S' retching the Orthodontic Mlnd ", 01 .

N e Dimenslons

'R'O" 'B'E"K'T 'U'R"R"A-V' 'R"IC"· 'KETT' 'S

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~ :2,002 AffiericaiJ'il IjlJsti6Jte! fOr Blopi'OgM$~ Edu~lloli1i SOO'ttsdale, Alnzor!'ai

Rlic1t:.etiliS Research ll'brary Md Lea;m ng Ce~ter' lLoma IUllilda Ufl'iverst~y

Lorna U:n:eJlal, Garffomia

fr~Loban; M. Ricke1tS~1 D.D.Sul 1M,S., N.M.D.

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E.-md~ 1'ifict@<!J!1ala.eom

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PREFAC=:

STRETC Hl NG THE MIN D TO NEW DI MENS IONS T~ ble of Contents

DO YOU UNDERSTAND?

Orthod onti c Prog rRSS Barriers

Sernant'cs

NE!W MO'll8:I"Tl8!lt:ii and Adva ncerrents not Recogn ized

PART I:

PART [I:

THE BASIC MATRIX

A.

Ge neral concepts

I nfo rmatlon and Kn owl e.dge The nee-d for Science ResP-o::3rch

Qu a I~ty of ute

B.

Movements a nd Attitudes

1. The- E'lliden DB Based ld ea

2. Six Major OrijectilJes i~ Orthodontics

3. Objectives ~n Total Patie nt VVeifa re

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Movements. in Physics

4. Ti Ii erian Physics

5. Access to 'Patterns

e. DFsi ntegratio n or Mass

7_ Vortex energy and Paramagnetio:; 8_ AI lotro p ir: Conversl ons

D.

The New Bioi Ogy

9_ Etheiic Phenomena

1 O. TIle Cell Membra ne as its Bra.i n

11_ The Fin;;l! En",i rn nrnent' I nterstina I FI ui d 12. Enzyme and Hormone Recog n~~on

't 3_ Leukocytolysis

14_ Minerals I Trace Mi nerals and Phytomi neral s 15_ Prob ioti ce

16_ 0 ivin e- Pr-aporti ons: More than Esthetics

CLINICAL MOVEMENTS OF SIGNIFICANCE

17. Abri dged Analysis

16. Frontal Cephl1liometrics

19. Dent[jm~ncs and Peruo-norphlcs

PART III.

SUMMA~Y

20. The Haftir'IfJ Zone Matrix

2"'1 ,The Cu rve .of Ma ndi b ular GrolNth

22. F crecasti ng .a nd Objectivism: Short anc Long T errr: Th i rd Molars

23. Treatment Desi-gni ng and Maxiil ary Ad a ptivity 2-4, Control Ii ng the Man d~ble: H istiol ogy

25, E~rly T reefrnent Acvs nt.agos

2.6_ Terrooral Bone Monitming

27 _ T empomanotbuLa r Jo int Pathosis: Clas8ifi catl on 28. Dreg eneratlve J oint Di sease

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MECHANICAL DEVF.L.QPMENTS AND TECHNOLOGY - I DEA:'S n~AT SfT THF STAGE r=OR N:I!'/'J MOVEME ras

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29- Scientific Eval u ation of the Mand ibl ar Postu ri ng Methods 30_ Co ntraindications for Hi g h Pull F ace Bow

31 . Condemnation of t-l igh Pull

32. Confi rrnaf on of Root Ratings for P re€wre

33, the Advent cf .457 mm (.018") Slot and .406- mm (,Q16~1 Sq.uare Wire {A further reduction of (.017) or .4:3 rnrn slot was designed)

34. The F acijl-e- F ormu!a. "for Tubes and Brackets

Angulatior.s r Torques

.. Raisas

- Rotations 35. v.Jh Y Loops

36, Two- Band Orthodorni cs

- Two Molar Anchorage

37. StagiTlg Meehan ics: The Matrix

36. Secti 0 nal M-scha nlcs and Anchorage Control 39-. E::dra ~i on Mechanics with F 30 Ie F ormuis

n The Rici.etts Extraction Pattern Preference

40. Lip Surge: ry

41. Advancl ng-RBdlJ:cti 0 n Genioplasty 42.. Distraction O:steog enesl s

43. se mi- Pjastl c Appli ancas

44. Soft Tissue BeJl:avior 45_ Pri n ciples of Correction 46. Consummate Occl usion

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PREFACE

For the past fiva da<;3d~$ the a ether has been Ie-j step r:.y step by a I~ng cl"'I.a in of research projects in .... olvfng both clin leal and a-:-Dlied 5.:::ienees. A':.. the same time. tt' e findmgs. a nd the resuJli n g: developments have been free Iy and open Iy shared witt'. colleagues .a ro uno thE:! VJO.rI:j fty the cornmor- good.

I n tr.e past 1hree de-cadas. the resea rcn has !=ir'Je€oded up :)!P' virtue aj the aeva rtages by us-a- of the computer. N-e.w paradigms eme rgsc.

New ioeas ""e~-e ~$teO:. OM study a -one required tn.at 'our hlj~droo 1tJ..ousa nd pieces of data was to be abstra cted.

At tle same ti rre, develoc lYlent$ in other related 5cientifEv fie~s l'leedl!ld 10 be emb~ced for thinking if nol for their practical value. CDmrnned.:h ts ~nform;atiofl 'i ieksed th.e DaS: S tor the torrn I..: la1..lor'1 or se-v~ral concrete principies-ind<:!!ed lntri "s.icali1ies Some of these rna .... · appear stange or' e .... en $cary but on~y because they are d tfJ'ere nt.

SpeciiiGalf~. from irnerest showr. by :students and from reeuests by co lIeagues fo r 'what is new"" or 'what is the rea I truth'. ~h!5 boo", was written. The a uthor is also routineiy asked '\'\Illere are- WE; goirtQ in the fl.lt~re?'"

History is no mere than a record of tM event'S o! rha past Evaiution, however. ofters an explanation for changes recordec Movements usus lIy occur en a broad front Yet the automobile and the a irplane were started af'lld (le ... .;.lo~ by sin glc YDung peo Die experimenting In a gamg-5.

As a list of movements accumu lated and infonm ation needed to be PUl down fo I comm L.: ni ca.ion in tea &ling th is booe toe k its present -fc M'I. Thl? aumor ss Inn,,;; btad to M~. Marti n Br.u sse and R:.G..<Y Mountain Ortnodornics for ttl<:!- finances fer Its. pllnti n:a ;;: nd dlstributien

In 1 %2. just 40 yei;lr'"5 .ago t,'!' author was cha rged wLth writing a eh apre r in 'Vistas oj orthodontcs' cr nis personat clinrcal research, CJrrently. rr ay this 'll.'ritin.g serve :a s a nothe r t'I.a II mil rk: of ptog rsss

One fact IS certan'l: t ... e eoblie has bseoms a'l'lJafB of orthodontic service. f.. privi lege is headed for a demand statu s. ft i$ IlOW I,J P to future :leneraiion$. to de liver ~G hlghesi q u alit~ of 5\.1 pply! May thrs book help serve that end.

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STRETCHING THE MIND TO NEW DIMENSIONS Robe-rt M~ Ricketts, D_ 0.$" IVl-S., N- M, D,

DO YOU UNDERSTAND?

'Mler 1 blank expressions .f'l~ ~EII~n- on the faces of students 'Men the fore~ 0 iilg que~l 01'1 is asked, the teacher iinds it necessary to stop back up and find a m~w .:ii ractlon in ore e:- to proceed, If th e re is no substratum, there is n oth ing :0 blJi id OJ, and less that can no rcgistcre:j in the mind. Many thi nqs m ust be learned before a compreh ensiva s~l'E:I can be ",~ad red.

Me mol)' C 8C:UIS f:-o.'n great i --npressi ens, much repetrtion a nd protouoo assoc ations A:3 learn: ng advances, I it:e iettofs u nfled !or ¥ICIrdS and then sentences, m or-a an d me re is inc~u dec. Thus, l{ja~ning mea n s expan s i on-ao u nfol·:ji n g ar.d a reaC:;lling outwa rd, which never SlOpS. The whole body is associ atsd !n the mind.

a rtn odonti c Prog ros~

The first compilation cf mforrnatian in ortnooo.ilics occurred ir. or.ly about 1850. Fifty years later: less than r::I dr.:7~n peor.le ga~hered 10::- an orqanizat on for CO mrnon interest and mutual ben cfit. But th€}' a II suffered a double iland~cap. F~rs·_ i; wa~ lunitsd rnaterlels and rnan.nacturlno lechnclogy. Sec.o~d: and of gre~ter coneequnncc. they wore constricted by insuffi:::ient knowiedqe in biology. The ouservat.ons made di rectiy W€lm oTIFJr.. mi slrtervete{j due to abS8r..C8 Df too Is for ;:Sp p!i catio:J of the sci 8flI:ific method,

Curren:ly. several tnousanc minds are aVdil~blF::"!-, a hast .:IF rnanutactorers g: ..... e us appliances ths~ are like jewels, and cornpctalon testers advancement, Technolcqy and a .... ailable Lnfcrmation has surpassed the abllry to communicate, an d t 19 mass of I iterature may be overwnel m i_"1g.

Barriers

I n addition t.lel8! are roadol Dei<: s to th~ di scovery of no ....... · t~uth S, 0 no::'! rs I~t: it or C;:J s1:]:'11 VY'hi ch givGS ri S8 rc corn p lacency and sali $fa.cti On. Anc+ier :';3 rri or rfl8Y !::Ie such e lack c.f d isci pl!n~j serrse.:; th at tn .... i:h wi I~ not bl:"l r~ :";;:Jyr ~iz~d e'.,'"cn when ;_)re::;~r rted. A th ird r. u ~dl e can be :.he ~r.fI.L.::13 nee of fragi Ie authority. :J n proven iL:I:::l~S n~ve bee n so is t'1act\.'e and repeated :J 0 -extens: vely that hey Lp.:;::)!TIe accepted as gener;,f ·;;i\VS Consequertly, t'1ere aro rurnerous examples of mere hypotr. e sss cc m~r.g to be consl dorod sol id t '-ust\NUr~~lY t ~u~h s. A fi rial ,:;;~ u ~,cl i ng bock is t~e cstan.atlou S. Del ief that we i<.now it all and tt-.e re is no : urthcr need fc r expo oration.

A 'Wi:~: Ie fi b"!:J n ~y :!::r.ffe r beea :.Jse (;(~r:a~!I . d l?a.5 may be ::::::::!TI~ i !l1e-g ~ ated l-nc a I ide-ology consssttnq only of bel :efs iI'l ttl e f rst place.

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Semantics

rut.lef, there ~j"'e p-oblerns in semantics. Terms rr ay be cor.Jus~ng or net :1.3' .... 6 the S~LT;8 rr.aani rl~ of o ne- a s to :3 nothcr in eomrr u n ication, P.h II osophy ;:5 often em,J: eve j "_0 m eon a bel ief systorn fo! I :J'M r:g a partied ar ta a:her or :ecrriqu.;::-. ::ll.!"t ph.losophy as a "ove- o~ wisdom' takos ::::n phenomena '..8 be rea S 8.lej abo u; t.lat have not yet been ca p(ured by ll: t! sclenti sts' mas S u!"i'lg :00180.

Lo~ i ~ i E: t he study of j·Cec:1 :houg 1t ar.d truth; eth los is the s~·.Jtl y cf the method of ;c::F;J;J: conduct anj tamess; esthetics is :he study ot .ceal beautv; r= a;i ti cs i.s the study of .he method s of i deal socia' uryani zattcn .;3n(1 g"8od' .... i Ii:

I""l-e:;]~r,y·sics ;8 ccncernao .. • .. ith ~h~ te~ati~;iship of mind and mattor and ultimoto benefits. S::.; 8000:1 0.5 mea s u:-crr 13 nl ~ f-Inc quanti fI oetions are a p 81 i ad and orde t is es.abliahed, the: term philosc::;Jhy no I:':':Jlger appl.es.

Ano:h.er confusin 9 ' ... 'Ord is matrix. 0 no C i·:;·ti onary G:3 .. 'e tc: n me a n ing:,:;.

B·_l a c~ i n:6 <: I: S bel i :/5 ma'l be-come a matrix. T:1F::::! wore ::::--:gi n a: Iy meant "w'J moO:.: or ~moth.er':I or "me', It has ceon a·e.sc~ibed as a place cf ccrntcrt and a ~fla!ing of sa.feJy ~t i~ 3 t~Sr.NCrthy place 1D return. 'I ho gnaiholDg:st's rnatrx is t.1e

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arlicutator The edge' .... ise or-'lodon:iMs mstrix is the- idaa arCI or the contlra.cue

· ....... .ro, As S OOr: ~s 0.11 th ~ tc-:::~h a.'e in ali gnment a comfort Lone is rescnec 50 tha t. U:"1f;J.:iu:lately, may :'e::;;:::~Yle a first pri:..:-j:y.

r."'3tnx a lso is th 0 ught of :5 8 sornetbl n 9 from \Wiich N ... vithi n 1A-t: i ch cth e;thincs are s'Jppor~sd. Ccnsecuently, the loess connective tissue supportnn organ s, s kir,. rru, sci es and nerves is called the extra-cellular matrix.

I~ tbe ideal of "ma'rix" ls exter,ded fllrlr,er, the basic 1r?-r.l9WOrk o~ orth adontics consists of a n integration of psychol og:cal ~actaf$ togethe r \1&'1 th e fcrrnu ;~t ic n 0: s oecific object ives. V{th :J:...J~ drect on i l is i :n;:.oss big tn obtai n orcer and prog r-e ss.

A paradl gm '.'8 -:y ssrn p Iy is a mcdel or a ~ pattern' , II P ara" mea ns a long sicl!? cr. Pafacrines are tile hormonal s'qnsls frcm one cell to its aOjaC€'nt cell. A p a rameter is a certain moe su rornent used !or the deterrri natl In of vari a:;J1 es. F a ~ cxa mpl e. lh ~ F acial Axi So has bson tc und . to b-e t.....,e best pararretor fo~ the in:ll cation Of the central di rection of the bee,

N 9W r.J1 ovements an d Advance: menta not Rei! C ogn i zed

An alysis of currant developmen~s led to ths r6!cogni ti CJ1 of ~ev ...

/novem ents: · ....... hi cr. ' ... -ete p .acod into thr-ee general ceteqorl 8 So, These vsue:

I. The Bd~i c Matr:x (Phi I asophical and Sci entitle)

I : . eli li ca I M~vem etl·.s of S igr.ifi c.o:1CC

I: I. Me: ;::hani ce I DElve lopments and T echnol 00Y

;',:~hoL.;gh tr.FS whole t.eld was -d! ..... id9d in~o tr,ree P3rtS: each it9m or subject 13 nu mcered consecutively for PL:~JP:Jse of rafe renee.

