Skeletal Effects of Orthodontic

Forces: Growth Modification

By
Dr. Sara Shah
Department of Orthodontics
 Biomechanics
1. Structure and Function of PDL

2. Orthodontic Tooth Movement

3. Theories of Tooth Movement

4. Effects of Magnitude & Duration

5. Deleterious Effects of Orthodontic Forces

6. Skeletal Effects of Orthodontic Forces

 Principles in Growth Modification

 Orthodontic force applied to the teeth has the

potential to radiate outward and affect distant
skeletal locations

 Orthodontic tooth movement can correct dental

malocclusions

• if the distant effects could change the pattern of

jaw growth
• possibility of correcting skeletal malocclusions
Jaw Growth
 The maxilla grows by
apposition of new bone at its
posterior and superior sutures
in response to
• being pushed forward by the
lengthening cranial base and
• Pulled downward and forward
by the growth of the adjacent
soft tissues
 Jaw Growth
 The mandible is
• pulled downward and forward by
the soft tissues in which it is
embedded
• In response, the condylar
process grows upward and
backward to maintain the
temporomandibular articulation
 Growth Modification - Clinical
 Pressures resisting the downward and forward
movement of either jaw should decrease the
amount of growth
 Pressures adding to the forces that pull them
downward and forward should increase their growth
 The possibility of modifying the growth of the jaws
and face
 The extent to which treatment can produce skeletal
change remains controversial
 Characteristics of patients who would be good
candidates for it
Effects of Orthodontic Force
on the Maxilla and Mid face

 Teeth erupt and bring alveolar bone with them, a

contribution to growth of both jaws that is of great
importance in orthodontic treatment
 Manipulation and control of tooth eruption is properly
considered an aspect of orthodontic tooth movement
 Growth of the alveolar process has a major effect on antero
posterior and vertical jaw relationships
 In treatment of patients, the dento alveolar and skeletal
effects cannot be divorced so readily
 Modification of Maxillary Growth

 Important sites of growth of the maxilla are the

sutures that attach the maxilla to the zygoma,
pterygoid plates, and frontonasal area and
separate the middle of the palate

 Where it might be possible to alter the expression

of growth
Modification Of Excessive Maxillary
Growth
The concept of
treatment would be to
add a force to oppose
the natural force that
separates the sutures,
preventing the amount
of separation that would
have occurred
 Deficient Maxillary Growth
The concept is to add additional force to the natural
force, separating the sutures more than otherwise
would have occurred
 Modification of Maxillary Growth
 Moderate amounts of force against the maxillary
teeth can impede forward growth of the maxilla

* The moderate forces recommended for restraint of

forward maxillary growth tend to be heavier than
> those recommended for tooth movement alone
 Modification of Maxillary Growth
 Heavier force is needed for separation of sutures and
growth stimulation

 When force is applied to the teeth, only a small

fraction of the pressure in the PDL is experienced at
the sutures, because the area of the sutures is so
much larger
 Mid Palatal Expansion and Age
Mid palatal suture becomes interlocked with increasing
age
9 – 10 years of age – opening of midpalatal suture is
relatively easier
15 – 17 years of age– partially interlocked suture
requires micro fracture
After adolescence – increased interlocking of suture will
require surgery to be released
 Growth Modification Treatment
During which tooth movement is undesirable

The objective is to correct the jaw discrepancy, not

move teeth to camouflage it

Type of force applied

•Heavy continuous force can damage the roots of
the teeth and the periodontium
•Heavy intermittent* force is less likely to produce
damage
* The stimulus for undermining resorption is diluted during
the times that the heavy force is removed
 Tooth Movement
 A definite threshold for the duration of force
* Unless force is applied to a tooth for at least 6
hours per day, no bone remodeling occurs

 Time of day when force was applied to the jaws

 Short-term growth is characterized by fluctuations

in growth rates, even within a single day
 Tooth Movement

 In growing children, growth hormone GH

is released primarily during the evening

 More likely to occur during the times of

active growth
 Force Prescription For Headgear
To restrain maxillary growth in patients with Class II
problems
Force of 500 to 1000 gms. total (half that per side)
Force direction slightly above the occlusal plane
(through the center of resistance of the molar teeth, if
the force application is to the molars by a face bow)
 Force Prescription For Headgear
 Force duration at least 12 hours per day, every
day, with emphasis on wearing it from early
evening (right after dinner) until the next
morning

 Typical treatment duration 12 to 18 months,

depending on rapidity of growth and patient
cooperation
 Effects of Orthodontic Force
on the Mandible

 The mandible, to some extent, grows in response

to growth of the surrounding soft tissues

 It is possible to alter its growth by

• pushing back against it or
• pulling it forward
 Effects of Orthodontic Force
on the Mandible
 The attachment of the mandible to the rest of the
facial skeleton via the temporomandibular joint is very
different
 The response of the mandible to force transmitted to
the temporomandibular joint also is quite different
 Effects of Orthodontic Force
on the Mandible
 Efforts to restrain mandibular growth by applying
a compressive force to the mandibular condyle
have never been very successful

 It is related to
• their willingness to cooperate with the duration
and magnitude of force necessary or
• may be the result of inappropriate force levels
within the joint
 Effects of Orthodontic Force on the
Mandible
The presence of the articular disc complicates the
situation, making it difficult to determine exactly what
areas in and around the temporomandibular joint are
being loaded by pressure against the chin
 Effects of Orthodontic Force on the
Mandible
The geometry of the rounded joint surfaces makes it
difficult to load the entire area

A force aimed at the top of the condyle might well restrain growth there
Effects of Orthodontic Force on the
Mandible-Clinical
 Use a chin cup to
deliberately rotate the
mandible down and back,
redirecting rather than
directly restraining
mandibular growth

 This reduces the

prominence of the chin,
increasing anterior face
height AFH
Effects of Orthodontic Force on the
Mandible-Clinical

 Class III functional

appliances produce
exactly the rotation

 A patient who had

excessive face height
and mandibular
prognathism would
not be a good
candidate

Two thirds of the prognathic patients have a long face as well

 Effects of Orthodontic Force on the
Mandible-Clinical
 Skeletal Class II

• The condyle translates forward away from the

temporal bone during normal function, and the
mandible can be pulled into a protruded position
and held there for long durations with moderate
and entirely tolerable force

• Exactly how the mandible is held forward out of

the fossa is important in determining the
response
 Class II Functional Appliances
Mechanism of Action
 There are two mechanisms for protrusion
• Passive: the mandible is held forward by the
orthodontic appliance
• Active: the patient responds to the appliance by using
his or her muscles, especially the lateral pterygoid, to
hold the mandible forward
 Class II Functional Appliances
Mechanism of Action
 When the mandible is protruded (or restrained),
changes can occur on
• the temporal
• the mandibular side of the temporomandibular joint
 Class II Functional Appliances
Mechanism of Action
• If the musculature relaxes, the reaction force is
distributed to the maxilla and, to the extent that
the appliance contacts them, to the maxillary and
mandibular teeth

Headgear usually produces a greater effect on the maxilla than a functional appliance
 Effects of Orthodontic Force on the
Mandible-Clinical
 Identical force system
• When functional appliance contacts the teeth to Class
II elastics, which would move the upper teeth
backward and the lower teeth forward
 To maximize skeletal effects and minimize dental
effects, the reactive forces should be kept away from
the teeth