Contents
Introduction Anatomy of maxilla Anatomy of Mandible Applied aspects Skeletal malocclusion Anchorage Cleft plate Oral asymmetry
Introduction
As orthodontist are heavily involved in the treating abnormalities in the development of not just the dentition but the entire dentofacial complex, should be able to manipulate facial growth for the benefit of the patient.
Bones of head and neck include somatic bones, the skull, seven cervical vertebrae and the hyoid developed from the second and third brachial arches. The skull cap is formed by frontal , parietal, squamous temporal and a part of occipital bones, develop by intramembranous ossification being a quicker one stage process. The base of the skull in contrast ossifies by intracartilaginous ossification which is a two stage process (membrane-cartilagebone)
The skeleton of the head is called as skull. It consists of several bones that are joined together to form the cranium. The term skull also include mandible (the lower jaw). Skull can be divided into two main parts a) The calvaria or brain box b) The facial skeleton constitutes the rest of the skull and includes the mandible.
1) Parietal
2) Temporal
1) Frontal
2) occipital 3) Sphenoid 4) Ethmoid
Norma Frontalis
Norma lateralis
Norma occipitalis
Norma verticalis
Norma basalis
anterior
middle
posterior
Anterior part of norma basalis:1) Alveolar arch:-bears socket of the roots of the upper teeth 2) Hard palate:- formation anterior two third by the palatine
Greater palatine foramen:- One on each side is situtated just below the lateral part of the palatomaxillary sutures. The lesser palatine formamina:- Two or three in number on each side is situated behind the greater palatine foramen. Posterior border of the hard palate is free and presents the posterior nasal spine in the median plane. The palatine crest is a curved ridge near the posterior border. It begins behind the greater palatine foramen and runs medially.
Middle part of norma basalis:- The middle part extends from the posterior border of hard palate to the arbitary transverse line passing through the anterior margin of the foramen magnum
Maxilla
The term maxilla was derived from a Latin word Mala which means cheeks Its the second largest bone of the face
The two maxillae form the whole of the upper jaw, and each
maxilla enter into the formation of face, nose mouth orbit the infratemporal and pterygopalatine fossae
Features
Each maxilla has a body and four process Body of maxilla:- The body of maxilla is pyramidal in shape with its base directed medially at nasal surfaces and the apex directed laterally at the zygomatic process. It has four surface and encloses a large cavity the maxillary sinus. The surfaces are 1) 2) 3) 4) Anterior or facial Posterior or infratemporal Superior or orbital Medial or nasal
Maxilla contributes a large share in the formation of facial skeleton. The anterior surface of the body of the maxilla presents a) nasal notch medially b) the anterior nasal spine
c) Infraorbital foramen
d)Incisive fossa e)The canine fossa lateral to the canine eminence
The frontal process articulates anteriorly with the nasal bone, posteriorly with the lacrimal bone and superiorly with the frontal bone. The zygomatic process of the maxilla is short and articulates with zygomatic bone The alveolar process of maxilla bears sockets. The palatine process
Anterior or facial surface:- Directed forward and laterally Above the incisor teeth there is a slight depression the incisive
Above the canine fossa there is infra orbital foramen which transmits infraorbital nerve and vessels. Lecator labi superioris arises between the infraorbital margins and infra orbital foramen. Medially the anterior surface ends in a deep concave border, the nasal notch which terminates below into process with the corresponding process of maxilla forms the anterior nasal spine. Anterior surface bordering the nasal notch gives orgin to nasal depressor septi
Infratemporal surface
Convex and directed backwards and laterally . Forms anterior wall of infratemporal fossa separated from anterior surface by zygomatic process .
Near the centre of surface open two or three alveolar canals for
posterior superior alveloar nerve and vessels.
Posterioinferiorly there is a rounded eminence the maxillary tuberosity which articulates superiomedially with pyramidal process of palatine bone and gives origin laterally to superficial head of medial pterygoid muscle. Above the maxillary tuberosity the smooth surface form the anterior wall of pterygopalatine fossa and is grooved by maxillary nerve.
It is smooth ,triangular , and slightly concave and forms the greater part of the floor of orbit. Anterior border forms a part of the infraorbital margin. Medially it is continuous with the lacrimal crest of frontal process.