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PART I

THE BASIC MATRIX

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& Genera[ Conceets lnfOrrnati on and Knowled ge

I nto rmat ior i s ::l ra presn nratiors of racrs : ransmitrad in S:J~A fr.: rm Knowi edge is a medley ar facts perceived i n tbe mind. Knowledge has rn V~ luc L.: nti lit ls retri sved o:gan izeti and appl led, (Ricketts) Or lee the rTI i nd is expan dec to .a .new d i.nen slon, it cannot be contracted. (Emerson) 0 nee a r. ew idea is thou ~h~ througr it ca mot be u~-thoug ht. (Dsbono)

Bec:au S E! ~.act~ may stan d alone: tney otten rn ay ne contusi ng_ 1 tlus. a bas i:. order n eecs :0 be established sa that knowledq 8 Can be inteqr atec enc f'"l.ade use~~1. Fl;rtner, VYitn the ~inf{lrrnation high'~( of the CUrfr;ant world maki~g 50 m ucn in::. rmat ion a va il aol e I ~here i 5 a need fc r abstraction a nd a certain amount of re d ucuon. F u ncarnentel cu rrent truths need to be identifi ed and related in a practi cal sigriificance.

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The Need for Science

The .an:::hesi s of order is chaos. Cha 0 S rna ans contu slon an d lead s tc i:-- ustratlo-i and stress. The p urpn ae of sc.ence is to create order and provide for ~;r,e di scove r~" of truth. Scien[".f! rP-qt J=rp-s IT"! p'.::J:surerril~mts Th! s m~~r ~ tools i:::I r£ ne-edo&c. M athemat cs i 9 me :oo! ~o 9XSI Iii r 8 t hg natu ~a of m sasurem snt. But an the powerfu I statistics mea n n oth i ng if th e wrong th jng is mcas ured or th e ri gn t thin g is me:aGured in thoij wror1g way. S"W98pi ng con cl'Jsi 0 n 8 '1ay~ bs-en drawn from ~a lse or urtre I; able ; nformatirrt

Sci ence It S 81f has varic us level s. 0 n.e of the rn est bas ic is si rnple

oascri ptive scler ce I ~[Ch characterizes 'Uer1tgenograp hie cepr.a lornetrics.

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Sci 8 nces in g ene~(ll are d vi dec into tl1e a bstract. p ~,y5i ca: and bi o·.og ca I. Sci e nee is :il eo . process ~ by wh~ch knowler1 g.f.: is obtai ned. B as ~cal!y, rnatte ~ i 5 exa mined by ch erni strv, wh: I e ens rgy is stu died by physic'S, out the two a re C~J rrontly often comb; -:"l ej,

Research i.ses scle.ice wjth an aim to .evlse accepted conclusions whe~~ the need IS d iscoverec . Pu rc rc~ca:rch h a$ no outslce ai fI ot her t~' a n facts. Basi G or PI imar 'I resear ch is a imed at a pros pecbve di n leal -r-ference. Ar: p liAG research is adaptive to real situaaons. Clir·ical research consists of cireet examination of patients .al~d beil clinical records.

Wth soci ali zatlon systen 15 in practice El dichotomy te nos to erne tge 0 n

.hc one: h and is the med i ocre or 'good eno ~g h' attitude U nde I a soei 211 systerr. an dverc.gE:"! lmprovement T1@¥ be consrdereo ~Q be the proper entttlernent. On :he other :";a nd, qual ity reoresents tt.e h ighest ord P. r ot 9 cod :::!1m a hlg h deg ree of excellence. Ironically, it's .as ea-sy in tho Ions run to obtain Cl routine qi,.,aHy f ni sh by corrb i '1i ng s-cien ce witt"! art A h ig h nual ity of res.slt ·6:8 us to the bdle: 'JpP D rtu nity for a ~ onq -te rm hig h qual ity of life for tho pati c n t,

B. Moveme nts-A ttitud03

1. ThD Evid e nc e 8ase-d !d9a

It ;:3 strange to th(o auth 0 r th at such 81 sta iome nt as '·E:WiU~'l (:;8 based" could be;,;omp. popular.zed W~1€n it ... vas a.W:::Iy5 assumed bat ellery lecture- or author s~ould SPG8k tram true evidence in the first placo. Evidence rFj"ljLlil ~s scie Ilti~IC ~ order ," Noone c.a II p red i ct u nleas Dne nome na CCl n be e-x:p IHi ned sntisfactorily, Old" clinica. observations may require new L'D:r anatk .. )"1s a3 bioiogy i!; better ur: de rstood ..

"Orde r" moans a pleasi ng a rra ng ement .;)f d nyt~ i ng. lt cons 'sts 0-:

sequences. svste-ns. purposes. clars. methods and procedures. oder further rl'le;:~I~$ a froodom from eenfuslon. I~ imp'ie::; p.-labor~tC!nE::;!~~ and tile prevision fer a solution. The \fTO and VTG establish order.

"Dl sordor rnsar.s chsn CI? a I::IM: hap hazard ness, d isol easi n g, d isco -rrort and confuslo-i. Thus, "evidence must be organizod in order :.~at i: ma~· be a p p~i.gc, wt,i ch me ans sc ie-neg. VJith evi.:i~n oe based ir: rormano f":; ~~e i dsa of J p 0$$' bi ity" is p ~e3ented a iJd t.Lje ~p ro b~ bl ity" od de arC! c! a rified.

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Ce?h~lomotricg and E ..... ldence Basi ng

01:: r,··c b lcrr s 'NC:O :h:; ~ rneasu re rr.en ts e T;p I cyec C i d ~ c:

~e;:-re5er.t the lr.tern.

pa:""<;!rT'eters: ...... ·I~:ch were roccrtod .n 195·~ and have been (I..: .... her abstracted. M~ny il',f;...:emial teachers irnpedec prQg~e$$ by sl..:sta~I"ing of cl:;:i id'.?as 3..:~ r&q U4::!S ts ~v~ i '": .Form a ti 0 r· to ~ n C',·.' 'nove Tie n ts -::0 n ti n ue.

C e oh a:,jrTI etri C 6.:1 a Iysi sis a de tcrrrl n utl 0 1"'1 of th e co Tli o te n ctu rc c f th 0 ::;0 nd i ti ~ n D: s cove f)' cf po' a riz a: 'on an d ~~: 0 metrl c p r.en ern e na si rrp I Jied f'.H-:i ~ I Y raw~I', 1-;):- a bette r u ~·d e ~ ta 1':i '1 g, cep h e.crre t· ics b ecs-ne ih e intern Oit:.::,n;:;1 la.',;guage of ortbcdcntics. "T"he f:Ju-?()si~on '~ra~s·.~iCinai ar.alysls'

s ;;:J I.(~ 'fn <11"'1·-:;" fo ~ me n ito ri ["1(,) p r c·:;;· e::::5 Y/ 11..:;'8 ~i r i'lL;! (.:;;:1 i I:C;! ~ hi rty- ~ho!:.;- jlJ:i:I r s

cercre ~~~i~ ' ..... rltinq. (Fig- 1 A & 8)

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s ():c'., ;::;;:. ~ f'.. Cc -nc de;'" explo :-8::ons ',loB rtled us: ~c la !it}' 8xi sts a: :h e ba se of the S ~.r. GIn·::: id ocnc · ...... hl?·e .r':'; C '"; aoica. ond P~Y31~I:::-J ic ;:;h~"""! ems '"19 i£f(: conto rec. I r t ne -:':'"O:ltg I ps rs p6cti""9 gnc r:".:::-n C €;:;;': re ss' on s · ..... 'e ~e ~:r.;:: loved :: 8 cau Se ~: i~]o laJi:y ...... as to ;,..:nd 0 r_~ ~::: r ~ ~C:'". s ide of ::l~ face.

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. N'i' 3 ·U.::. ere ~ ted 1 e/ 27 M P 6.7 Yrs. t.Q 1-5.';

::;ig. 1 a. Tho Transl; onal Ana IYStS &s bcccme the orthodontic standaro Ie r depjcting d1e d ift.;.ren ces bei'.W';-Jl g 1"O' .. 1th .;t:)d treatment changes_ Pesi tlon S 1 and 2 ara for sk.gloEl~1 a ppraisal. POSitiOll5 3 and 4 ara for dental cha r·;; es relrniIJHI,.. Pos.ticn 5 shows d"ii1'eIOl1tia I ct onqo S c:~ :...!ppe!" & la'.ve,~ molars 09 n::..1 the .2haviQ:" or the occ.:u~al plan e.

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2. Six M.1jor Objectives in Orthodontics

I: is a pa.~;!::dox that cblsct'vss are "predetermined' by a clnclans belief i!"': poss i.:.i I lt.e s, Firs: a r. d iron ically, becau se t~ I;: va st majo fit)' ot 0 rth oc ontl s ls co not me-iter patients reg:..:la.1y: (jlOY must rely un lectures, literatura Of (~i::::,c:'1 ssl m15 with collo a9u.e-s reg a rdin 9 tTU e po 8!3 ibilities. S ncor d Ii, be-caw 5 e dlffDrent appliances are applied in many ways, tr.~re- may oe disagreement arne n";1 inve sti-;a 'ors is! nd cl.n i cians reg a rd ing the pass lbl e 0 utco me. Tnl rd Iy, th e r~ has be e n an entre nched d octri nn of J lmita H ons . tha t e merged from te I;: h rl~q ue 5 em plo yed seventy yea rs ag o. .M a ny of th eS6! ti m ltatic ns stl It dominate grad'Jate teachi.i.g but are ~ro~un:Jty wroflg On a current basis, $1X D bj o ctivs 9 are jomi nant.

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Esthetice has been and alwa ys will be the fo rce that emoowers orth odon ti cs. The di ff8~en ces in esth ati c po s si bil it'.{ li e In concept ens ot tho to cal den to-a Ive 01 a r a rea as contr as.ed to hb~ s at s keleta I" structures (with IJ ut s u rgery). Th is bel iet fu rth e r extends i Me the as e at wh lch treatrns nt is in stitute d. Prese nt i nfc rrna .ion d i rects a tte r.tion to eta rti ng p atier ts by no I ate r tha ~ ag~ 5 ye~rs, which is a shock to traditional bclic~.

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b. The obj~ctive of a ske.esel maxillo-mandlbular coriqruty in all th ree plan e S ot s pac8 is atta i nabl a, particu la rl 'I wi th ea rly ir.terventicr . SKeletal changes seem to be pcsslble as I-::l:ng as effect ve ¥ rowth of th e patient re mains. H Q·I"J13-var, cu rrs nt data 8u:Jgests it is easier to obtain and is more permanent ln the

. P rever. t ve . a nd In terceptiv e P hases th a n wa~t i.'lg tJ n ti I

adol es cence.

Th 8 ob jec~~ve is to obtal n a un i tizati o.n of the two bas i c 'leg eta ti V II;} systa ms. Wh% '1 eke le:.al cc rrecti 0 n s of jaw retabcn s

c.

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a re a ch.eved . a n 0 rrna I lzaflon -01 several tLj_1.c~iOLI s of t r e rnssti cato 1"'1 anc res pi rata ry systems n atu ra Ily tollows m05 tofte n.

d. The rncst aopropnats denture emplacement for tile panents. age, sex anc tfJe to'lows the objective of skeletal correctton. The ton g.to rm go a lis 0 puma I e sthstl c S a n d functl 0 na r harm ony at maturlty.

eo. Th e 0 bj eetl 'J-;: is to pre d uce the most c Ofl5U mrnats 0 eel u s ion or ::,n~r:ge'nel'lt ::.f ~he teeth, This means their fit, their function and tho ir PHti'I ane nt i1 CH"'I ~:.h.

f. The objective ~s fnall~' to ';:mh::mce tte patient's qua~ity of Life th rou 9 h maintenance of the 0 ccluslon an d th ro ug h ed u caf on toward life extension, (Fig. 2)

:3. 0 bj ecljve s in To ta I Patient Wo tfa re

Research has again supported the idea or relationship exists bewfeen O:TII h e a~1J: a '1 d ca df ova 9 Ci!1 is! r f ~nL!! S s. G anera I Fled ian e, .a nd p:;uticu lady In!8grativE!- Mea.cine: recog.liz-es tbls importance, The public now seeks a qU.2.Jity or ur~ anoj gieatE:f :onge v ity_ Degeneraf:iv@o d1anges have come under the sU.'IJ!3illance of dentistry as well as medicine. Nutrition has become qujte cl osely ri n ked to th e lm m un e sy s le m. It is to be re me m~E:'red that di 9 cstioa s ta ns i n L~ e ora I t.avjty,

Q~~~ II ty of Life

Co.c.p-uity

Un H.r

.'

~ Moyo-m CI n ts In Phy!S iC8

4. Tlllerian PhYSLCS

Anew p hys ics ha s been d e\'e~op€d which ·we s ha~1 ca:~ ~Titl eria n' .

C lass.cal p hy 5 ics has bee [1 called h N ewio nia n". It wa s th 0 ug h~ that e nerg y Wa& c-o rwerted ;;") fo.'m. Mo!i 8[1 and rnsch a nics, press ... re, 0 pti cs a!"] d efe{:tri city were a n d sti IJ are c:I assi c. Q u a ntum ph Y5lc5 emerg ed with t he stud y 01 the 3tO m. th e m 0 leeu I ar structu re a no sol id state p~en 0 menon, Jt became rec8g n lzcc til at e nerg y cou ld be fixe d. 6 ut nowh e re in p hysies WE! S ~here rec-:.g n itiJr!- o: h urna n i ntenton.

V,lith carefu~l"Y controllfrd experirnentailon, Dr. Will[arn Tiller has shown tha: seVe ral 1::If: g-he[d ttl eolies in physics must be moc;Hied. H u mar. i nte nfion was ca p tu red on -el e etronlc deVLI;:C.s wh 0 n N 1 9 au 9 e syrn metry ',,'Ji:!S pre sent i.1. e I sctric mo nop 0 les and 11a 9 netic d:p oles we rs provided.

Tn roug It consciou S i nton t th e pH of wate' has ceen sh ifted up c r d C'Wn 0 ne full ul~i l in viiro 'INOrk lNith enzymes has .a Ite red the prod ucti 0 n an d acdon of AL P [al ka I:n~ ~ h os ph ata S 8}, ~ spcciflc Ii lie r e nzy me. By u si ng th e fru it fl'l becaus e of the v ast d ata avail Rhl e, th e 9 rowth eye: a ha s be-en speeded up or delayed b1' co nsciou s i nte nt. B ut av« n more d ra mati c, i3 pac e itself has been co n dltl oned, Th is Dr. Tiller has ca lied "va cu urn en e r.gy~. which tra ve I;; mu ch faster than I ig nt. It is th 0 ug ht to be the prana or ch i of tho E: astern CU Itu re s.

