L4 - DENT315 - Diagnosis of the Orthodontic Problem (Part 3).pdf

DIAGNOSIS OF THE ORTHODONTIC PROBLEM PART THREE Facial & skeletal diagnosis Are the jaws responsible for the malocclusion ? Has the skeletal discrepancy an esthetic impact ? Dre Julia Cohen-Levy DDS, MSc, PhD, FRCD(C) Diplomate ABO McGill 2023 1 2 FUNCTIONNAL EQUILIBRIUM BIRETRUSION AND...

DIAGNOSIS OF THE ORTHODONTIC PROBLEM PART THREE Facial & skeletal diagnosis Are the jaws responsible for the malocclusion ? Has the skeletal discrepancy an esthetic impact ? Dre Julia Cohen-Levy DDS, MSc, PhD, FRCD(C) Diplomate ABO McGill 2023 1 2 FUNCTIONNAL EQUILIBRIUM BIRETRUSION AND HYPERTONIC LIPS 6 Neutral zone (from Mills 1968) https://www.dentistryiq.com/dentistry/restorative-cosmetic-and-whitening/article/16358434/ staying-inbounds-the-neutral-zones-importance-in-successful-dental-restorations DIAGNOSIS DIAGNOSIS OF THE ORTHODONTIC PROBLEM • Problem list diagnosis • Intra-arch Skeletal (Dental & Periodontal) (3D Shape, Growth) Diagnosis Inter-arch (Qualitative & Quantitative) Soft tissues (Esthetics) 8 Macroesthetics Miniesthetics Microesthetics Dr David Sarver 9 FACIAL ANALYSIS : SOFT TISSUES (CLINICAL EXAMINATION, PHOTOGRAPHS, CEPHALOMETRY) & HARD TISSUES (CEPHALOMETRY) 10 Rules : Natural Head Position Relaxed lip position Smile (posed, broad…) Profile is facing right (if asymmetry can take both views + additionnal) 3 dimensionnal assessment 11 QUALITATIVE AND QUANTITATIVE ASSESSMENT OF FACIAL FORM • Is it within the spectrum of a craniofacial disorder ? Is it a growth abnormality ? • Is is stable or could get worse ? • Could it involve other organs ? • Is a mild, manageable problem ? • Is it skelettal, muscular, dento-alveolar ? • Is the problem from the cranium, the maxilla, mandible or a combination ? 12 Frontal : Symmetry Proportions (Transverse & vertical) Profile : Sagittal, Vertical By convention patient is facing right 13 NORMALITY • Midline landmarks coincide : Sagittal median axis is a single straight Line • Horizontal lines are parallel : Eye-Brows Center of eyes Bizygomatic Bicommisural Bigonial 14 A CERTAIN DEGREE OF ASYMMETRY IS NORMAL 15 NORMALITY • Facial proportions 1) Eyes are half way from the top of the head and the chin 2) Bottom of the nose is haflway between the nose and the chin 3) Corners of the mouth line up with the center of the eyes 4) Top of the ears line up with the eyes 5) Bottom of the ears line up ith bottom of the nose 16 NORMALITY • Facial proportions Rule of thirds Golden proportions Milutinovic et al . Evaluation of Facial Beauty Using Anthropometric Proportions Scientific World Journal · February 2014 17 18 NORMALITY • Facial proportions Rule of fifths Some genetic abnormalities are associated with alteration of the intercanthal distance. Milutinovic et al . Evaluation of Facial Beauty Using Anthropometric Proportions Scientific World Journal · February 2014 GENDER DIFFERENCES 19 https://www.yourfaceinourhands.com/blog/defining-the-jaw-jawline-with-fillers/ 20 MASCULINE & FEMININE TRAITS OF FACIAL FORM • Forehead and supraorbital ridge • Hairline : Male hairline tends to be more M shaped Vs more O shaped in females • Eyebrows more curved in females • Midface : wider zygomatic bones, more poreminent but delucate (rounded, • Nose : overall smaller in females • Lips : Lip heigth higher in males, Females have higher incisor show • Jaw line : Lower face is domiated by the shape and size of mandible • Chin : Narrow, short, less projected than the male chin (softer, rounder) Scheefer Van Boerum et al. Chest and facial surgery for the transgender patientTransl Androl Urol. 2019 Jun; 8(3): 219–227. 21 INTER-GROUP DIFFERENCES Liw S et al. Consensus on Changing Trends, Attitudes, and Concepts of Asian Beauty . Aesthetic Plast Surg. 2016; 40: 193–201. Published online 2015 Sep 25. 22 23 INFLUENCE OF ETHNICITY ON CEPHALOMETRIC NORMS (MODIFIED FROM PROFFIT) American White American Black Chinese (Taiwan) Middle east Japanese SNA 82° 85° 82° 82° 81° SNB 80° 81° 78° 79° 77° ANB 2° 4° 4° 3° 4° I/NA 22°. 