016x.022 wire. 126I tree mony, Me aw, una Daw in Occisal Corssuction nol othe murs ving MOAW and serucal elisa, tert ihe olfct sire she mclare tly shred Mien the up tack Hed pled the mew! ft of he oft es degre foe apolar ars ae lige MEAW 8-Gmmm T-Bmn 5-6 mm rma eee” 76 § 43 2112 3 4 5 6 7 “SSSE6S “eae 016x.022 stainless wire Peau thos grace te ‘MEAW an ro the Teed the purpane ol th za o daieane the Kl de . talon crestor lacrat wos tthe posterior eto the mo Khused in combination with the archwires. The force system used in MOAW is shown in Figure 2. The flexibitity of the combination loop in the distal part of the canine regulates the movement of the molars. The vertical control of the molars are attained through the tip-back bend. Vertical elastic possesses a force for the distal alignment of the molars rather than a vertical movement on the anteriors. A distal tip back bend in this case supraerupts the molars and a mesial tip back bend applies a depression, force to the molars. MOAW is being used mainly for alignment ‘and to apply a depression force to the molars, in case here distal movement and vertical control of the molars are needed, a longer ofiset bend of 2-3nun from the distal surface of the bracket of canine to the molat buccal tube is bent. The vertical elastic of 3/16” 6oz in the anterior region in combination with the tip back bend, aids in applying a depression force to the molars and possibly inhibiting the labial tipping of the amerior teeth due to the reversed action of orthodontic force in the molar region Multiloop Edgewise Archwire (MEAW) MEAW was first developed by Dr. Young H. Kim, whete a seties of horizontal loops is bent in the contact point starting from the distal part of the lateral incisors to the posterior part of the entire dentition. MEAW is made from a 016x.022 size of wire (Figure 3). The procedure in making a MEAW is shown in Figure 4 and 5 including the important forms of an ideal archwire. Alignment of the teeth from the premolars to the molars is possible with the continuous tip L. the of MOAW, MEAW, an DAW in Ocelusal Connon back bend of MEAW (Figure 6). Moreover, reconstruction of the occlusal plane can be done with the force system coming from the tip back bend and the vertical elastic. ‘The MEAW has some features which are shown in Figure 7 (Sato et al, 1989). The horizontal loop of MEAW decreases the load/ deflection rate, and displays a continuous low orthodontic force, Moreover, the horizontal loop in the various contact points separates one tooth from the other. In other words, various tooth movements like the tip back bend or step bend or torque can be incorporated in the rectangular wire, thus shortening the treatment time. Double Archwire (DAW) Double archwire was first introduced by Dr Cettin (Figure 8). Initially, this method was used for the retrusion of the maxillary anterior teeth by the latter's bodily movement instead of using an extraoral appliance. However, this was not generally applied because the reverse action of the anterior teeth depression resulted to distal tipping and elongation of the molars. DAW is composed of a base arch wire from the 1® molar teeth lo the other side (.016x.016) with the sectional labial arch in the anterior region (.016x.022) (Figure 8) An intrusion force is produced on the maxillary anterior teeth by attaching thehook of the sectional anterior labial arch to the base arch. ‘The force system attributed from DAW, as shown in Figure 8c, depresses and retrudes the anterior teeth but produces supraeruption of molars. Labial and Lingual tipping of the anterior teeth can be controlled by the change in position of the hook of the sectional arch in the anterior 1291 Hotd the wire withthe rounded ent of the 2. Use the cornered part of the pliers when 3. The fist bend should look Tike right piers dove, bending the dial part of the wie angle |The proper postion in alling the pls, 5. Hen e diva orion of the wie using 6. Berd ina way that i is pra to che ‘he hands previous one, '9. Then bead to make it in parallel with he ‘8. Pas he wire auint the rome end wf he previous one +. Reposition the pliers by placing the pir Holding dsl portion ote wire tober sounded end onthe tp. Figure 5. Procedure in Bending MEAW, (1) 130TT §__ i itt ormoav, seAw, and DAW in Occlual Consirution 1, Reposition he pliers. Hald he wie closer 2. Ber to the previous one as" "a esta part of the wire for about 3. Reposition the pliers again ant slightly hold the distal portion, thea continaoxsly bend unl the half ofthe remaining angle is bent arg RST once mar, slily 5. Reposition te wie making he lecp tobe 6. Bend the disal endo he wire making in, ‘ove fo the cist part of the wite allowing. in contact with ech otaer Parallel withthe previous one, the previous ber to be in contact with the lane ben. 1 Thehesaatal lop beading is competed. 