All these fiI".d I ng s can ente r into th e concept of heal ir.g. Thay fu rthe r retect the rol e of Love r n physi ca I phenomena. In of he r wo rds, th e role of con 5 ci 0 usaess has be en n e gl ecte d, as a I~ Lnvestig a ~r$ u ~d ~ rstan j th e powe r of p.acebo:

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5 r Ac:ccss to ;, Pattern 5!'

By way of access to "E!I€'ctrom~gnetic dscharge" of the body, a reading of the body's health condition is attained. It would seem that !hiS Is. .;Ii .. hol-og ra m-fike" pher omen 0 n ~n whlch a n aw d i::3g riosnc reg ime is possible

Further, trc ctrnon t ca r, be Institute d by e ne rg efic su p po-t for the org a n or tissue, I~ cOl1ld be, but cnproven as yet, that this may be accessing the va cu u m or etherle energy p rcvon by Tifle rand can be a part of th e e nerg y medicine movement underway as. described by Dr. Richmd GE!"rbe~, The body is both a t6 cej ..... er a nd a eon dor of th .s to rm of i nfl uen ce.

6, Disi nteg rati on of Mass

A rna ch i ne ha 5 been developed wt" .• c h w:11 d i 51 ntegrate mats ri aJs th.rOU9_'1 reso nan ee an d without dire cl be-mba rd me r t N u mere LIS a pp!i ca ti I) na a re avail aolc, but when foods a nd herbs are processed. the cenu I 0 51::l e nvetope is d isin:.eg rated _ This, in theory, makes f::.od an d mi ns ral So severa I ti mes mo re bio-avai lab le_ It is ~ lsc an 0 p portu n:ty far the rep rc C8.5 sl ~g 01 wastss.

7. Vortex Energy and ParamagnetJt::s

Te::hno~ogy fOr the produclicn of fullnel v ortex is a second method o~ mass reduction. This precess. however, converts foods, ordinarily neutral. to posse 6 spa ramaqn etlc pro pert!a s. Thi stech no[ogy r:; rose nts oPP 0 rtu nities for treatment of ma.1Y tyP€S Df materia ls ::i nd explores t h~ 0 pporunltl es tor th~ en 8 rgy of imp lcston. Magnets have a deeper i m p!icati on than most sclenti sts real lze, (F i g. 3)

Fig. 3.

With cathode rays the longitudinal lines of energy are photographed. The red center of each "cable" is the positive potential while the surrounding is the negative potential, .. The greater the distance, the larger the cable. Note the spirals and the graduated divine proportions. Do the divine proportions in the face and body originate from magnetism?

8. AI.lotropic Conversions

An isotope is two or more forms of elements having similar properties and the same atomic number, but different weights .. Allotropes are different. Allotropy is property of certain elements to exist in different forms with different physical and chemical properties. For instance, carbon is different in diamond, graphite and anthracite. Through discrete processes some elements produce different qualities which may alter their biologic effects, But also, new metals with new properties and even color and weight can be produced.

12

~ Tho New 8iology g. Etheri c Phon omena

Th I:: i da :1~f.cati 0 r. of an ethe ri c ph e n Omena or wn a t WQ m(JY caH e U I t! r i:..: djSC~H~ rge ha s c ~8 r.;g e d so me of the concepts of Ilea I~n g. D;;:I ta tn d lcstss there are si~ nlf ~ r t ben efits from p rayer :n he :;:!li n g, an d the rr.e cha.i i 5 ms are b seem i ng cloare r. T he fact th at space can be con dt.lone rl and that Love can r,;Elve a tal1gible effect brines to 'CCtiS a new bmlogy. Data in d icates that levi n 9 care ell h anees pi on t growth, and cows prod uce more mil k in CI lov~ng erl'Ji ronrnen t. The: h ~ PQtI1 a larnu s rn8'1 he in '110 Iv~d in the effe cts of mind and matter, whic~, ironically, involves the field of metaphysics.

10. Cell M-embrane As Its Brain

The cell memb ra ne on the cell surface S1919CtS a fI d tra nsrnits ch em leal s ig n a Is to the. c~11 Gytopl a:;; m. Pr'ot.;.i ns a nd t~an s ml tte rs in th e cyto pi as min iu rn fe ed back to th e cell memb ra ne what it is. to accept or excret-e, These rnerrh ra n~ ::-@.-ceptc-rs a re sxtrem aly nemerous and are cri ti cal to the ce: I fu ncti 0 1_ VVith sue h a feedback, tbe cell becomes. adaptive. This r.as arlered the concept of evolution ar.d grov-rth. The nucleus of the cell acts m-ore like the g::J r.a d a nd i s more re st.tcted to growth p roes sses an j re pair.

A T K~II~r Lymphocyte C::Hl ~ill 27 cancer C~1J8 befcrc it clcs. (Fig. 4)

11 r The FI n.al Envb'oo rnent: lntersfltial flu id

Tho fjn:a I Of] vi ron man t of th o cell i So th e i nte rs ~ t: a I ~ u id. It Co ntains the blood an d Iy mph ca pi Ilary n stwork. I: is the sHe of nerve end i ngs bath autonomic and central. It contains flbroevtes. nistioc¥tes, plasma and mast ce lis. It is a n:~seruoi r for oxygSf! and a I~ kind s of n utri e nts anc pe ptides.

J n a jd i ti 0 n I ~Ili s flui dis the con:ror area for a cid-ba se bela nee and elecl~ulyte:s. Being: rernarxahly lik-D th~ characteristics of ses\N'ater, It also I; '_be recei: ... ing t~nk for cellular wastes, {Fig. 5)

13

..

4-

Fig' 5.. Th;e ~C"efllillar li!"mtit'bi; ool!limmi~ il!lterstJdm lilt'll is, 1Jrne11k;Qy to bIIl1Qg1!(.. 1~ s:I .. eosam nco gtycans, 2), 00 11 ag en, l) er>esijc ~ tissue. 4) mast oeD. 5) d8'hHliSe~ cell. 6.) librocyte.. 1) lileliVi!!i' rMlmllgiS. 8~ ~lJlaTY ~O Nse_nt mem'tn'arle. 10) rCEII wllh mid IJ,IS

J5

· ....

12. Enzyme and Hormonal Reyulatory Functions

Th-e I nte rstiti a 1 fl ui d i-s a 103 0 a most vita I com m u n.catio '1 r e tvm rk..

E nzv m es are Ii~-<e th e trig ger on th@- gun, Hormones are- a part M the powd e r_ T.h e end 0 crlns gl a nds ::3 rEi a majo r part of the regu I ate ry me ch ~n~30m_ H owever. a uta cri ne fUrl cf 0 ns ope rate b'l CE! II to a distan ~ ce 11 com rn IJ n icat.on to each other wi th i r. the t1 ui d ,

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13. Leu ko cyto lysis

V\~!.h i n the blood th e re is a proce 5 So not wefl recoq nizsd wh id1 ~~ ca'l e·:j leukoeytclysls. Leuko~'tas are the w)",jl.e blood coils, More leukocytes. fo rrne din th e bone rna rrow, en :et th e b bod lha n I a ave it. The :br@-a kd c ... m of the- leu kccyre v,rlthi n bl Dod pi a::; 01(:11, P055ib Iy by ap optc s 1.5, roees. 1.. 'le p rotei ns. a rn.n n acid prod LJC!S, P ojysacch and eSI lip ids I ouctele acid 8 I al~ sorts of h 0 rrnon es I oxi redtJ cti 'lie complexes a nd other nutrient co mponents as me lh nd of rl utrl en t a vaiJab ilitf to the I nte rstltial fi ~id, Th is I therefore, is a hio!ng ic process sel d om recog n ized.

, I

14, M I nera lSI Trace Minera ls and Phyto rnl n e ra ls

Miner:;]ls are essentlel for electrclvte belance and ncrmat ionic tra n sfe r of n utrien ts from b 100 d to i nterstl tlal fl u ld and ttl F; rice to the cetl (Se 8 Fig. 5) fda ny carl s are dependent on trace mi neral S often dep leted in sol 1$, Phytorninerals (having passed through plant or a:'limal life) are avallable 11 prim !!ve deposits prier to turning to coal, These can be 'extricated frorn humic a cids and ful vi c acid s. Pro csssed to become a bas e mate ria] I they are ea lied Ful'.ric Base TM (by M-organics, lnc.). This is an .rnpo.rtaltt step in the formation and mainter-unce Qf bone and joints. Ninety percent of body protein is In the 10 rrn of co I iag e n,b ut a most nc tab Ie so u rca of vita I p hyto calciu m is fro m th e coral ~Jl the sea. The bocy pH is vastly lmpcrtant. Fer longevity, alkaline water to und 1'1 ear a coral seC! also carl ns utralizs wa ste prod uets in the bod y_ C;:!lciLi"m js the number one m~nera~ fer health.

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16

15. Probiotlcs

In the GUHural con dkons of : h9 m odorn ._ ...... :wld. antibi otlcs destroy g r::.oj or fav:::rabl-e bacteria t:Jgethe:r v"Hh ~'1e oat. Mi!::rcoes ot many kmds are .... it:=.1 to norm a I d ige~ti on. M icrooiaJ action- is n stu re's method of b icd eqradatlon a nd eye] rtg wastes. Microbe s prod u:e erzymas, wh len hel p break down foo-ds for essmllstlon. The replantng of microbes within the digestive tract is referre-d to as "probloucs" Good healt.r.. starts with a good gut.

16. Divine Proportions: rJlQr~ than Esrh~tics

D i .... ine prcporti ons and -gnom on IC terms am not by a-ccident. Tbere is a. very ?rimiti'/a matrix wilh c basic polarity. This pnsnorrenon is. somehow comeoec v..Hh neLErotro.~r·ic distriDJlion. tt may be connected to vortex ener:JY a nd ths procs S s of i mptos ion. (S ee Fi g. 3 and F :g. 6) It i.lay be 6 n.ergy c m1lvTl In rather than radi atl n.g outwards, Blood flO"N is on CurV-E:S and v. 'C3ter or flui as 5 p:n. It i s a pa rt of n stu re's. raw of conse-vation cf. enargy and ti sSU e.

lt ~~ p erheps extremely prrmtivo and stored in the role OF earl lost f 0 rrn!~J hyal U I o ni c 8 cid as a ba sic material f-or 8 structu r-ed rnatri x. Together wi tr.. basi c Fibonacd numbers: it is. also a natural phenomenon.

Perna ps the 'Will] Ie ba sls for the ph ysrc;al and cherru ca I worl d wrtho IJ:~ and lNi :h~n au r bod ies re lates to motion, epi nand vo rtex p her omena. (Fly. 8 j

17

Fig., [6.. UrTIdetstafidi~ iimplo~ ia!nd . dian': '1II00tg' Ileoacl5 to better [~iiiderstal'iJd'~ 011: DOO,y mechanisms"

18

PART II

CUNlCAL MOVEMEMTS OF SIGN'FlCA~CE

f:i;asi call y , cl i rncal ann oaontl cs has TWO p a rts. Tne fi rst, and rrost

tundarnental. is the determination 0'" what needs to be accomplished. Here a problem an s.E!'S because 0' metho:::ls employed for that d etermi nation. F .. Hll~~r, t~e k~owtedge ot posebi'itv is esscnflal.

With the coctrine of ~i rnttatlo n established i r'I the 15305: orthod onn cs beca me al rnpl 'y' th e al ign.fl108n.t of teeth. Correction of arches was thot. 9 ht to be Ii mited to alveola r p recess chan ge, If skeletai req u i rernents entered the sol utior., o rth og nath ic s urg e rl was recomriended. r-l oweve-r. d~ag [lOStS, P rog nnsi S 3-:lU pl~nning of objectlves can no: be sophisticated without know·iedge of present day rrec han i C$,

Thus, th-e second part or cl~:1ical practice is the "hO\H ton sice. We have .;r cI uded t\¥el1ty d iffere nt types of a pp:3 ratus em~ I oycd can si je r" n g the 'Tla.jo~ :a--:u r.l~ ...... or :3 p ~I i catios LS. Atte r the tech n ic ue tS mastered a no tho skill 15 developed. t~ c c eterrni na uon rsso lu'ton processes (DRP} become the ma jor chatle nge.

1\ SoW cI i n ical move ments req ui re learr i ng.

t 7. Abr~d 9 &d AnalY$ LS

A D:i dgeme nt i 5 is! GUn Je~l Si:;!d fo rrn. wh i ch om rts the .esscr imp orta nt parts but mad ntai ns ~lli eortents. D lJe ro the neeo of Mude nts f:J! ;:;I rJ1:) rE! 9 imp ie stan:;r1g point. the lateral analyses were scaled down to the "core mat-lees" anc bas ic facto rs fa r refe ren ce. Thi s can called an AbridgF.!o Anal yS! s or an "Ab5tracte~ Analysis".

l-or the basic skeletal morphology, the Facial Axls (1) is a potent describer oi cilln position. The Total f aGia I t lei 9 ht {2.) is re .ated b~ .. the co rp us axi s to the nasi-cranial axis, The LOW'Elr Facial Helg.ht (3) is the oral gnomon Ans - X -PrT'!'. raci~1 Convexity 1:4) is the distance of point /\ ro the Facial Plane. (Fig. 7}

For dentu rf! .f! mpl acernent the l.owe r I ncisal .edg.id' (5) is fel ate-j to th e APQ PI5IrJt and the Upper Mol:;lr (6) is related \0 the PTV Plane. If c:esir~, t~e ~.Ol}~' I ip (7) ls rreasu red from the- Esthetic Li'l8.

I n extreme d yspl asia the pal ate can be rneas 1,..1 reo from Fr. P I ans.

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Fig. 7 n. t: emaie age 7. 2. ~rnple descfiplt\i~ ~bp-;..jged anal~:s: ~a(::j;~1 Axis, Total I- a.::::&:Il Heig ht, l.crw!;-< F a-:::i~ Height, COr'N"cxit)', I~r irdscr. U~I inular, I;:!vffi intMDrrs to :: Ii na ShCoWS Class II overbite- 'hith high 'paJaLaI pli:lrll;' (1; (0 whrle n:),TIl8I Is . 2~)

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16- F JO ntal CepllalomBtril:::s

Frontal ceehalornstncs has been -a ~ng time in reach,ng routine clin leal usag-e, H took comp utcr d ata to develop a practica! ap p~ic;:iti on. Because no statist! caJly sig nif ca nt corte lano ne {on facial type) coul d be found with tha tatsra I, ~ F acial-Mandib ula r in-d ex was determl ned tor assaying frontal facial fa rm,

.;.