Posterior border forms anterior margin of the inferior orbital fissure,in the middle it is notched by infraorbital groove.
Medial border presents anteriorly the lacrimal notch which is converted into nasolacrimal canal by decending process of lacrimal bone. Behind the notch,the border articulates from before backwards with the lacrimal ,ethmoid, and the orbital process of palatine bone.
Surface presents infraorbital groove leading forwards to infraorbital canal which opens on anterior surface as infraorbital foramen. Inferior oblique muscle of eyeball arises from depression ;lateral to lacrimal notch at the anteromedial angle to the surface.
Forms a part of lateral part of nose. Posterosuperiorly displays large irregular opening of maxillary sinus. Above sinus, there are parts of air sinuses which are completed by ethmoid and lacrimal bones.
Below hiatus ,smooth concave surface forms a part of inferior meatus of nose. Behind hiatus ,surface articulates with perpendicular plate of palatine bone. Front of hiatus; nasolacrimal groove which is converted into nasolacrimal .
MAXILLARY PROCESSES
ZYGOMATIC PROCESS FRONTAL PROCESS ALVEOLAR PROCESS PALATINE PROCESS
ZYGOMATIC PROCESS
Is a pyramidal lateral projection on which the anterior , posterior, and superior surfaces of maxilla converge. In front and behind it is continuous with the corresponding surfaces of the body, but superiorly it is rough for articulation with the zygomatic bone.
FRONTAL PROCESS
margin of frontal bone ,in front with nasal bone and behind
with lacrimal bone. Lateral surface is divided by a vertical ridge ,the anterior lacrimal crest , into smooth anterior part and a grooved posterior part.
Medial surface forms part of lateral wall of nose. a) Uppermost area is rough for articulation with ethmoid to close the anterior ethmoidal sinuses. b) Ethmoidal crest is a horizontal ridge about the middle of the process. Posterior part of crest articulates with middle nasal concha ,and anterior part lies beneath the agger nasi.
. The anterior smooth area gives origin to the orbital part of orbicularis oculi and levator labii superioris. Posterior grooved
The area below the ethmoidal crest is hollowed out to form the atrium of middle meatus. Below the atrium is the conchal crest which articulates with
ALVEOLAR PROCESS
Forms half of the alveolar arch, and bears sockets for the roots of upper teeth. Buccinator arises from posterior part of its outer surface up to
PALATINE PROCESS
Is a thick horizontal plate projecting medially from the lowest part of the nasal surface. Inferior surface is concave and the two palatine processes form
Superior surface is concave from side to side, and forms greater part of floor of nasal cavity. Medial border is thicker in front than behind. It is raised
ARTICULATIONS
Superiorly articulates with 1) nasal 2) frontal 3) lacrimal bones. Medially, with 1) Ethmoid 2) inferior nasal concha, 3) vomer, 4) palatine 5) opposite maxilla. Laterally, 1) zygomatic bone
Growth
The attachment of facial skeleton anterioinferiorly to the
Zygomatic bone is attached to the calvarial skeleton at the temporozygomatic and frontozygomatic sutures. The maxillary and nasal bones of the anterior aspects are attached to calvaria at the fronto maxillary and frontonasal sutures
The nasal cavity and the nasal septum have considerable influences in determining facial form.
Direction of growth and resoption of facial bone at various sites. The overall effect if the combination of these growth sites is a downward and forward displacement of face and vice versa for the cranial base
The frontomaxillary, frontozygomatic, frontonasal, ethmoidomaxillary, and frontoethmoidal sutures are the sites of bone growth in a largely vertical direction as a result of eyeball and nasal septal expansion. If the nasal septum is defective, the height of the middle third of the face is less affected than its anteroposterior dimension resulting in concavity of the face. Sutures function mainly as sites of fibrous union of the skull bones, allowing for adjustments brought by surface apposition and remodeling.
GROWTH FIELDS
All surfaces, inside and outside, of every bone are covered by an irregular pattern of growth fields comprised of various soft tissue osteogenic membranes or cartilages. The genetic component for bone growth resides in the bones investing soft tissues muscles, integument, mucosa, blood vessels, nerve, connective tissue, the brain, etc.
control bone growth whereas the bone itself only reports via a feedback mechanism which
Mandible
The word mandible came from the latin word mandibula meaning chew. The mandible ,or the lower jaw, is the largest and the strongest bone of the face. It develops from the first pharyngeal arch. It has a horseshoe-shaped body which lodges the teeth, and a pair of rami which project upwards from the posterior ends of the body. The rami provide attachment to the muscles of mastication.
