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Ortho Part II Ortho Part II Paul K. Chu, DDS St. Barnabas Hospital November 21, 2010 REVIEW FROM LAST LECTURE 1 What kinds of steps are the following? Distal Mesial Distal Mesial Moyer’s Analysis Review 1) Take an impression of a child’s MANDIBULAR arch 2) Measure the mesial distal widths of ALL permanent incisors 3) Take the number you get and look at the black row 4) The corresponding number is the mesial distal width you need for the permanent canine- 1st premolar- 2nd premolar i .e . the 3 - 4 -5 ***(Black row) ----this is the distance you measure**** 2 Moyer’s Analysis Review #1) measure the mesial distal incisal edge width of EACH permanent incisor and add them up **Let’s say in this case we measured 21mm.** Step 1 Moyer’s Analysis Review Maxilla Look at the chart Mandibular Since The resulting number measured should give you needed 21mm we look widths of the maxilla or here. mandibular space needed for permanent canines and 1st and 2nd premolars. Step 2 3 Moyer’s Analysis Review Maxilla You also use the added Mandibular measurements of the mandibular incisors to get predicted MAXILLARY measurements as well! Step 2 The Dreaded Measurements Lecture 4 What Are We Trying to Accomplish? (In other words) Is the patient Class I, II, III skeletal? Does the patient have a skeletal open bite growth pattern, or a deep bite growth pattern, or a normal growth pattern? Are the maxillary/mandibular incisors proclined, retroclined or normal? Is the facial profile protrusive, retrusive, or straight? Why? Why? Why? Why does this patient have increased overjet? Is it maxilla too far forward? Is it mandible too far back? Are the maxillary incisors flared too far forward? Are the mandibular incisors retlid?troclined? Why does this patient have a deep bite? Is it skeletal? Is it dental? 5 Whatever you do- do NOT memorize now..just try to reason and make sense of these numbers!!! Structures to Trace 6 Structures to Trace • #1 - Facial Profile 7 Structures to Trace •Sella Turcica •Nasal Bone •Orbit 8 Structures to Trace Ear rod Pterygomaxillary fissure PTM, - the projected contour on the lateral film; anterior wall represents maxillary tuberosity outline, and the posterior, the anterior curve of the pterygoid process. 9 Structures to Trace Maxilla Upper 1 10 Structures to Trace Mandible Permanent 1st molars Lower 1 11 12 Facial Outline Sella Turcica Orbit Nasal Bone PTM Ear Rod Maxilla Upper 1 Lower 1 Mandible Now that we have the structures, we can find points! 13 Standard Cephalometric Landmarks Sella Nasion Porion Orbitale Articulare ANS A Point B Point Gonion Pogonion PNS Menton Gnathion Standard Cephalometric Landmarks Sella Nasion Porio Orbital n e Articulare ANS A Point B Point Gonion Pogonion PNS Mento Gnathion n N, nasion - most anterior point of the nasofrontal suture A, SubspinaleSubspinale--deepest midline point below the anterior nasal spine B, Supramentale - most posterior point on the outer contour of the mandibular alveolar process 14 Nasion Can be difficult to see Very important landmark Inward notch, or sideways “v” A & B Point A: Most posterior point on the outer contour of the maxillary alveolar process B: Most posterior point on the outer contour of the mandibular alveolar process 15 Standard Cephalometric Landmarks Sella Nasio n Porio Orbital e nArticulare ANS A Point B Point Gonion Pogonion PNS Menton Gnathion ANS, anterior nasal spine - tip of the anterior nasal spine PNS, posterior nasal spine - tip of the posterior spine of the palate Pog, pogonion - most anterior point of the bony chin Gn, gnathion - midpoint between the most anterior and inferior points on the bony chin Me, menton - most inferior point on the outline of the symphysis Standard Cephalometric Landmarks Sella Nasion Porion Orbitale ANS A Point B Point Gonion Pogonion PNS Menton Gnathion Go, gonion - point midway between the most inferior and most posterior points in the angle of the mandible P, porion - uppermost point on the outline of tthehe ear rods of the cephalostat Or, orbitale - lowermost point on the orbit PTM, pterygomaxillary fissure - the projected contour on the lateral film; anterior wall represents maxillary tuberosity outline, and the posterior, the anterior curve of the pterygoid process. 