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The level of Nasion was taken from a line through the rnadlal @na of ths zygomati co-frontal suture at), Menton was used as the lowest border of the ch i n. Nasion~MI3 nton rep rese nts facial height, but the iada~ mask exte nds to T rich ion at the hai r1~ne, V.Jidth of tho mand ihle at the region of th e mota rs was reg istered at th s lower border of the uthedral emi ns nee or anteqonial tubercle {Ag). The 1 ndex was detennined by way of mandibular width (Ag.-Ag) x 1 00 over tile facial height (N asion-Mento n). Tile ad ult index 13 7S ± 3% _ ~ F!g. B~ Higher ind i~s indicate brachytactal. Lower numbe rs illd lcatss dollchotad at.

Transverse data did not le nd i~elf to ang ula, eval uafien. Therefore, d i reel meas uremants were employed which n eed to b.e evafuated by ag e_ sex, type and 5Lz8. D~rect measurements a re ~efetr.ed to charts for a sta rUng base. (Chart I) These were: for the nose, the Widest poi nt {] n the inside of U"le nasal cavjty (Nc): for the maxilla. the t::F"OSsing olJer of the tuberosiljJ outline with the mala r ridge or jugal process (J); for the rnand i b!e, the Ag. points.

. :..-

.:

For the teeth, the W'idest buccal surfaces and canine tips are vrs.ible and therefo-re data was slJppned for about 1.0 nun, of enlargemel1t in x-ray images ante riorty and 2_0 mm, a~ the molars.

.'

22

· t,.o1.C. 9 Tl 7.223 5-11·73

I i

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I I I I

58

94

68X100 94

- 69

Fig 8.

Frc nt$ll ..... i~~·J af p.atie nt seen ln Fig. 7. Hig h -aE?'Jiat.ed septu m na rrow na sa I ('..3'..' tf .31 d maxi lIa, $~ightly lor. 9 tace, no rrow ::EI~(;ho;l ~ and e;epnalometric rncla r cross-bite.

Chart!: T ransva rso OJ rnenslo ns
Nasal Ma:xilla Mard[ble
.' ~::.
Nc-Nc J-J Ag.Ag . ~

Age.3 yrs_ 22.0 mm 55,0 rnm, 67.0 mm. _
Age B yrs. 24,5 mrn 60_0 rnrn. 74.5 m11_
Age 13 yrs. ::7_0 rnrn, 65_0 nun. 82..0 mm I ~~
89.5 mm. ~.
Age 1 S '1':8. 29_5 mm, 7D.Gmm ,.
F Of N eoroid an d Mong 0 loi d I add 3,0- mm,
Typ ical G row"(n 0,5 @)lr. 1.0 @ yr. 1.5@y~. The In d 8:':- v.ra s the fi rst factor (~ ).

\.

Measure:nents from these references w-ere: the widths of th-e nasal cavity {Nc) (2). maxilla (J) (3) and rlandible (Ag) (4) were second, Drsa 9 reeme nt is. noted tty non -parallelis m of lines, The- d ista nee from J ~ D i nts to the frontal facial plane adds to the ~:lforrnation (5 and 5).

Th 8 width of the lower dentu re serves a s a tou n dati on, A maxi mum i nterbu ccal width of first molar tee1t- i So a refe renee (7), The upper fi rst mota r is related to the b.'J.IH (B} (9). V'Ji.jth.5 of the IOWDI'" first premolar w-ere found to be critical to arch form (lQ), lntercanine wi:J~h is the last fucto:-, Thus, due to the measurement 0 ["II both sid es, thoE! frontal at! ridged ana Iy sls, in the end, was more e~el\~i ve tha n 1ha: rate ral. (See Fig, 6}

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t 9 r De ntometrlcs and Pentamorph i cs

It is iro ru c th at r'ldde~ an alysl s has I e-d to co ntu s ion i [1_ the p rote s sio n.

Tile procta mations of Nance in t 94 7 we re taken as ebsolute dogma, but they have not stood up solen ti ~ cally.

In ord er to corre late d entu re wldt'ts with the face, two sites err:e rged as I(ey relErB nee s. The first was. th e lower fi rst mo la r wid ths. wh ich are related to p OS te ricr faci a~ factors, S eccndly was the lower fi r5t p remolar, wh ich me st sig nit. e-s :3 rch form, 1 he canine a rea al so r~f1 sets the nmiGuj,'Jrl..O:; otis complex.

The lowe r arch is. ij,e mo-st criti C::lJ and is therefore evall);;:Ited ti rst, pta nn eo fi rst a nd ~n is hed ii rst: 'T he rna xi liar y 0 I ch has g 'eate r adaptab mty .

Th esc ~JO fa clors bein-g paramo un l. the maxi mu m d i men si ons at th E: most h uceal crown widths beta I ~ Ie critical. A.lso, tile arch wi re was placec in t'J bee or b~acke\s en the bucca I sid e, I I'll a d d ition, the bu ccal su rface S I.N'ere more easilv i do?ntifi ed ir. I:fl e frontal head film, Mea n da~i:l was obtai ned togeth er with sta nd ard d eviati 0 ns of spacif e sites in the perman e nt doe n\ure. (F tg. 9 AJ These were at the widest bu ccal poi nt on 1t.e first molars end f rst pre mota rs and the cani ne ti ps of each arch. 0 ata wa-s fu rther derl v.ea Jor th e mi xed and d ecid uou 5 levels of d eve lop ment, (Fig, 9 8)

1 r, order to co rrel a~~ wi t1 I a teral ceph ~I ornetrl C5, the depth of the a rch 'Na~ ta ke n from i=J tn e tn ro l. 9 h the mssi a I co nta ct a rea of th e fi rst mo .ars to th e ::3 'Ie t5;g e ce ntral i nc.sn r edg e corrected for asymmetry _ (Sc-e Fig. 9)

Stud les led to a concensl I1g d own to five a rch forms to CDV€r the ra n~ e of c Ii nicsl needs. Ur.~rea ted normal model s were used tDg eth ar with 1 0- ye a r stab Ie Heated pare nts' mod e Is [or s tucy. T he most corrrno n a 5. expected was the Normal Arch at 38 "'/;J , The Gioid {25%} an!] Tapered (15%} to :ollow in free uency , The 10 unh was the Narrow Tapered shape {12%}, and the last was the Narrow Ovoid (10%). (Fig. 10A)

By using the arch form projections for the lndl ... 'Fdual patient, the

Co mpa ri SD n of the actua I to t:le i nts no e-~ per:nRs a vlsua lizati 0 n for r.eeded cxpa nslon a1 tho bracket line, (f ig. 1 0 B~

Ceph. 23~';:;

2" r:' ~ _ I ~

. .3 3

.... t

q

I

N = ;~O

. ,

. , ,.

_

. ..,

.

. . . . .

,

--

. l

. ,

Ag. 9A.

Mean data with standard dBiarir:.ns For mea;sL1remen~'S at tL'ccaf point:;: :i:I'1.j arct. depth f:'"O:'r"t

lin 8 th iOl:.lg h mesial rno lar C[Jf"lt3Cs-

05 f

..1;-:;.0:; .. :'!o 4

"'Iv ...............

39..8 !20 40 30.36 fLS

26

26

· .........

__..~-~I-....... <,

1---- _ __ -- .......

j /)~-. ~.~ \

.. ~ .::- ........ , °9

,: ,,' ,I '.: .. l ........... .:....

. ...1 .... "'_: _ ._-_.J \

.: / --:; ........ -2(-·- ~--"".' 4.1

i t.t, ..- ~ (.1 J< \ !

'_~ l X'

, .... .,: 1 '

/ _C+-~ .,r,)\48

!~, , ) )

'I !

\ . !

P HOV IS 10 NA L DEC IDUO US

----- _ ... ------~--~---

Dlm-e na lon e ro u rrd e d out in i'C1 rn.

<~~~\

( .... x._... .. -- 3 1

;' (')', -I_.~__'

..' u ... • .\ 43

.... (,"~I 2 9- ,. ~, ~ ~-

.I _j. .._ ,-1 \

,. ~,-..;. -r I . \

.. ( '. • ( .... I. I

: I I .. I .=...

: ,-.'. , ~

/ ~'~-~ ./;'/.- " 57

/ s:

\. -j /

. .___._'

MlXED Age a Yr,

"

.:. I:IY,- nLr:- '1-:-:.1 ... .:- ..... r. O·Yr:-::I::1rI':: .... I ...... ~ .. ,.

NORMAL

__.

NA R ROW TAPE R=:D

~ig. r OA. The e;!assic: ewe .a reh sha ps-e: with their pefCen~g8s. in t"le ortho dontic pOPJ !ar ·('n.

Be-lor~

~ 6748

Aft 9 t

.... ' .......

Fig.10B.

G,A, J

Age a-4

OVOIO

\ORMA.

..

Class It patient G.A. wii1 normal arches compa I"I3d ~c C rig h al maloccl U sl on showing needed expansion for various torrr:s. He VIa s treated to • r.orma I" to 1YI .

20_ The H afUng Zo ne Matrix

The i nterface be-tween Ine calvara and ttlo face Ii e-s esse!ltially paffi~le I along a :ine ~rom B~::;;;iorl to Nasion. (Fig. i1} The bravs medulla lies 0["1. ~he cl ilfil. s, wtl i~'l is tho upper part of the occi p ital-sphen cld strut. -I he root ot the naso-pl lli~ynx i So lh e counter surfaco in the face. The B a -N P' ane has ceen called tr,e ~ a s(.-cran~al Axis. It cuts across the roots of the pterygoid plates and CJt..s off the- ba,.;;;e of vomer at the :'"Osfj"um of th is! sptre'loid tt passes near the exit Qf tho maxillary dwision of the fifth nerve at Foram~rr R.r:N"I.,mdum. It passes in the serr.e di rection and near thG: same P lane as the zvqomati co-temporal suturo. It transv-erses direcny through the inferior orbital fi ssure. \M1ir:r: sF.f1F.!n:::It~s the great wing of the sphenoid from th e maxi Ila. It cut nea~ tho I inc of }U nctior, of th e rnaxul a with the l3b}'linth of t.r,e eth mol rl ::lnrl f~ Irs ina line v.~H~ tl It:l j unctior I 1.)[ th eo ~fOnral process of th 8 maxi lla, Posteriorly, the ~i n.e cuts just at the bore sr of th & :ymr;:::l n i\.; plates.

By 3111 DrOC9SSBS of raaSOt1iflg, it i s a Ii nc of separation of the face with

the calvarla But even further, the use of the Bssion-Naslon Plane is

statistically mere ep propria~e for faci;sl rnorphol ogi C oascnp.ron.

Ho: .... 'ev~r c another 'ha [lin g" princi p Ie is at V'IOrk in the verfical plane at the region of the coror a~ su! u:'"e A vfJrti{""..a~ lin [J was dropped perpendicuiar tn th:3 FrankJon plane at the base of me pterygc:id plates (Pr), and .... vas C-r"1!I~d the pteryg::-Id Ver:icdl (PTV). This tine seNe'S as a baso line for antero .. posier.or cranial growth a nd a reference for horizontal rnorphcicqv. I t is, r u1her. a reference fef den[al d 8v-a1 0 prncnt. (See Fj~. 2)

Thus as a jUEll:tion of two hafting zonas, a complete cran iel bese sc~FCllding is founc at the- lIflil')n of two rlam:.ls· tr8 Hasi-cranial Axis anteriorly and the F;',ankfOrl plane nostericr to PTV. {Seo ~ig. 11)

· '.;.

· ~ ..

· .":

JO

PART II

CUN'CAL MOVEME NTS OF SIGN IF ICANCE

Basi cal~y I di n ical ortncdonti cs has twu p-a rts, The fi rs~ I and most

fundarrer.tel. is tre determination of wl~at needs to De acccmohshec. Here a problem ari sas becau s.e of methods emptoved for th at determi n af on. F urthe r. rie k~awledge of p-Dssibiiity ls essenaal.

With the dOC\finB of limitatlon established in 'he 1930~. orthcdontioe ~ecame si mp iY the alignment of teeth. Ccrroction of a rchas v. ·8:5 th 0 ug ht to be lmited to alveolar precess r:hang.e. If sKeletal reculrements entered th-e solution, orthc g nathi c surgery was recorrrre nd ed. However. d iagn osis I p rog nosls ~ nd p.1 a nn i n~ of 0 b jecti ves cann nt tJC"! ~GP histicated with-o IJ: k nowledq e of p rose n~ day rnechancs.

Thus. ~he- second oart of clinical ~r3cliCG is the "how to" side. Vve ha .... e included NJei.ti difersnt typ..::s of apoaratus employed ccnslderino the: maier and rr.i nor appucati 0 nos. After H II:!" tech nique i5 -nasterec and the ski'l i~ devetopec the deter tli n ati 0 n rcsol utior: ~rocesse:s (D R P) t·e come the major ch i=31~en ge.

No!::w cl.f1ica~ rno .... errents requ're le~rnJ;g.

lY

, 7, A bri dg ed Ana t~te; i.s

Ahridge-mem is a condensed form, which o-nits th3· lessor il"llpor:am pans b d~ rna i nta ir So its contents. Due to the need d students "for a ['tl():'"o? s i mrl c::startillg pomt, the leteal analyses were scaled down tc the 'core matrices" and basi c -=actors f:J: referen::::e. T hi So can c:a I: ed 8 n Abridg ~rl Anal ysi S 0 r an

• Ab strs cted Ai,l:i Iys~s" .

1-0 r ~t,e basic skeletal morp hoi ogy, the F acial Axis (1) i 3 a pete nt desnri IJ F.:T of chi n P Jsiti on. The T eta I Facia I I ~ei 9 ht (2) is related by the 00 reus axi S :0 tnc basi-era ru a I axis, The l.owar F acl gl He Ig ht ':.3} ls the ora I gnomo n Ans - X -P m. i=acial Convexity (4) is the distance 01 point A to the Facial Plane. ~Fi9. 7)

For eentu re empl a~m~nt. th.e LO'i'JeT I ncisal .;:!c..:.Q€ (5) is fi:::!1 ated to th 0 A PC!

Plan e and ~he Upper Molar (6) is rei ated to the PTV Plan e. ~! desi red, th e Lowe' Li p (7) h; me;:;! SLJ rec from th B E5~hdit: Lin 8-.

I i, extre-ne d yspl as ia the pal ate cs n be rna ss I,JT-=:d trc rn F H P I a ne.