BODY Each half of the body has outer and inner surfaces, and upper and lower borders. The outer surface presents the following features. 1. symphysis menti 2. mental protuberance and mental tubercles. 3. mental foramen. 4. oblique line 5. incisive fossa.
Inner surface
1) Mylohyoid line 2) Submandibular fossa 3) Sublingual fossa 4) Posterior surface of symphysis menti 5) The mylohyoid groove
RAMUS
The ramus is quadrilateral in shape and has two surfaces, lateral and medial, four borders, upper, lower, anterior and posterior, and the coronoid and condyloid processes.
The medial surface presents the following: Mandibular foramen and mandibular canal. Lingula The mylohyoid groove Mandibular notch. Coronoid process Condyloid process
The lower border is the backward continuation of the base of the mandible. Posteriorly, it ends by becoming continuous with the posterior border at the angle of the mandible. The anterior border is thin, while the posterior border is thick.
FACIAL MUSCLES
1) Muscle of the scalp 1) occipitofrontalis 2) Muscle of auricle 1) auricularis anterior 2) auricularis superior 3) auricularis posterior 3) Muscles of the eyelids 1) orbicularis occuli 2)Corrugator supercilii 3)Levator palpebrae superioris
4 ) Muscles of the nose 1) procerus 2) compressor naris 3)dilator naris 4)depressor septi 5) Muscle around the mouth 1) Orbicularis oris 2) Zygomatic major 3) Levator labii superioris 4) Levator angli oris 5) Zygomatic minor 6) Depressor anguli oris 7) Mentalis 8) Risoris 9) buccinaor
MUSCLES OF MASTICATION
MUSCLES OF MASTICATION
Masseter muscle Temporalis muscle Medial pterygoid muscle Lateral pterygoid muscle
COMMON CHARACTERISITICS: 1. All are inserted to the mandible 2. All are innervated by the mandibular division of the trigeminal nerve 3. All are concerned with biting and chewing FUNCTIONS: 1. To move the mandible 2. To secure then stabilize the mandibular positions 3. To determine the direction of mandibular movements
Masseter muscle
It is a flat quadrangular muscle, partly tendinous, partly fleshy. It overlies the lateral surface of the mandibular ramus. ACTION: elevate the jaw, with the superficial fibers causing protraction
TEMPORALIS MUSCLE
It is a large, fan-shaped muscle at the sides of the head.
ACTION: anterior fibers elevate the mandible, while the posterior fibers retract the mandible Blood supply: Deep temporal branches of maxillary artery.
Action: assets in elevating and protrusion of the mandible acts together with lat. Pterygoid of the same side in rotating the mandible
Temporomandibular joint
The temporomandibular joint is an example of ginglymoarthrodial articulation and its movements are combination of gliding movements and loose hinge movements. GINGLYMOARTHROIDAL: The TMJ offers hinging movements in one plane, therefore it is considered as ginglymoid. It also provides for gliding movement, hence arthroidal.
The temporomandibular joint is made up of the following A. BONY COMPONENTS 1. Condylar head 2. Glenoid fossa 3. Articular eminence B. SOFT-TISSUECOMPONENTS 1. Joint capsule 2. Articular disk 3. Ligaments C. MUSCLES ASSOCIATED WITH THE TMJ
Muscles of mastication Muscles attached to the joint Muscles of facial expression Muscles of the neck
MAXILLARY ARTERY
The larger terminal branch of the external carotid artery given off behind the neck of the mandible. It has a wide territory of distribution and supplies 1) the external and middle ears and the auditory tube 2) the dura mater 3) The upper and lower jaws 4) The muscles of the termporal and infra temporal regions 5) The nose and paranasal air sinuses 6) The palate 7) The root of the pharynx
Branches
ROTATION OF JAWS
Studies of growth were carried out in the 1960s primarily by Bjork and coworkers in Copenhagen, the extent to which both the maxilla and mandible rotate during growth.