2. AL the sine time, make a horzeal log? 3, Finished MEAW. All ofthe above hen atthe contact point Steps are important io making an ideal arch. Figure , Procedure in Bending MEAW. (2) 131 ae ae me ReFigure 6. Procedure in Bending MEAW (3) ecomtlop inthe distal part of he ara nsisors, The eave (Fist order ens in th cine eth by Slight tip back bend of MEAW 15" tp bck bend of MEAW (8. Occlusal surface of MEAW teeth. Labial tipping results from the hook applied anterior to the center of rotation of the anterior teeth. Lingual tipping results from the hook applied posterior to the center of rotation of the anterior teeth (Figure 9) DAW is used during the ir itial period of treatment in patients with mandibular distocclusion with insufficient vertical dimension. First, determine the physiological reference 132 position by restoring the vertical dimension. ‘Afterwhich, the need for tooth extraction is examined in order to obtain the final occlusion (appendix 5)oo ti or tn, A nt DAD ctl Cention ‘Treanuent Effect of Maltioop Edgewise Arch Wire 1. Guidance the pysiolng cao pasting 6. Todt Mevennant RP semneily guided ts physnlopel postion wie ‘Movement of te ance dentition is veined at ‘wang an entrant force forthe ajgnient of tie moles Deough shirt period of tine boas of tie oiodantec the claninalon of cusp mterteraie onl chenge into octal farce pleas. feXson ai irusion of ete, {\ qe a eee ! ‘Place is possible through the alignment. lz 2 5 Torque Comtrot ‘The effets the torque conc with O10 x 022 isemtsundy rehired “Seough te actin ofthe borg loop 2 Toodh Algumens The ted tee aigued ough be hee Joopby its low med contnos erode Teace en eich oop. 3. Abin of an CP ‘he force sysem ilk LEA end vertical ese ligne tae feed aod ffects fe aeroujaion of en oth A sable ‘Troatment Objective of MEAW 1 To sin cocking pysilogia! RP 2. To esti an accion nie prenunve cat, cxpal anv occlusal mturerance 3. Te obi astble Omri stop and nee an ccc sport. 4 Tonle a coreetentesor guidee for the frictional movement sf Ge moni, 8. Terni te tipping of de echsal plane wis he condyle tind miter tdece pat To inane the auerir caupons of cactus fre by obtiaing ‘core sil ping of eed Figure 7. Minsraton of the wesiment effets of the ose sytem with MEA and vertical elastic (revered oclusion)> 133Figure 8 Contrel of the vernca! dumensiia yt MEAW Strusure of Mosted DAW Inds auc, she Seton} ae ante asters por {© Iktation sbowrng the conel of vesueal dens 134 hooked wo the mam aichiave which are engaged she premolus and IY molars o oa Figure 9 Consol ofthe anterioe roth mavement ised on the ecg DAW inche antercxregion 2 Bork fied srierior tothe center of 1o4uoH of dhe ek of the ooh to he eofer oF rotation he cemer ef ritauon oF re oF ae2. Occlusal Reconstruction in Skeletal Class III Malocclusion ‘The orthodontic treatment of malocclusion with abnormal skeletal growth like the skeletal reversed occlusion and skeletal open bite are usually known to be very difficult. One reason for this is the incorrect concept of the cause and process of development of malocclusion (i.e. that the skeleton is the cause of its abnormal development and not related to its functional abnormality). Evolvement of the chin cap appliance to limit the growth of the mandible as well as the protrusive traction applianoe to induce the growth of the maxilla resulted from this concept, In cases where these would be ineffective, surgical operation as a s treatment has been known to symptoms. However, even if these have been freely practiced, the occlusal condition is not stable, and recurrence or a different type of malocclusion develops in most patients. In short, it could be concluded that all of these can only improve the symptoms and the pursuit of finding the root cause of malocclusion has been neglected. ‘The great effect of mandibular growth to its. functional movement and position has been clarified in numerous fundamental researches. Moreover, as repetitively mentioned, the direction of growth of the maxilla is controlled by the dynamic mechanism of the maxillotacial skeleton. Thvs the dynamic harmony of the components of the maxillofacial skeleton must be in a stable condition. The