2G

.~

.. v

. ':',

, '

... ;

...

": .....

. ,'

! I

M.e. 9 7.223

6 -H-73 .'

p-

. 89

Tl

____ - . ____ ----

. ~.

2

r:

I

rig. 7 T1. Ff;f'fIale age 7.2. Sirr:ple descriptJ'a'l!!I abridged analys.ls: F~~I Am. I otal Fa~i~1 Heigtlt. l~r Faci.;ll Height 'Com'eJo;lty. Icrwer incisor, UplJ'tlf mul~r, laNa h'rtm1ofJ:s to F I ir\e ::; 11m.....::

Cloos It oC'.'f:rtlits w:ith higj'J palatal pl"!IrII;;!. {1 1 ~ w11ile normal .. s .2~}

2]

}'

18- Frontai C e phalometrics

F ronta~ caphalornetrlcs 'has. been a long 1i me ln reaching routine cI i nical usage. ~t took computet data to develo p a practical applfcationBeca use no statistically slgnlflCln~ carrel atlon So (0 n fad a I ty pe) cou lei be feu nd with the latersl, a Facia1-Mandibular indsY was detefm~ned for assaying n-olltar fac! al 'form.

·1 ,

.. --_

:1

......

."

T he. level of N aston was ta k-en from a. line through. the med i a' end of the zygomatico-frolltat sulme (Zf), Menton liIJ3S used as the lowest border of the ch i n, Na$ion~Me n.ton rep resents fa elal helg ht, but the facial mask @xt@ndSo to T rich ion at the hai r1i ne. \l'ndth of the ma.ndible at the region -of the mol ars VIaS reg isteled at the lower border of the trlhed ral emi ne nee or a ntegon ial tube rcle (Ag). The ind ex was determined oy way of mand ~bular width (Ag-Ag} x 1 GD over the facial heigh t (N a@on-M@nroi1)- The ad u:t index is 75 ;t 3%, (Fig. 8} I t ig her in d ices indicate bra cllyfa cr;:ll , lQW6r numbs rs ind leatss dol lchofacla.,

. ....

.-

T ra nsverse 0 ~ta did not lend itself to ang ular eval uation. Therefore, d i r-ect rnaas urernents v/ere amp loyed wh[ch need to be evafuated by ag e, sex, 1y pe and size, Direct measu cements a re referred to charts for a s.t~ rti ng base. ~Cnart" These we re: for the nose, the widest poi nt on ths inside or the nasal ~i3vity (Nc) ~ for the maxill a, the crossing O\I'~r of the tuberosity oumne with the malar ridge Or jug 131 process {J}: for the mand ible. the Ag points_

Fur the teeth. the widest buccal surfaces and can ino tip!S are visi bte an d therefore data was sup-pi led for abo ut 1:0 rnrn. of erdargeme nt in x-my imag as anlerio rly and 2-0 rnrn. at the molars,

2.2

M_G, 9 7.223 6&11~73

I Tl

94

68XIOO 94

- 69

Fig. 8.

Fronta I ',I~ew of pa~i &nt S(!6r. in Fig. 7. Hi!]h d.:::vl.a t.;::.d saptum I narrcw nasal cavity and maxilla I $1 fghtrj long fa co I narrow a ret- es and ~pha·,;)m8lrjc: molar cross-bite.

23

..
G ha rt I: Transve rs Ii!! Di mens ions
Nasaf Maxil1a M9ndible .~.:.>.
N{-Nc .J~J Ag~Ag
,
Age 3 vrs. 22.0 mm. 55.0 mm, 67,0 mrr., . ....
Age 8 vrs. 24.5 mm. 50.0 mm. 74.5 rnrr,
Ago 13 yr~. 27,0 rr,m, 65,0 r.1[1'J, 82.(' mm
Age 18 yrs. 29.:5 mm. 70.0 mm. 895 mm. .'
::-.:
For Negr~id and Mongoroid, add 3.0 rnm. 1,'1'
Ty pi cal GroNtll 0.5 @ yr. 1 .0 @ yr. 1.5 © r The lrd ED." l,{Ifd s the fI rst facto r (1 ).

Measurements trorn these r&terenoes W{:TC: the v .. idths of the nasal cav ity (N c} (2), maxi Iia (J) (3) a nd man d i bJe (Ag) (4) we re second, Oi sBgreeme nt Is noted by non-parallel ism of lines, Th e d ista nee from J pai n is to the Frontal facial plane adds to the lnfcrmafion (5 and 5),

The width of the lowe r dentu re serves ,8S a tcu ndaticn. A maxi r.1 urn jrrterbuccal \N'idth of first mctar teeth is a rereren ce (7). Th€ upper first moter is re laled to the lower (8) (9). Wid!h s of the lower fj rs t premo tar w-ere fouJl d to be c:riti ca I to arch forrn (1 0). I nte rca ~i ne width is th e last factor. Th LeS, due to the measurement, on both sides, the frontal abridged anelysis, in the end, was rno r(o' exte ns ive than the la teral, (See Fig. 8)

: .t

•.

'JA

_ .....

~ 9 _ De ntornetrlcs a n d Pentamorpn tCS

It is ircruc ~_hat model analysis ilas 'ed to confusio ..... in tho? protasslcn.

The proclamations of Nance in 1947 were taken as absolute dogma_ but they ha ve not stood up sci enlifica lly_

! 0'1 oro er to correl ale d entu re widtn S with the bee, two site-s eme~g ~c as kay references. The first was the lewer first molar wi1ths, which are related to paste rior fa(;~a I facto rs. S eccn d Iy \WaS the lower fi rst pre molar: wh i eh mo s.t sig n!fies arch fo rm, The canin eo a r-ea also ref] ~cts th 1:7:! nrbir;lliari.-:; oris rompl e x.

The 1000000r arch is. the most cri ti cal and is the refore eval uated fi rst, pla nn ed fi rst a nd fin ished :lr~t ~ T he maxi liar y ~ u.h has 9 reatsr adaotabi!ity.

Th esc two- factors b-E:~n-g pat arr.o Uti t, the maxi mu m d i mensl 0 1'$ at the most buccal crnwn widths beca me cr itical. Also, the arch wi re W"BS placed in tu bes or brllCk09ts on the b uccal s i<f e. I n ad d ition, the 'btl cca, 5t1 rfaces '....rete more easi ti i d~n ti n ed ill th-e fronta I head fi' rn. Mean data was ob~i ned ~ogether with standard deviation'S of spaciflc sitos in the permanent denture. (F tQ, 9 A) These were at the w~dest b ucca' poi nt on the first rno lars and first prernoia rs and th e can; ne ti ps of each arch. Data was fu rther deri " ... ed fm th e mi xec a nd d eci d uous levels 0 f develop ment. (Fig. 9 B)

, n ord er to co [Tel ate wi th ~8 tera I cephalornetrl Co. the depth o! ~he arch was ta k~ n f10 m F.I ii noS! t1 ro ug h :t1e- mesi a I conta ct a rea of the :1 ~M rno lars tc the ave r.;g e Ce ntral i ncisor edg e co rreeted fc r a symmetry. (Sec Fig _ "9)

Slu dies led to a condenslnq d own to fiv-e a rch forms to C.UVoC:F the ra ng e of d n~c::r needs. U ntreated normal mod el s were I,.!$~d tog eth er with 1 0- year stab Ie ::reated patie nts' mod e Is for study. The most cornrn 0 n as. exp e cted was the Normal Arch at 38%, The Ovoid (25%) and Tapered (15X} to foilOW' infrequency, The fourth was th e Narrow Tapered sh ape (12 *'). a nd the last was the Narro'I"" Ovoid ,:1 G%). Wig. 1 OA~

8y usin g the arc h form p roje eti nns for the in d ivi dual p atien t th e

co mpa rls 0 Il: of ths actual to- the- i nte nd e1 perrrns a visualization fer ~eed e d c;.:pa ns ion at the bra cket I in€!. (F ig. 1 0 Bl

2'7 -5

· } ,

: /

-

.. 1:

· ....

, ~

Gepb. 23.5

39.3 !'20 40

~i""M +1;]'

v._.~-r:) DIfo .o

25.3 !; ::',6

, -.

· I ~.::-.

:"'.

26

Fig.9A_

Mean nata w.it:h standard ceviations for measurements at bucca 1 points a nc arch depj'J fro rn 1 ine through rnesia 1 m ola r oorrt::'.lcts.

26

P ROV IS ION A L esc IDUO us

/' ("\ 'I i I ~

\ I J I ( ,

',I ' L i

\ l,

D lm e n slo n 8 r ouud ~nl Q u t in mm.

!vHXE 0 ~ qe 8. Yr,

Arch Selector

16% ?

/ \ .:

I y\

I ...

/ I \, ~ NOR~IAL /J

NA RRQW T "='.?ER =: J

. ~--- \ \ /1

/ --:- \ \\ I ;

10% I .'