Forward rotation of the mandible with the center (type I) at the joints (a) With the center at the incisal edges of the lower incisors (type II) (b) With the center at the premolars (type III) (c)
Backward rotation of the mandible with the center at the joints (a) and with the center at the last occluding molars Type I:Bite is raised increased Anterior facial height Flattening of cranial base Middle cranial fossa is raised in relation to anterior Incomplete development of middle cranial fossae Type IIOccurs in relation with growth in the saggital direction at the mandibular condyles Because of position of the center of rotation at the molar the symphysis swung backward and the chin may not follow this movement and a characteristic double chin can occur
Cockwise rotation
Conterclockwise rotation
Internal rotation (IR) rotation occurs in the core of the jaw bone Core is the portion that covers the inferior alveolar nerve
Remaining parts of mandible like alveolar process the muscular processes condylar process
Total rotation
Bjork and Skieller distinguished two contributions to internal rotation (which they called total rotation) of the mandible: (l) matrix rotation, or rotation around the condyle (2) intramatrix rotation, or rotation centered within the body of the mandible
Hemifacial hypertrophy: evident at birth tends to be prominent at puberty. Unilateral enlargement of the mandible, the mandibular fossa and the teeth. Bifid or Double Condyle: results from the persistence of the septa dividing the fetal condylar cartilage.
Skeletal malocclusion
CLASS II MALOCCLUSION
Components of class II malocclusion:-
Maxilla
mandible
Dental position
Skeletal position
maxilla
mandible
Normal mandible
Retrognatic mandible
Normal maxilla
Prognatic maxilla
Deficient in mandibular size Mandible well defined but still class II due to posterior
Treatment
Once the component has been identified one or more specific
Protrusion
Retrusion
Protrusion The most common treatment for true maxillary skeletal protrusion is extraoral traction. Extraoral traction appliances are divided arbitrarily into two types 1) Face-bow 2) Head gear
Retrusion
There are a significant number of class II patients whose malocclusions are characterized in the part, by maxillary skeletal retrusion
. This condition tends to be found in patients who have a long lower face height, a steep mandibular plane angle and a retruded position of the chin point.
Maxillary skeletal retrusion is extremely difficult to treat directly. Occasionally retrusion may be treated indirectly by using such appliances as posterior bite block or the veritcal-pull chin cup that may produce a slight upward and forward movement of the maxilla and a counterclockwise rotation of the mandible
MANDIBLE
mandible
Treatment options
1) 2) 3) 4) FR-2 of frankel Twin block appliance Herbst appliance Bionator The first two are primarly indicated in mixed dentition. Herbst in early permanent dentition.
Improved clinical use of Twin-block and Herbst as a result of radiating viscoelastic tissue forces on the condyle and fossa in treatment and long-term retention: Growth relativity AJO DO 2000
Light bulb analogy of condylar growth and retention. When the growing condyle is continuously advanced, it lights up like a light bulb on a dimmer switch. When the condyle is released from the anterior displacement, the reactivated muscle activity dims the light bulb and returns it close to normal growth activity. In the boxed area, the upper open coil shows the potential of the anterior digastric muscle and other perimandibular connective tissues to reactivate and return the condyle back into the fossa once the advancement is released. The lower coil in the box represents the shortened inferior LPM. The open coil above the yellow condylar light bulb represents the effects of the stretched retrodiskal tissues.
Biodynamic factors involved in condylar-glenoid fossa (C-GF) growth modification during orthopedic mandibular advancement in treatment and retention. Metabolic action describes the pump-like influx and expulsion of nutrients and other chemicals from the engorged blood vessels of the proliferating retrodiscal tissues (dark blue region) extending between the condyle and the fossa. This biodynamic action (light blue circle) occurs in the retrodiskal tissues and fibrocartilage during condylar displacement. The expulsion of these accumulated metabolites occurs during reseating of the protracted condyle and is clinically evident as relapse of the previously observed condition.