16 Nasion Sella A Point B Point Orbitale PiPorion ANS PNS 17 * Pog, pogonion - most anterior point of the bony chin * Go, gonion - point midway between the most inferior and most posterior points in the angle of the mandible *G* Gn, gnathion --mmidpoi nt b et ween th e mos t an ter ior and inferior points on the bony chin * Me, menton - most inferior point on the outline of the symphysis Gonion Pogonion Menton Gnathion 18 Frequently Used Planes The board exam will test you on angles that these points form...it’s from these angles we can determine possible growth patterns. Frequently Used Planes SN Plane Frankfort Plane Palatal Plane Occlusal Plane Mandibular Plane 19 Frequently Used Planes SN Plane Frankfort Plane Palatal Plane Occlusal Plane Mandibular Plane 20 S - N Plane From sella to nasion Frankfort Plane Line connecting the superior border of the external auditory meatus with the infraorbital rim. (Po to Or) 21 Palatal Plane Line connecting the ANS to PNS. Occlusal Plane The intersection of the upper and lower incisors to the occlusal contact of the upper and lower first molars . 22 Mandibular Plane a tangent to the lower border of the mandible Go to Gn SN Plane Frankfort Plane Palatal Plane Occlusal Plane Mandibular Plane 23 Cephlhalometric Assessment Cephalometric Measurements ••ManyMany different analyses 2 MAINMAIN-- STEINERS & DOWNS ••Remember….thisRemember….this is NOT an exact science ••CombineCombine information from ceph with other clinical information to make a diagnosis and treatment plan. 24 DOWNS ANALYSIS STEINERS ANALYSIS Reference Measurements are norms 25 Skeletal Measurements Anteroposterior measurements SNA (maxilla) SNB (mandible) ANB Wits Vertical measurements Y axis Mandibular plane angle Skeletal AssessmentAssessment--SNASNA 82 Where? Sella to Nasion to A Point SNA: Evaluates maxilla to cranium Norm= 82o Antero-posterior maxillary assessment 26 Skeletal Assessment -SNB- SNB Where? Sella to Nasion 80 to B Point SNB: Evaluates mandible to cranium Norm= 80o Antero-posterior mandibular assessment Skeletal Assessment -ANB- ANB 2 Where? A point to Nasion to B Point ANB: Evaluates maxilla to mandible. Norm= 2o Antero-posterior bimaxillary assessment 27 Skeletal Assessment Wits (AO-(AO-BO)BO) Where? Draw a PERPENDICULAR line from A point to occlusal plane; B point to occlusal plane Wits Measures? saggpyittal discrepancy between the upper and lower jaw Similar to what? Norm: -1, 0, +1 A- N - B AO BO 28 Skeletal Assessment Y Axis (to Frankfort Horizontal) Vertical Skeletal Assessment Where? Sella to Gn; intersect with Frankfort 59 horizontal YAxis Measures? Growth potential Skeletal Assessment Frankfort Mandibular Plane Angle (FMA) Vertical Skeletal Assessment Cephalometric landmarks used in FMA determination: Gonion (Go), point on angle of jaw that is most inferiorly, posteriorly, and outwardly directed Menton (Me), lowest point of contour of mandible symphysis Orbitale (Or), lowest point on margin of orbit Porion (P), midpoint on upper edge of external auditory meatus Frankfort horizontal plane, plane intersecting right and left poria and left orbitale. 29 FMIA; IMPA FMIA = (()62) Ang le between Frankfurt Horizontal and long axis of lower incisor. IMPA = (93) Angle between long axis of lower incisor and Mandibular Plane. FMA = (22 +/ - 3) Angíe between Frankfurt Horizontal and Mandibular Plane. 30 Growth Cranial vault: Intramembranous Formation Intramembranous- No cartilaginous precursors. nvolves the replacemIent of sheet-like connective tissue membranes with bony tissue. Growth Cranial Base: Endochondral Endochondral ossification involves the replacement of hyaline cartilage with bony tissue. Most of the bones of the skeleton are formed in this manner. 31 Growth Maxilla: Intramembranous Intramembranous- No cartilaginous precursors, occurs in area of tension- not pressure. Intramembranous ossification involves the replacement of sheet-like connective tissue membranes with bony tissue. 32 Growth Mandible: Intramembranous & Endochondral!!!!! -condylar growth is appositonal - other areas apposition & remodelling ReviewReview-- Frankfort Mandibular Plane Angle Angle between Frankfurt Horizontal and Mandibular Plane. Norm: 25o 33 High or Low FMA? High or Low FMA? Clockwise? Counterclockwise? 34 Long Face Syndrome i.e. Dolichocephaly i.e. Vertical Grower i.e. Clockwise Growth Short Face Syndrome i.e. Brachiocephaly i.e. Horizontal Grower i.e. Counterclockwise GGorowt h 35 Dental Measurements Dental Measurements Now we measure angles TEETH make Maxillary incisor measurements Mandibular incisor measurements 36 Dental Assessment U1U1--SNSN Incisal Angulation Assessment 104 Known also as Upper 1 to SN Norm= 104 Dental Assessment L1L1--GoGnGoGn (Man 1 - GoGn) Incisor Angulation Assessment Known also as lower 82o 1 to GoGn Norm= 95 9 5 37 Dental Assessment U1U1--L1L1 (Max 1 - Man 1) Inter-Incisal Angulation Assessment Known also as Upper 1 to Lower 1 Norm= 130 Smaller Angle= incisor PROCUMBENCY (usually in class I or II 130 patients) Larger Angle= incisor RETROCLINATION (class III patients) SOFT TISSUE ASSESSMENT E Plane 38 Soft Tissue Assessment E Plane CHANGES WITH AGE! A Line drawn from the soft tissue chin to the tip of the nose -2 mm Patient One Standard Patient SNA 82 81 ••ClassClass
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