PENTA'Al~. - I /1 \ t: ....

~~~~~+-T=\ ~\ / .~ \:)1

,~~ . =====---- '

R 1(::r;:i"=r.;8J11 / f" \

C I")~~ -'''0 1)::10:- HLI. ....... :".lIrt-.:"''' I:''' =-(:1 ... 11:-'- I .....

TA.PE;::E::-

..

I

\ ~

~ 12~~ .

... _- ~ / -,

v. Y )U_ \

( I \

0'./010

..

,

I • :'

. ,

I=ig. lOA The cla ssic fi~·-e a~cil shQ~$ with thai r perce ntayt"!5 in th~ orthodo ntlc po pulatio 1"1.

28

: '1

G.A, C!

Be-fore

748

A,1tB1

Fig_ 108.

Ago 1 '-7

OVOIO

NCFor.,·lAL

Cia 5:5 ;, patient G .A. witb normal arczies corjpa red to ortIi:1 til malocctu sion sho·.·iing needed expansion for ver ious forms. He W~5 treatec to 'no rmal'' form.

29

20. The H aft~ng 20 ne M atrix

T r.e i nterface bet .... ;een the calvaria and thg face Ii 80S. 9ssontially parallo I along a line from Gas1Qn to Nasion. ~Fiq. 11) The brein's medu!a lies on the cl ivi u s. ,,,.11 ich is tha upper part of the occipnal -schsnoic stnn. T116- root of the rl.aso-prarynx is. the counter surtace in the face. The Ba-N Plane has been called th P- Basi-crani;;::ll Axis. it cuts across the roots of the ~te.')'goid pi ates and cuts off the bF.lS60 of vomer at the rostrum of the 9opheMiu. It passes nea r the exl of thE! rnaxinary division of the Mth r)ef\'e at Foramen Rotundum It r~s~p.s 'n tha sams d ir-eclion e nc nsar ths &€I mE:. P ianc 8S fhc 2ygom;;]iico tempore I sutu re, It tn:=.!f'I~\.IEWRP.S cii rl:::!ctly through thB inferior orbital fissure: v..11 ich sep.tll ales the y reat 'M:-]9 af the sphenoi d from the max itb. It cut near the Ii ne of jutlGtion of the r: na xi lla ·M th the labyr i nth of it Ii::! ~lhn 10 id and ralls in .a line VY'ilh the juncti en of the fronta~ prOCEr-SS of :ne maxilla, Posteriorly: the linG: cuts Just at t""18 border of the tympanic plates

By .:;dl processe s of rea soni ng. it is a I jne of s.~ pi3 ration of ttl e face with

the calvaria. [Jut even further, the USE: of lhe HasionNaeior- fllan8" is

statisti cally more appropriate for facial me rphol og~c dsscri ption

HO·N8 ... ·er. another "hafjng" pri no pie is at work in th e vertical plane at tho regi on of the ccrona I sutu re. A ve-rti ca I 1!r16' INa s dropped pcrpondicu lar tc the Frankfort p~~mf:" at the base of the pteryqoio elates (pr): and 'liaS c8:18d the Ptery~~id Ver:ic.al (PTVJ. Thi s li ne serves as. 8 ba s eli ne for At)tero-r.:os~r- or crani al g rowlh and a reference for horizont~1 rrorpnoir:gy. I t is, further. a r~ferfloncp- fer rj·;:mtal d avp-I n pmsnt (St.-n F~g. 7)

Thus. as a junction of two hafting zones: a com p lete cranial base ::n.::~fufdiflg is founc at th6- ut l~ n of t· .... o pi anes, lr.e B a si-cr anial Axi s antalior1y a.nd the Frankfort plane posterior to P1V. (See Fig. ~ 1)

....

. :

."

. "

.. :: ..

, ..

~ ... s

30

: "

Bregma l ......

~_~

~- ~

<..

1. .

2 < "'::0:.

1-

\~

t

~

f

1

Pterion·

.,~ Lambda

~

Glabella

J

Nasion

Protub.Mentl Pog6n!on

/1

. GnathIon

Fig. 11. Logic of the Basion--Nasion Plane as a calvaria-facial interfa.ce. Red is Basj..Cranial Axis. Green is Pterygoid Vertical representing Coronal Suture Plaoo_

31

21. The C ~rve of M andi bular Growth

01 d er concepts he! d that the mend ibl0. g~ew u pWf.l~d <-1nd t::ad·wvHrd.

Comp:...Itw c-:wr_p~~itF.!s 1.1: 90 i.ntraateo subjects, howover, vr::rific-:i that ~~~ rna nd ibu I ar CD re bent upward and forwa rd with natural gro·""t~]_ M'i::i!8 n date and s1..8 ndard d8!vi.atiom:; \II."S'rf:o d p.tl:7:! rrni rlA-:i f::Jr ;jrCJ'Arfh ~mm the X pn int F1 irth A ~ iimaly~i s lac to. mo d ,scove:ry of 3 common curve located not th~ougr th e condyle but th rough the c enter of the base of the GO rona i d process starti ng at Protuberance Menti Pm (Fig_ 12} Variahons VI/Oro natura I, but the ba sic curve was an ir. divi dual rna rke::-

It became an Issue to deterrnirte the behavior of t.~e i n divi d lI31 processes from this curve. As this method wCiS compared to lrnp.anl studies. it was act·Jallj' to und to b.e superior to the i mp~8'nts. for forecasting.

Instead o' superirnposinq on Mer.ton and the lower man~ibular border.

SU penm positicn 0:'1 Pm and Rr nolnts reveal 8-d trus gW\M.h hehEl .... ior much moresuccinctly. l/Vhen al\ g'-o'Mh phenomena w;;)s put :Clgc:ri\-;r, it rovoacd that tnclov..-r-:-r rta rrum £}TLJpfeD upward and TGfW"ard a nd til at no resorption or ver y I ittle cha:lge occur~ed e: the a nteti or border €I:(capt in rs rc p~thclogic inGtan cos. Tlli So I eel to ~ wt. nip. np.w {Xln[,ppt of torrh nru ption, occl uSBI pI..: no rna n aqernerr and af1.::;hCl"~g.(:. The: fi ndi n9s lee further to no- .... methods for 10:-1g ra nge 10 recastinp. {Fig. 13;

Finally, it is to be r~m-ambar-fl{i lha; ths mandlbl-a grQw.s -ourJ.fard as. it grm\'s upwa rd. (Fig 14) Condyle errest lim its ~ateral y rowth also.

'::~I

... -'

,- ,;. -.-

. :'="

. ' .

.. . :'

',.r

. :-.,

F jg. 12. ft._ The trod tlcnal cortt..ept or gmwtll hm:j (hat upwarc and backwa rd ta 'Tla I q I"OVIt1 wa s characterized .b~ enter iur ramal ffi50rption, (S08 FFg 15 for eva)

6 Studies led to :Ji::;.oovefy o~ a curve constructed frOm t:::Vi8 ?Qint anc me Pm Pnin-_ distance fc ~ tt I)::; :adi us (1971 ). SiX sites a I"€- mod IFI ed ~\,'itr: ql'o'..v-.h a I~ the CJrv8

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Fig. 14. Arc: curve cr 'G'1"O' .... 11"'1 s irnulatad in Frontal P;'eno. Note roo a v £ol'"a Je Width development at 60') angre.

.35

22. F orecastl ng and 0 b j ectivlsm: Sho rt a i1 d Long Term

It is strn!lge that th 8 who I~ id na of prog nosi S 0(1 r roreca stl ng togeth.f!r with trs atment desig nin 9 pu t down 0 n pa per have met with 8t1 ch d i sfa vor and ridi cu Ie. Ed ucators and cl inl cl a ns. however, ap p-ear to be so ovewhs l--ned wi Ut va rtauon a nd the ta ts of the curve of d~stributro n t hot th oy h:~: I to respect th e en orrnous cen tral te nden cy an d ma i nstream Possi b Iy d ue to older rnethcds {If $\1 P e rimpo sing, they may not try to recogni ze the S(g n a: sand signs of p red leta bl e chan g e fror:l a pattern wh e n th ey are obvlo IJS. A "let:'"! e r rea S{1 n k)r rol ucta nc~ is. th at th ey fuil to identi~' iatroqe nic phenome na an d rnlsl nterpret p reduced ttl a nge S as nstu ra I growth c.hang es.

Sta tistlC$ s how th at 7. OSf of c h.i Id ren wtll 0 utgrow Class 11 malo eel USLon du ri ng the tra n sttional g!"o'.vth chan ~e:5. 0 n tne cth er h a nc, a bout 30 % wi It wn rs en: particu 13 r1y wh en deep bites are p rsse nt but al so w".th co ntin u e-d 0 ra! malfunction. It wou l-d seem logical that cl i nici a ns would have an interest in the state of the art -av ~i I abl e to heto di sting !,Ii sh d i Fferon C€"S in 4D% of a pract.ce F tJ rther: many clin lcians rna y reject any attern pt to treat those p atients doomed to worsen ff not to correct panonts th at wi Ir not ch :;mge.

It h as been a bserved that many teach or cc ns id er cephalo metric a nalysls to be the last word in dLag~osis. But descrl ptive a nalys is is on Iy the first step i n the d ete rrnin ati 0 n reso III tio-n process. Th e constru clio '1 of a vi su alized treatrne nt ob jecbve I n the usu a I two-yea r lime frame (or VTO} may be CQ nsi d ered too cornol i cated fer th e stu de nt to grasp. Eve n con srderec:t more grotl n dle-ss is ~he fo recast to rnatu rity with long -ra ngl? goal E to matu rity rendered ill the VTG.

As an 0 th er asp ect to th e pro blem in th e professl 0 n, g raouate tea cners are not avail abl e to- su per .... i ss the torecasti ng an d desi 9 n mg learn i ng precess. Yet students ass ign@d the task or: a cold bas IS h ave mas te red the work ln on Iy e few heu rs, With out exp os u re to th e facts, th e stude nt the '-More is OOflt<9 nt to

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~voi d tl e process al tog ether _ ~n actu a I p ract]:ce comrns rei a I a it is :::rv.3.EI a ble vla th-c corrputcr, but to soek that ir:ronnation seems to be a political 9mb 81 rra S S men t

F oreca sti ['Ig with trecfrrent O()~~g ni n gin the long ra ng-e tech n iq u e CU nsists of essentially fi ve p or ts. Each p.a rt Carl be! I F.::'! am ed SI:! p a rately a nd then co nr. ected.

The fi rsl 0 rder is th e a rcial growth of the mand i b Ie followed oy the ca rry ove r of reference I ir.es s uch as the 0 c.c.lu sa I pia ne and 0 r3~ gnomon.. (See Fig_ 12 & 13)

Th-e s econ dis ~he exte IlS 'on of tile hafti ng LO ne- refe re nces a ceo r1ing to age, sex <;3 nd rnorph 0 log ~ and perha p::; with treatme nt. {F ig. i5} Without treatment th e Ba N poi nt A an g Ie is indeed a Imost a constant.

The ~hi rd is the i nte n: of m Ddi ficati 0 n of th e rr:i d fCJ ciat campo" ents. The ha rd pa ls 1e ::::r:m ~I? rr R nip U 1;3 tE!"i1 a net {on 'J8xit~ c ha nged.

T he- to urth is the most dcsi ra btc or fC~$i b 10 €'mp lacerno nt of the teeth.

T he fifth 8 nd fina~ is ttie grol"vth an d frsatme nt mod F:Jcation of th e soft tissu e prnfiie.

T",,'O book 3. we re written as basi c refe re nw. for tn (;! :1~rai ls. The

statement was made. Aceuracy is far beyond that required tor oractical va~l.lo. Wilen th e actual varies greatly from th-e \iT G. the j)l oced u re be curnes d i :::.g nostic.

37

FOR~'IAT 1975 no 2002

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~.

Third Mo I a rs

Another controversy, still boi ling, is the idea of forecastl ng space ~or I m"i'8 r

th~rd molars. Proof of its validity showed a 95% accuracv. lrunlcally, nata suggests that orthod ontists save Dn~y abo lJ1 1 6% of t'1i rd mel ars. But a p rndi c:tion exerci:se leads to the preservln 9 of almost 50%. Th us, CO nua, y to common opmio 11. the forecast lead s to a much more con~eNati lie app roach even thoug h about 30% of a mixed dentif D h (age 8.S years} popu latio n can benci"rt from germectorny. (Fly. 16A & B}

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• .. seen rn r-Ig 7).

39

23. Traa trnent D es~gni 119 a rid M axHlal)l' Ad a ptivity

One of ~ he gr'i::i!::ttest centro: .... srsies ro ern E:Ige in cI i;'li cal ortnod w ntics con s:e::'lS ~r. e- a~tma b ·1 it, of th e maxi Ila. C hanoes invoke a three di I":l ens ions I coricept vr.Ji ch may ~.F! difficult to una arstand. F €"N argue the fact ~hat pal ates ("'.ar: De split or uncefgo rapid dtsuncticn. 'i'Jith th-e FacGmask in the ya:....jng grc:v..illg Child, no one doubts that a maxillary complex can be moved fDrNdrd, and Q u ito {Flpi d 11'. [3lR for psculi 8 r pcradoxical reasons, U te id~a Of rotracti 0 1 {F even tile hcldi ng Df a rnaxfla backVl.l'iard has met wi th mjectton, The same idoa has pre ... Cii I{~c 'M th toot h i:1tiusi on. Tr; cse fa ctors prom pt some expl a nanor.

Suture-.:=! have adaptr ..... e bone on both sides 1..vtJ:le the tooth membrane has oi.ndlo bene on one sid.e only. ln addition, h the region of the: prerygcjd plates, a d.fJubl8 s uture Is present gi'ling ri;!=;8 to tour ~ay9rs of bu ndle bo ~e ch anye possfbHity AI so, the sutu ras I i ~ at oblique a ngJes. [ven further, rrurir g max~~1 a:-t rotanon w:th corvlcal tracti on :..J3~ng .cUlchuagF:::i- DIl th e molar alene, certa i 1 of the ~l.iVre8 are slipaed <1'ld others ~re olsjonsd!

Evid~nce upon more evidence points to the passive luocttonal nature -of the m.d-facial como.ex. Tnis lnd.catss that t;le maxillary complex should be the pri,iciple tarqat for c:JI'T(lciio."l. This app-les both to the short and the rong ran~e, Th is has been proven :Jy !;tP. ti st!cal data. {Fig. 1 S A & 8)

Of ~ven greater r. ote-vvort:,rn ess to c·i n :t:at appl icatton i So tha: the nos Iii! struc.uro together witr. tile suparior lip muscles are atlachec to the basal maxillary skeletal parts. If that ~tructur'e is transtormed H19 ultimate result ps a clfierencB in th& ness pcsitlon in tho fRee from w11en~ it vvould·-have been wilh':Jut treatment. Thus: total faclal esthctice becomes tho goal. not just the teO"th ar. d the srnl e. r1easons fo.~ ~i1E:::! reluctance to accept th i3 poss~bi lify doctrine is. tnat conventional treatment starts much teo tate and. rurther the techniques are poorly i.nderstcod and therefore an:'! not applied. {Fig. 17 A, B, C & 0)

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41

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Fig, 17B. Transitionai analysis shov ... in!J meier orthopof:!d i[; maxillary altoratlon, lower molar intrusi on. vertical cundyle gf'O\.lJth ~nd :)nf~ cno deg te€- mandible rotation,

43

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45

M~C'i ~ .c,

Ar,'e 15~4'L~Hl' 8/2,4l8.1

r;ig. 1'11:. MLC. rCcmpariSlJiiI fQ~; lNIiltu.n 't~tmlllnt forecast Is. r.n ~nl, Natice, th F't-erm;a~~!'TilkI dOll ~{).rJ a~ u'l'JPBif molar ~iiereooe ellS MiftJ, l,J~r~l'lC:i'oor of iIe. ImillllfliiKl ~!f ~O!5e tip of 5, min.

24, Control Ii ng the Man di ble

Earliest investiqations on behavior of the condyle du:ing treatment showed 1~lal a 1m ost one th ird of patients treated with Ed~'J\~ se for C lass tI r0S1J It08d in a cotldyle further dista II y and/or supefiorly position ed in the fossa. I n ~c,e rna i ns.reern of denti stry at that ti I'lA th i s .... vas C"..o~si dered fa'J[}rF:lhloFl Thi s fi ndi ng has now given rise to a different i nterpretaf on.

ajarn conf rrnoc VI/ttl implants in 196& the Rickets findir lYS of 1952:. An upward and forward growth of the condyle and ramus was cons iSfoFlnt VYith forwa rd chin ceva cpment A more up-ward and bac kward growth of the condyle was charaeterlstlc of mom VQrtical lncraasas in facta I h ~ght. (Fi g. 18}

k first. under the doctrines of the 1940s, th9 author accepted as. taught that such d~fferent changes 'Were strictly genetic... Fof\l'ltard or backward di roctional ct]c:;:ngcs -wora an expression of type. Now it wou ld appear thai en viror imer Ital factors must be superl rnposed OV8f the:;. gfmAtjc, p;:::nt~fns. at least in tirr e peri od 9- I ess than fl ... e years. These fi I'l:dLng s have a profound rnfl uonco on eli mCElI rons.derations_ Un-less darnaged Of diseased, the '!J~ owtl t ur th:i! I nar uj ibis and its positi on in th-e face in long term is remarkably predictable (sec Fig, 1 7 Q). \'Vhf,:n stware-Iy rotated by three degrees 0'- more. the condvl B ar ~ the chin w:11 continue to drop or r:ot reoovgr.