abnormal growth of the skeleton means the disruption of that dynamic harmony The primary orthodontic treatment objective then, in this case is to find the functional abnormality and the removal of the cause ‘The remarkable changes in a patient showing a high angle skeletal reversed occlusion is the flattening of the occlusal plane, and the anterior rotation and repositioning of the mandible in response 10 it, showing the preservation of the dynamic harmony. In addition, flattening of the occlusal plane is mainly caused by the supraeruption of the molars, The occlusal plane is normaily very stable during the growth and development period and usually, there are no remarkable changes during the successional eruption of permanent teeth. However, ina patient with reversed occlusion and aggravated skeletal symptoms, occlusal plane is 5°-10° higher or even more. Discrepancy may result to this change especially in the molar area (posterior discrepancy). Supraeruption of the molars in posterior discrepancy slowly flattens the occlusal plane. Therefore, the symptoms mainly observed in discrepancy are crowding and maxillo~ mandibular protrusion. Nevertheless, discrepancyis also seen in the molar area causing the problem of “squeezing out effect” which is recognized to be the cause of skeletal malocclusion 135‘Once the occlusal plane flattens, occlusal interference occurs in the molar ares, There is a functional protrusive deviation associated with the protrusive rotation of the mandible consequently leading to mandibular condylar growth. This is one of the growth processes of skeletal reversed occlusion. The process, which is: posterior discrepancy = supracruption of molar = flattening of the occlusal plane = functional deviation of the mandible = skeletal growth abnormality, is considered to be an important phenomenon from the viewpoint of the dynamic mechanism of the maxillofacial skeleton. These are mostly important aspects of consideration in the diagnosis of skeletal malocclusion, and establishing the treatment plan, ete Treatment Objective of Skeletal Class II Malocelusion Basically, the elimination of posterior discrepancy and the reconstruction of the occlusal plane are the basic treatment objectives in the orthodontic treatment of posterior discrepancy associated with the flattening of the occlusal plane The usual premolar extraction to eliminate posterior discrepancy is not an effective method. In modern orthodontic treatment procedure, mesial movement of the molars is not that effective in eliminating posterior discrepancy. Extraction of the premolar causes lingual tipping of the anterior teeth, This has a longer treatment period and causes complications during the treatment process. Since posterior discrepancy occurs in the posterior region, extraction in the molar area is considered as a means 10 eliminate posterior discrepancy. The upper and lower 3" molars, ot the upper 2 molars and lower 3 molars are 136 Reconstruction of the occlusal plane is accomplished by using the a modified offset archwire (MOAW) or the multiloop edgewise archwire (MEAW), and vertical elastic in the anterior part or short Class III elastic which is attached (0 the distal of maxillary canine to the mesial of mandibular canine. This guides the retruded position of the mandible applying a functional pressure to the mandibular condyle resulting to the improvement of skeletal symptoms. Moreover, orthopedic results are expected from this because it has an action of pulling che maxilla anteroinferiorly where an extraoral force is not necessary. The madibular condyle functions as the fulcrum in class TI cantilever (Figure 1a) ‘However, this fulcrum becomes a class I cantilever when there is an interference in the molar area brought about by the supraeruption of the molars (igure 1). This displaces the mandible and retracts the mandibular condyle, consequently leading to its growth. The treatment objective, therefore, is to remove the fulcrum in the molars, and use a force system that can correctly place the mandibular condyle back to the mandibular fossa (Figure 1e). Basically, as shown in Figure 2b, the fulcrum formed in the anterior teeth, the closing muscles are used as a force system to retrusively guide the mandible. Moreover, occlusal interference is eliminated through the alignment and intrusion of the supracrupted molars, using a force system illustrated in Figure 3b. ‘Treatment Procedure for Skeletal Class TI ‘Malocclusion ‘With this procedure, MOAW, shown in