VERTICAL EXCESS
Skeletal open bite Long face syndrome Elongation of maxillary and mandibular posterior teeth
Rx OF VERTICAL EXCESS
HIGHPULL HEADGEAR TO MOLARS Maintain vertical position of maxilla Inhibit eruption of maxillary posteriors
Rx OF VERTICAL EXCESS
HIGHPULL HEADGEAR TO A MAXILLARY OCCLUSAL SPLINT Gummy smile Excessive incisal show (increased ant. dental height) Disadvantage: allows mandibular teeth to erupt freely
TRANSVERSE DIMENSION
The transverse dimension of maxilla can be widen and this temporary defect in the mid palatal suture region remodels with osseous tissue.
Suture is formed by the junction of the three opposing pairs of bones namely premaxillae,maxillae and the palatines but often for practical purposes they will be treated as single entity called as a Midpalatal suture.
The suture starts to ossify posteriorly (Davida 1926) and always shows a greater degree of obliteration posteriorly then anteriorly, while ossification comes very late anterior to Incisive foramen.
Cleft plate
The simplest definition of a cleft is that Its an opening in an anatomical part that is normally not open. Orthodontist plays a major role in the management of the Cleft patient. Palatal integrity is essential at birth to enable feeding. The orthodontist helps in designing and fabrication of the following appliances that may be used for the Cleft palate patient management: Feeding plate for the neonate. Orthodontic correction plate for the gum pad.
Bone density and Misch classifications Stationary anchorage failure often occurs because the TAD was placed in a region of low bone density with inadequate cortical thickness
D1 (> 1,250 HU) is dense cortical bone primarily found in the anterior mandible, buccal shelf and midpalatal region . D2 (850-1,250 HU) is porous cortical bone with coarse trabeculae found primarily in the anterior maxilla, the midpalatal region and the posterior mandible. D3 (350-850 HU) is thin (1 mm), porous cortical bone with fine trabeculae,found primarily in the posterior maxilla and mandible. D4 (150-350 HU) is fine trabecular bone, found primarily in the tuberosity region
Stedmans medical dictionary symmetry may be defined as equality or correspondence in form of parts distributed around a center or an axis, at the two extremes or poles or on the two opposite sides of the body
CLASSIFICATION.
Asymmetries can be classified according to the structures involved into dental, skeletal and functional. Dental asymmetries Skeletal asymmetries
Muscular asymmetries
Functional asymmetries
Dental asymmetries: These can be due to local factors such as early loss of deciduous teeth, congenitally missing tooth or, and habits such as thumb sucking. Lack of exactness in genetic expression affects the teeth on the right and left sides causing asymmetries in mesiodistal crown diameters. Skeletal asymmetries: The deviation may involve one bone such as the maxilla or mandible, or it may involve a number of skeletal and muscular structures on one side of the face, e.g. hemifacial microsomia
Muscular asymmetries: Facial disproportions and midline discrepancies could be the result of muscular asymmetry, as might occur with hemifacial atrophy or cerebral palsy. Sometimes muscle size is ill-proportioned as in masseter hypertrophy." Abnormal muscle function often results in skeletal and dental deviations. Functional asymmetries: These can result from the mandible being deflected laterally or antero-posteriorly, if occlusal interferences prevent proper intercuspation in centric relation. These functional deviations may be caused by a constricted maxillary arch (even if the constriction, in itself, is symmetrical), or a more localized factor such as a malposed tooth. The abnormal initial tooth contact in centric relation results in the subsequent mandibular displacement in centric occlusion.
Conclusion
One should have a thorough understanding of the basic anatomy constitution of the tissue structure and anatomy of the area before intervening or indulging in deciding treatment plans.
REFRENCES
Contemporary Orthodontics William R Profit. Text Book of Craniofacial growth Sridhar Premkumar Colour atlas of dental medicine Orthodontic diagnosis- Rakosi Orthodontics and dentofacial orthopedicsJames A McNamara
Text Book Of Anatomy- Grays Anatomy Human Anatomy- B.D. Chaurasia Facial growth Geoffrey H. Sperber
Janusz Skrzat et al., The morphometry of the human palatine sutures(Folia Morphol., 2003, Vol. 62, No. 2) Improved clinical use of Twin-block and Herbst as a result of radiating viscoelastic tissue forces on the condyle and fossa in treatment and long-term retention: Growth relativity AJO DO 2000
Age related differences in mandibular ramus growth: a histologic study- Mark G. Hans, Donald H. Enlow, Regina Noachter