The i ntenl of forward: pnsturi n 9 techniques has been (0 proc uce posterior condylar growth, If this is at~ained: then biological;y: the cn~rl drops mom vertically {with the 11i1::kat~s-Bjr'..rk tneoryj rather Ulan mor-a forvrard in !he face unless 1t Is accompanied by mandibular over-closure. (FiS- 19)

On the oth6f ha:ld: records have suggested .strongly that i nc reasee ir: vertical growth of the condyle or- eva n upward a nd forward growth on thearc produced by postetjor increases has been consistent with forward chin development.

Indi vidual recorde have gi veil the irnpresaion. and profound data was cornpi.ad by RRUr1:rind in 1981 Atld Ricketts. in 1 960: ~hat at least a temporary increase in pcsteri or ramal h~igt]~ and chin po.srtiDn with cervi cal tracuon @no often 10000r molar intrusion is a reality. (Fig. 20)

47

UPWARD CONDYLE

Ricketts 1952

, . '"I

F'ig. 1S. Findings In 11152: lI.rn"", romall;rowth W<ls a"ociat~ .,ilh iOIW""j chin d.v.lopm ..... t. ~rd bendi!'Jg was conSis!enl OpenlrlJ rotatiOrt.

BACKWARD CONDYLE

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DURING C~ERVICAL TRACTION

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intrusion of lowar molar and vsr1lc;:H ccndy12' growth. -,

50

OLJ r fi rst date in 195... accrued on t:'eate:d patients with conventi ::trial straight v..~ r-e orthodcntics showec a mean rotation of foor deg::£!C8 {4. J.-=-) on the Y axis. As now exam ined on the a rcial m atrix, the condyle \!\IOLi Id be: a ssessec to b~ con pressed against the eminence or at the depth of me fossa. It SD. it is i nhi bHed from n o rrrel qrowth exp ress ion, The rna tldi ble with severs rotatl on. in effect, may become wa.rped open and the chin retracted, (SI:!€! F ig_ 1 B}

Ro(;ovory W-:'1~ seG'n ~n many pa:ients. In oth ers, aai d .ag sin: the vertica I uattern ·took uf"o-.: and became worsanac. [n:11 Jr ignL):"F.lnca, aU this vertical behavior was considere-d ~o be due to genetics. Now we percci V£: it as irnrogcni c.

Thus, the idea of "mand i bular control" smerqed. It started witt} Toiea-pin 9 the aneerior teeth out (If interference. In effect: it meant treating the overbite co mpletel y before comp I eti ng tho OVGr -jst eorrecnon, Thi s, i:) turr, .gave ri se to the idea of intrusion of anterior tee1h for dr::~p bite, It -wen! on to consider C1r.:[,j[Js;::}1 r:la-nq control t:.y cortical a nC'lOr8ge and treatj ng th e lower arch to the ori gi nal level of the fi rst pre-mol ars. These p:-emolars, replacing the deciduous firs.t molars. represent true physi(J~Dgic face heighl. Th F) tnoory dev~d oped that up to two o(lgroes of Faci a I A>:!s rotation is witrun safe ri m it9-. Openinc further +ian that is thought tc in'l/rre com1ylA C"'.ompress ion nf a secon dary natura

Th US, the M'O aspects of '"O~atiorl emerged. The fI rst was tho provorf QrI of ',)i.ysioiogjc rotation for bit€ opening. The second WE:lS for the yr{Jwf~l benavior of the rnand Ibl€_

The f n d flogS from use of the X ooi nt and Pm point bscarn e a -d isereet matrix to rreasure l!"ie behavior of growth during treatment. Ijeiore tts lJSG, as a certral or core- matrix, "one externat featu:'€!::; were often ·:.orifusiflg: and nconcus ive. \l'Jjjth the new matrix and tho usa of j,he critical Facial Axis. the detei ls are revealed for open or closinq phenomena.

S 1

Histology

~ Dr 7.0D years n has bee:l bali e ..... ed thal tl19 cond yle grew stra ight upw.grj and back ..... ard thereby thrusUng thg ch;n downward and rorwa rd in the face, Gephalome trio trs cing::!o superjmpuseo i n the: conventional rna rmer. with the fO".NE!r border -of the mar d i"ol a reg istar-ed at the chrt1: seemed to sr. Ow it. {See Figs. 1 2 & 13) It followed, therefore, thal e;;lUS~rlg the condyle to grow more backVll3rd would na sten the ch in tc doE!velo:J more torwa rd.

t I owevs r, im plant stu-dies of Bjork and others, and experiment-Ell 'l/lAJrk.. fed to the d !8COIIBry ot CU'l"\!08 oj g~olNth pas sing. no! through the col'ldlyle but throug h the triangular ridqe at the medial aspect of fr.e coronoid process. (See Fi-g. 12) Thi s curve: appl ied to the growin9 mandible 8L.:g.gested ~hD condyle to typi cally -grow upward and 81 i ghtly forward.

It \I'Ii.:I S as ii workers \lV€!re S.Q convincod r/ thF.! direction th at they did not closely examir:;e the hi.stologi~1 evi dence.

T ne cross soctior s (Fig. 21} of three hum a n s u bjeds thr UL.:g h the con nyl€! are snoV\lfl to y[g!d ths same characteristic e'Y'tdence: {1) Th"8 rortiri:l;;lC is disturoed and thi ekes: (I{J "the upper anterior I ocatl on: (7.:1 th~ mioFJn!;;::u 'on of the develo ji ng trabecuiag is i nell Il'8d forward arr.:i (3) islands of resorption are observed On the posterior side of the eondy~ e.

Other examples wrth stams in :-119 fiving human tetl the same story.

Innibition of mesenchymal .and cets and effects on the prechondrcgnnic area by compression WDU~d stifle condylar growth vefti-cany _ Only the posterior cells coul d p roliferate form i:lg a fl attening picture_ This is prsci sely the concitl on tl-at FS ohsarvad The resuJt is a developing rettognatl'lic patta m. It can occur frcrn breath ing prnblern S .n vkI ich tbe me ndible is l.eld chrorical 'I fl.)flllf9jrd for ai rway provision It can also be iatrogeni c.

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Fig.21A. Section through a condyle of 15-month child. Notice at the arrows the direction of the cartilage and resorptive bays at the posterior site.

53

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In concl usi On, U'lte~ treatme:it e;<;per! en ce s hs .... e been found to inr i b: t 'IerliCC:t: condyle 9 rov...t.h. Th8lsa arc:

1. Excess IV€! forward ccndyl e- fY)si ti ens w· tn .a tr ansference ot f uncti on near tho en lnonce sum mil. (Fig. 22A~

::2. Excessi\'e mand Ibular rotatio n for treatrneru of deep bi:e_ C lass II unfavcrsble. C~as5111 favorable, (Fig- 22B,

3. I 'l~ru s ion of L...: pp80r rno: a rs wj: h r i gh pu il fa C8 bow for OD80n b~j08. (F~g. 22C)

In Class ill, c~nOYI e inh ibitior. is tavors blA tV~ mul d tlll?n rize that f(}i"'If.IRrd postu !"ing and ever -C'OS;UfC coutd sot Dff proqnathic grD'WI:h. Tbcrotoro. all Class t11 conditions shc.ul d be corrected r LO Idler than age 5 year s. ~ Fi~. 22D)

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IF-toQ. 22: A R,Octatiali IQf 1tJe. mand'ible be!/,ond 'Mr.o.,);Jegrees !has Hen Inotedl Jt;i) )COm;pFe5S, ooM)'ile by muscle kll:crurning. PhflOlJmenfi notedl irtJ me-an Dena~~ ~fII N~15, !5ialilTl~I'&. of ,drlildren nate.ci wif:h DitB IQWlifig ,Slfld ilii!~IlIIJ o'la5tic 'battJoo.,

51

M.H·9 10-22-71 4-& Yr.

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Fig, .22 B ,0.. four yoQ-.8 r 0 I~ dl ild I opsn bHe ':;:lXI1kId' with "nigh wit·, Fa(;Jd1 Axis closed hut patient po~tured tho mandible forw~!d_ Note flattened J::ond~ h:! (:lad posterior gro .... 1h snawing oon,dyha ~~ So vi or .:J:lrQ~iiQn,

Fig. 22(:.

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(2.) Transitlon·al ::;.nal~sl$ of Class III. Note rotation of d1 in. Note in Position :2 the beba .... ior of ma hard plate and maxilla. Notice es::;entially no vertical growth Of compressed condyle in 13 months.

;

25_ Early Treatment Advantages

Five generi511 di sedvantaoes to ec rly treatment are usualv expressed by ~I inicians, The lc ng-te~m manag:&rnent, econom ics, a'lc the fsar of rei apse dominate the concern, HOINevt1:r, ther-e ~s an ei:Jht-fold advantage .isted for ea!ly tmatrn ant rnaki ng fo1y -9 peclf c tactors.

F_8rly ~eatmef'lt is aimed first at producinq ske.etal morphologic harmony.

This tr an sforrnatl en is autQm~rH['..aI~y followed by a chan ge in function. I n. turn. th enatural forces of occlusion arc rocruted ~Ild natural growth is uti I.zoa. Orthodarjt .sts who a roe simply tooth oriented :lmi tbls d iffi ell It to conceive. l-urthcr, ths. anchorage factors are poorly comprehended. All these issues reoure c speoiel course unto it~81f A tour-volu-ne manual \'\'[:j!:j. preparec for ~elf~Quc;ation in early tre-atment.

· ,

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26. Tern poral Bone Monitorjn9

The temporal bone on a c:IFnica~ basis r·as been taken CIS a ~given"_ By superposl ng traci ng from birth om"lard. the : nternal and external aud i10ry canals

h ave reveal eel a slronq stabi lily possibly due to the petrous bono and its . .

cents nts. Experimemal ~at:xJratory V'IOrk h as shown, rO\Never: that a !rerallon at

n orvo afICI mlJ scu lsr elements may affe-ct the development of the """nole temporal .'-

· ..

DO.le as a unit. -r

In addition: the tem poral oono sits on the ocejpitel and sphenoid bones a nd it ::naps over" the ~ar ietal bo-ie. TIll:') patrons ponon of the temporal i So \lV9dgred batwean the basi -occoital and horizontal shoff of the great win!.=!' of the sphenoid Th e t[:.:mp(: ral bons al so supper ls t~le jug ular ~':Jssa_ Cr. nsequent Iy, the temporal bone would app8ar to be is: "basic' in cranial morphology. Heavy ml sci es are attached 10 the mastoid process.

I r. ~ 990: computer generated data revea leo tne gleno id fossa to move posteriorly Q.5mm per year or 5_0mm. in 10 veers, (Fig. 23 A)

: !.

: ...

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Normal Gr0~lth

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lOY r s.

N~73 Nontreated

46/27

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Fig. 23A Inf¢rrr atl¢-fl from oorr.puter data, ~ 969, ccnfifj"Joo in 1990, r.a-vea&ed a 1""T"IIG::m of 5.0 mm .11-: yea!" (01'" 0.5 @ yea r) posterior movement of the- ccnj~c [It Posterior Condi:{lion (Cp} from

the pterygo;d Vertical (PTI/).

6]

D avel coin g d eeo bites sho ....... 'ed th e greatest posteri or te rnoorel Done d isplacernerr cu ri ng develop mont of all t~'PP.~ stt Jdi ~d 111 rt of 1:::'3. pati f:! nts. (Fig. 23 B)

h , ..

;

The te rnporal bone posl ti on Can be reg istered as Porion I v...hi ch ha slang been empl Dyed in anth ropology Bnd cran lometry . To sl};]gest that it can be aITec:ed cI ini tall y is a very reserved stF.ltf'lom£nt. I nd! vi d ual patil:mts and cornoosltes of groups of pati ents, h o v. ~\/e r I ha .... e ir:ti Mated that posterior deve'opment as measured From the p.le-rygoirJ vt=r li cal plane {PTV) has beeri less in patients or groups trealed with cervi cal traction. (Fig. 23 C) A C lass In :9g81 8 treated with Face Mask showed the joint backward at a rate of 0.8 mm compared to 0.1 far the cer.J:cal traction group. Ir1 long range, reboundmq rT':;]y

..... • s-

,'.

".i:.

OCCUf.

Thi s compo nen.t 8-f correction of C 1.a83 II and C lass ~ II h ad not been ccnce-ved before. It must 8V1fBit larger studies. ~AoreDVer, N...o other siqniflcant gro ups yre:ldoo si'TI~1 F.Ir r"fJ S-I n-::;

Of further i nterest is fhc rotation of tho to mpo~1 bono squama po s ition rei a: lve to th~ potrous portion R nd thlF! development ct the arne u lar eml nence i n tbe joint. C I~nidans anc ros;~rch~rs tocus 0'1 the condyle ano ·.,ery I ittl e on the gr owth uf tl ~e ernlne nee. These t'J-:-of.: arsF.ls nEllF:lding fi Jri har [jHt~i~~r.: stu oy Rna th~ method for a:'Isl ysis needs to be highly critical. Poi nt 80lLo on Iy ados mystique to the situation.

It IS turther recopruzad that temporal bone dysplasi a is a prom inent component af Glass Hl rnalocduslon.

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62

D ev eloped Deep Bite Tl

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Class I

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F'ig. 23B. A sample at t"Jifle ncn-ueated dlild~n who developed daeper bftos, Sflowed as a rnean of O.S mm dlstal moveme-r'lt o~ tho condyle 'Nith developmeru.

f_" 'J_"

1 _i ..__, 1 a S B 1 1 A -,': J 4

Hi!;h Convexity

Non Ext.

Biop!'o

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T2 Cla~s II

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rig. 23C.

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. 64

27. T em pe ro mand ibul a r J 0 i nt Pa ttJ osls Classifica ti on

We classif eo t':l e types of conditi 0 ns ob se rved in enfere nt CD nd itions of the ccclusl 1:1 n in 1 9-50. F 0 u r basi c types werE! fo u nd _ They were ': 1) d i stal di5p~acement (distraction), (2) absenC€ of v~rti('.a~ posterior support (compression). (3) R contra-lateral interference phenomenon and {4) anterior range of tun ct! Q n . N oth i ng has been feu no in r,a If a ceruu ~ to a Ita r that ortg ina I presenla llor I_ MRI has on Iy conflrmed the Dng i nal contention 5. Tra atmant has unde rg one an evolu ~ on. irI owever. {Fi g~ 24) A fou r part man 1:,1 a I has been form LIla ted by the author fa r info rmatio n an d treatr-ient of th E: TMJ.

:2 B. Deg-e n endive Joint Di seee e

It is a. rnys.ter~ why the who Ie degen erative process i n ~he condyl e. and the cor.dyloid process toqether wlth alterations in the fossa and eminence: me so under-apprecrateo on a clinical basis. Perhaps orthodontists are 5G p reoccu pi 00 VJEtk the p rofile that they simpl ~r do not exa mi n.e pes teJi or moron 0 logy or maybe feel il is i ns~g nlficant. Secondly. th e routi ne use of tomography is. net popular. However, eA1reme~y major regressive chan.ges can occur in th E: joint of 0 ne Of both sl d es a nc go unrecog mzed. ld eopatoi c hYf)ertJop hy also cs n 9-0 en n otlced fo r a long ti rne, ~ Fig. 25~

A si g nificant factor also is that such conditi 0 ns can be i atroqenic despl~e some cls i ms to the contrary. Some ens nges have baa n ca lied i dlopath[c a septic n ecrosis. tt i So as if th 8 neu rotro p ~ i c su ppl y to th e io i r.l has bee n impaired. The f ndtng5 a re so d ra mati c that, an y:t1rne a severe li vertical growth pattern is observe-d the patie nt proba bly has undergone a dLstresse-d condy te. Wig. 26 A &. B)

65

l-y/ {

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.,

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(7

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,-Y

B

.[I,fF(lP.! ~

... ~fU: < _

Abwno:::- (If support (oomptof:lssioo).

c

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occi !)3i()l'l F:!: ~·I 1 r·w: 5 rc..:r-l

Fig_ 24. The ClassiFication, 1')SO: 0' tour f'tp9s af tunctionai QccJLJSiOrt5 Q iving lise- to d ist:..n:.a nW5 of the [a.=11f,l()rowmaoolbular [omt. NDthing ries cf1enged slnce then excspt the coruroversy.

.~

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Abnormal growth bohavior

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Fig 25. Types of growih croblerns in joints; (1) CortdyJar :h:rpartrophy (2) Osteoarthritrs (degener.Jtiv&), (3) Rhetlmatoid_lo.yal~ rlifferenre.s in oondyle gtoW"ih (A.-E)

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Dc 12· 8 3 • 5B

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Fig.26A Degenerative joint disease fo~loofflflY n-rst molar fJ::dractions at age 11.7 (B}_ Nota. that m ona year deqenoratlve (;hanges occurrao ~n the right JCIU'ilt (Cj. By ag~ 17.9 ~D} tho changes were advanced. o 8. Seen in Fig. 4:ti.

Norma I Grow1h

/

D e qe n e rative D isaa 36'

D .. B.

F 19- 268. Joint aoo mandibular seria' tracings show.:ng nDrmal left side iOInd diseased right si{fe in patient DAl sean in Fig_ WA-

69

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70

-,

PARTm

M ECHAN~CAL D EVE i.o P MEN TS AN D TECH NOLOGY In hi s seventh adiri on, Dr. E. H. Angl e stated:

Of necessity, tho nlstory Df appHances i9 C!055!jy con :lected ¥lith the h isrory of orthodontia and lal !J~I Ii rneasura sits progress. One surprisinp teaturs of the h IstO), is th~ freqlJe.'lcy of redi scovery of i donUc5I1 pri nci ples, their material lzation differing only in m inutiae 01 manufacture. . _ . . Th~ firs~ i=:Ippl i;;::mr.l:? that \tIIaS destined to mark ~ d isti net step in the written historv of Qrthodonfa wos that 9 von to us by F auchard. of France, in 1726, and ¥iii ch we wi II -ca~1 the E)'o):fJan sion arch. r Of illl c.l1i ef function i So to expand the dent a I arch

Mech a n icel s, fhree ge:naral movements have uu.:::_.u red in the spocialty Ajl a re practl csd currently _ t- unctiorrali srn, the fi rst, was characterized by rnandibu lar m an puiati 0 n, 'I/\'h iCl became the resolve. Trflditi onal i sm. ~1·le secor ~u wave_ converged on tooth man i pul ati on alone. J ~ lim ited the prospects of skel etal cha ng0, Progressivi sm. th e most recent, took the best of both previous th eones and orgtl'lized treatment nto stages tov..rard a go:!] I gauged to maturity. It 6'r"'I :)ha sized a doctri l1et of possi bll ity _ Thus e di acusslon oi mi nd stretcbi ng must h 8\'e a star ti r log length.

'11

.. ~

ideas that set the Staga for Nnw M ova rnonts

some iceas that set the staqo for n 8' .... ' movoments cf these arc: : .,

1 TnrBp. plRne-s of rrer.;hani cal control wer8 rroven desirabl8, vmich led to I igtltm squar0 wi res, {19-50:1

2. Progressi ve FiOd a gernt"!"n1 uf teeth wa3 CD '-':'3i ster.t with techniques tor early treatment aefore sll the permanent teeth

v rere aval lable. (1952 ~

3. 813:[:110nal rnecharucs and rortical anchoraqe changed the pas s i bi li~es ami hence the obj edi ves of treatment. (·1 9-54)

4. l. ig 'lt~r wires I P--:i to th~ use of more conti :lUOU s and I ight-ar preesures, This ir. turn ed to safe expansi on whi:;;h leo to smaller bracket s lots 0.46 m m t. 0 1 8'; (1958) and further to 0.43 mrn ( 01 T}. (2002)

8-. The abi~ity to (1) :!1:::::r.:omplis'l m~:.r;(ill.::lry orthopedics: {2) move me lars d istaily 61 "ld (3} to irrtrude teeth ch a ngoo the clinical ob jeGtFves further. (1 960)

3. Prefabrication (protorrnod bands) pc rrn lttod tho d~velopm ant 0; pr escription br ackets. (1561)

7. Fixed mandibular posturing methods {Herbst) demcnsti3ted

iB.stoundirrg tcrward placements 0 r the lowe r i r lastJrs. In· ':.:.

. ;..

.......

" t:

contrast to r ..... '-E:oDd ~Dllo'N8rs \....tIo seldom pi anned to move incisors forward, these tech niques even further changed posslblllty, attitudes and objec'Li\les. (1973}

3. Dond ing brought wi lh it the need for m UC.1 !~!Jht8t pressures i9st the bracket' So bonoi ng VifOU lc break, {197.5)

Th us the 'modern era" in orthodontics started in th~ 1 :8705 and stiil is. undergoing chan ~e!

• -::r

72

29. Sc~entlflc Evaluation of Mandibular ~osturing: Methods (Still Debated)

Sevente-e n n ifferem gm: lr~ of patiP.lnts. trn:::lt~d wth varieti ns of mrw::-:Ir.;i P05tUri Iltl devices, have been stud.ed ej:her ifl short range (d uring immed iate post treatment) and !ong term doration (10 yElars:~ The findintJ.3, during activ~ trcatm on1, h~VD rovcslcd a subtl e open ing ~endi tlg of tha ccrous-conavlsr axi S a '1gl1.:. Th is behavl ur yi elds em i nU eased Pog union-C Jndylion di rnensi on: cornparsd 10 controls, Almc:st a s soon ;;)8 It IS prod ueec, the: torm re .... srts to a normal pattern of development. (Fig. 27 A & B)

It may be difficult to detect "Without tho R ickotts detailed COre Tefe.~encg.g.

The same change can be el iciled by elastics ¥.lith 2aO to 25r} -qra-ns per si de and leads to :3 fulse sense of correction with all techn iques.

No E \pi de nee of Growth Act! vall on with M and~ bu tar Propu is.or1

In longer range, there is no evioor'lC9 that has bsan found to suggest an improvaman1 of eHhGr rna ndibular stze or its position in th 8 face; irom the posturL~ fOrw.:9rd techniques. In fact, seme samples appGar to ba slrght~y i nlu bitad i n "ort~c!ill ramal d eveloprnent an:! chin position These are revealed from a comparison ot controls V'JIth tho precncaons and also trom s comparison to controls o~ development without treatment (See Flg. 27 ABu}

The resuU.s do suggest a later ramoda Ii ng of m18 maxi 1~:!1 ry camp lex in the long-term sarrpl as aft-E:r mandibu lar posturi nq as shown by Dr _ K. F altifl. The i m medi ate eli nical successes are dJe to tooth rnovemems. A combination of ma.ny small changes together with a change in fu nctlorv-not 9 rowIh stirnuleti Oi1 of the mancEi ble accounted for the changp-s

Jt IS ironic, hOW8vcr, tha: perhaps a downward and backward fote€! on the rarnu s provides a OOtt9T gro"N1h input Such action is produced by c-.erv'cal tracti on ii it is not abuaed. The continuous fc(oe- '#as o'IJer....mel m ing. Tt1e large error was in tile assumption that i nter -maxi II~ry ~~s1j~ L1S8d 74 hcurs per day Ih'OlJld be correct for sxtra-orel tractlon. Ten hou rs of lJIJear a~ n.ight for thes~ devices was desirab~e.

Four [r~rpe'sl 'Class II m-,

of F'Unct~,onals

Tl

FUhC tiona ru,s

T2 13;".3 Yr ..

N .:: 1S8

-,2

fllQ. ,21A_ A oomP-'Osite !Of N .:ll 1138, CllaSS II patients lhavt '.' rre~lwa AC~:ivmlj)xs. BimJers" f~1rs

OJ BrooaIDrs. T1 ~hOM Cileep bJte tCeass ll, 12 Ii'S ::t5 yaall'$ later, f'adal A:Qs. Openecl101ll6 1"4 degreQ bt.il '!iJefflerelllll$U1t was go~1 to. not dUe kD me- ~siM 100r'the mandibfe.

PR ED ,! CD lOIN NO TREAT~

2 .. 5 Y~'s.

A.

B

f'". 2118, A~ Nmna Gmwtn ~ rw ,2.5 ~

B. hper".~loo ' .. :" 100 - _" : __ ' ."_ '_'~~':~d.IInI'lfu.8ted

~ Rad,~ IBlueI(~1

, ,

30. Condemnation of Hig il Pu I i (Face Bow Tractio n]

Whp.n the over·Jse (i n time) and impr::Jper application (in a mount a:'"1d auxi I ieriesj of cervical tracti on led to severe .otational problerns in the mend iol e: the "hi Jh pull craze" devetooed in tne 1 950s_ It gained popula ~jty with ffle idea of the : 'NCdgD effect.' Th 0 concl usions that 6J "h igh P Jfl" woul d- prevent opet'ling a nd ~wjri ~ the rnanol ble torwaro, hOW\o.:vm. wnr~ rn:;mF.l! I m~. i II founded and not sci a ltiFically derived_

By contrast to cervical pu F used at nigt·K only, stud ies or pa lients wi It I ~ li yt 1 P u11 reveal ed that the loss of posterior support by upper mol ar mtrusion could cause condyle cornpressl OfL fnhi bitiofl of vertical condylar and ramal growth was measured to be .statistically significant by Bau mrind (1 981 ).

However, for gummy amiles e fifty-qram liqht hiqh puh asslstanco wn-r.:ri a LJgmFlnti ng an I JprFl r I Jti~itf ;;Jrrn "for inci sor intrusion is a i.(".epted lt should not exceed 5{] 9 rams per s ide as attached at the m id1irte as suggested by Jarabak. M axill aJ}' i ncisor inlrusi ex 1 must abo ~ consi dered i~ 1 tl toE:! I igt ~t uf future ::;;y i ~l~ er id IQ'NOIir'lg of stomlon

E<::;:rlier. several factors W8 re I isted as contra indica.ior is for the hi gh pull the.ary. F ollowi ng many detai'ed stLIdi es, the neg::;tive factors added up tc: twenty-two. Th9 findin·~8 \lllara 80 profound that hi gil pl.:-II became colflp~etely· condom ngd by lhG author. 111131 masons a ro listed toggtilrar .... vith rntnor comments and are di vided !n.to five ceteaonea

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76

CONTRAINDICATIONS FOR HIGH PULL FACE BOW

Manag-e ment

1 . D ang09 rous bccau se pull is dtrected toward the eye_

2. Reqtl ires 20-hour Ylfear fo r cornpa rable cha nges. with ce rvicel at night only.

::). Da"ti me use is embarrassi ng (corml lance)

Maxilla

4. Rest:'icts grOJNth of naso-pharyngeal ai lway space (whi ch is already often dlstressad) .

• 11. Ofte n employed at pe rmaneot dentition age when "orthopedics T of maxrll a is more Ii mrted.

6. Foree is at more direct psrpe nd lcula r to sutures (wh il e C@"nlic:al p-u~1 is at "oblique" directions).

7 _ Often employed with an arch wi re. wh ich n;;!strtds tota I pal ata I ortt.opod ics.

Mandible

8_ Produces (on average) an opening of Facial A>:is thereby producing an openi ng rotati on rather than cl Dsin.g.

9. Decreases verti cal gwwth of ramus.

1 O. I nd uces an ooousa~ pi ant- upwar-d paste riorly wh\ch:

a. decreases effective Mt of the emi nence in function

b. I nvttes contra-latEr~1 interferences in func~ on.

11_ Disproves the wedqe effect theory.

77

Joint :'
12.. Produces all absence of posterior dental support: which leads tc
direct cond~e CD r:1preSSiOT1 I which in tu rn i nlli btts vertical candyl ar
growth. These consequently produce further hyper-divergency,
13. May ki ndle a posterlor-su peri or condyle dis pi acernent.
14. Mil ndi b ul ar di splacsment posteri or1y 18 the first c:duse of di SC . t
I uxatlon a nd subsequent eli cki ng.
15. A posterior positioned condyle may lead to function on retro-discal
pad,
.v , .-
, ~
Teeth
Upward and backward movement of upper fi rst mol a r restricts :
16.
spaC{':! for molars. "
'.
17. The use of conccrnlta nt arch V!Jire may axtrude upper ante nors or
~ ut (hem in E3 "rab bit" posif on,
1.8, Permits further su p ra-eruption of tower molars when they al ready
i3 re common Iy 100 high in Class II conditlons.
"
19. Tlpcec occlusal plane makes it necessary to employ .... c94orqued';
brackets on the lower ~ncis=:)I's.
20. PI aces iO\N'er arch in weak anchorage pes ltic n for intermaxiHary
traction (relati ve to extern al oblio ue ridg c). ";
21. V/ithout lower anterior intrusive action fi rst, tne uppar incisors may
produce ful\cti one' 1 ntarfcren 00, which feads to rnand i b uler rotation
backward.
'.'
22. Often employed with ncn-expanslo [1 theory and thereby i nvttes a
h,g her perce mage of extraction. : :a

.... r;..

'" :~

78

31_ Confi rmation of Root Rati ngs fo r Pressure

Pressure. by d.efini ti Of') i!;i. force per unit a rea. Sever:::d studi es h~ve 'Sho"JA,n tl lCLt tt s Ii Qarr,ent st~'9tchEJs, and S=::o:ey fo ;Jr,d that the toot 1 is agai n st th-:=:: horse if the socket "NithErl eight mi n uies ot cornprasston=-even di recti}, vertically. Therefor t!', li galll-6!nl is a very t ernporary source of Sir cho rag.e,

ThQ am-a under concern In anchcra 99 is tho root surface exposed to bone in a di red I ine of rnovem ent.

Experi ments ;ed: to th.g conclusion that one gram poAr sq LJ8ffi mi I ii meter of reo: sur-ace is a basic reference- for move mort wl:h in the ' septum" of alveol ar bane. The septum is thP. Cr::I nosllous area that separates the outer a nd inner compact bon e or corti cal P' ates.

Thus. torces for movements wilhin the v~roughJ: (or septa) were calculated from th-e cross section. of tr:e roots 8-f the permaners teeth in tOle dire-cti on of rnovs rnont. (FIg_ 28) The 3:-ea of each deciduo:..Js tooth: v.laS ~ e vera qed a ut' as a startinq rererence. IFig. 29)

Mod ificati 0 ns

If cortica: bone. either lamina dura or external plates of the all/oolus;, is to De r-10dif ej, the p ressu re i 5. reduced one-hart. Prc!&surc:s are 50% reduced for modification of the "ri dg:e. ~

It rnu st be unclerstQr;.r1 ltJiFlt stimulation for the outside of the ri dge ~.r)kc.s pi ace at ihe penostcum. For ridge change the pressL;m is cut in halt OJ' U_ S

-

grams. per rrrrr H: Or!' the other hand. anchorage is to be produced by the

precess of aclorosis of th.e me rnorsns and thG bone traoecutae, the press ure rate is coubled or tripl ed.

In eSS€llloa, th8:S€ seal es, reoonfi:rmed by S9veral studies: lead to rernalkably mora, Ii 9 hter forces than though~ possi ble partict, larty far expsn sian,

The rating scales prove to be marvelous g uidas for extraction procadures. for instance, canine retraction requires 75 grams at contmuoue light force. An o'd fashioned ti aback could .be over 1 COO grams, ND wonder anchorage was lost UE 1 a who lesale basis in extraction Ireatment.

79

l\l\'TING SCi\LE .rou rlOOTE~ 2

rom

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Sclerosis

1 10 60 60 80

25 25

l 05 I 35 50 ~ 70 65 70

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X 0.6 >
Ridge change 70 eo 'l.O ~'I'i 45 30 4D
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75 85 30 30 35 20 20 r I',

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Fig. 28. f.b3an ranKh:;;! of I'DO~ S lJrfP-:'":P. r~-"..~rl~at.[)11 in ttlrF:'!E'! ("j i[;:-J.;:! ns ion s rcr psrrn 81ne."";l Lee"!.I, 5.agitta I. tran S~ffie and .... er!i cal. R DtatK)1"'I eq L!8II-s sag i:1a I da ta,

80