4mm 23° 7mm 24° 5mm 24° 5mm 24° 6mm I/NB 25° 4mm 34° 10mm 29° 6mm 27° 6mm 31° 8mm interincisal 131° 119° 124° 126° 120° GoGn/SN 32° 32° 35° 32° 34° Y axis 61° 63° 61° 61° 62° 25 INTER-GROUP DIFFERENCES • Arabian Peninsula longer lower third in comparison to middle third of the face wider eye fissure length than intercanthal distance, wider nasal base in comparison to intercanthal distance. Men had a significantly larger lower third and nasal width measurement than women. Al-Sebaei M. O. (2015). The validity of three neo-classical facial canons in young adults originating from the Arabian Peninsula. Head & face medicine, 11, 4. https://doi.org/10.1186/s13005-015-0064-y 26 FACIAL WIDTH • Bizygomatic: Measured from the most lateral point overlying the zygotic arch 70% of total face height • Bitemporal: Most lateral point on each side of the forehead 60% of total face heigth • Bigonial : Measured from the soft tisue overlying the most lateral point of the mandibulr angle usually 50% of vertical facial heigth (1/3 less than bizygmatic…) 27 http://men-women-hair-styles.blogspot.com/2012/09/short-hair-stylesyoung-tom-cruise.html 28 Shao, Z., Peng, Q., Xu, Y. et al. Combined Long-Curved Ostectomy in the Inferior Mandibular Border and Angle of the Mandible with Splitting Corticectomy for Reduction of the Lower Face. Aesth Plast Surg 35, 382–389 (2011). https://doi.org/10.1007/s00266-011-9652-9 29 FACIAL HEIGTH Heigth : Trichion to Menton Width : Bizygomatic Will give you the overall facial type : Long Short 1,35/1 males 1,3/1 females 30 DOLICHO-CEPHALIC VS BRACHY-CEPHALIC 31 Franco, Fernanda Catharino Menezes, Araujo, Telma Martins de, Vogel, Carlos Jorge, & Quintão, Cátia Cardoso Abdo. (2013). Brachycephalic, dolichocephalic and mesocephalic: is it appropriate to describe the face using skull patterns?. Dental Press Journal of Orthodontics, 18(3), 159-163. 32 BRACHY FACIAL VS DOLICHO FACIAL 33 Franco, Fernanda Catharino Menezes, Araujo, Telma Martins de, Vogel, Carlos Jorge, & Quintão, Cátia Cardoso Abdo. (2013). Brachycephalic, dolichocephalic and mesocephalic: is it appropriate to describe the face using skull patterns?. Dental Press Journal of Orthodontics, 18(3), 159-163. 34 NORMALITY • Convexity Profile Angle is measured by connecting points Glabella (G’) Subnasale (Sn) and soft Tissue Pogonion (Pg’) 35 VARIATIONS 36 NORMALITY • NasoLabial angle Angle is measured by connecting points Columella Line Subnasale (Sn) and Upper Lip Anterior point (ULA) 37 https://jcadonline.com/nasal-filling-hyaluronic-acid/ ESTHETIC LINES Ricketts « E » Steiner’s S Ricketts line Pronasale, Pog’ Ls should be 4 mm behind Li should be 2mm behind Highly variable +++ Steiner line Midpoint of the S shaped curve between Sn and Pr Lips should touch 39 QUALITATIVE, DETAILED EXAMINATION • • • • • Cheek bone contour and orbital rim Nasal base Nasal projection Curve of the upper lip. And lower lip Fullness of lips 40 https://www.scielo.br/img/revistas/dpjo/v17n5/a24fig01.jpg Rizzatto. Class III malocclusion with severe anteroposterior discrepancy Dental Press J. Orthod. vol.17 no.5 Maringá Sept./Oct. 2012 41 Maxillary molar intrusion and transverse decompensation to enable mandibular single-jaw surgery with rotational setback and transverse shift for a patient with mandibular prognathism and asymmetry Min-Su KimSung-Hoon Lim Seo-Rin JeongJae Hyun Park. AJODO CASE REPORT| VOLUME 157, ISSUE 6, P818-831, JUNE 01, 2020 42 43 QUALITATIVE, DETAILED EXAMINATION • Labiomental fold: The labiomental fold forms an angle between a line tangent to the superior convexity of the chin and and the lower lip should be ±130. This angle formed, is usually obtuse in Class III cases and acute in Class II cases. • Lip-chin-submental angle: This angle is formed by the lip-chin line (labrale inferius and pogonion) and submental tangent and should be approximately ±121 degrees for females and ±126 degrees for males. The angle is obtuse in deficient chins and acute in anteroposterior excessive chins. Excessive submental fat, lower lip procumbence, and increased submental bulk will increase the lip-chin-submental angle. 44 45 QUALITATIVE, DETAILED EXAMINATION • Chin-neck length: This measurement is made from the submental neck point to soft tissue menton (Me) and it should be 42 ±4. Usually this measurement will be increased in Class III cases and decreased in Class II cases. • Chin throat angle (cervico-mental angle or submental neck angle): The chin-neck angle is formed by a submental tangent and a neck tangent (±121 degrees for females and ±126 degrees for males). Individuals with macrogenia or mandibular excess will have an acute angle while individuals with microgenia or mandibular deficiency will have an obtuse angle. 46 47 48 3mm 49 50 ANTERIOR ROTATION POSTERIOR ROTATION Condyle orientation vertical backards Condylar neck thick delicate Ramus robust gracile Mandibular angle closed open Antegonial notch rocking chair lower border Well defined Mandibular canal curve straight Symphysis shape bulbous Fine, tear drop Cortical thickness thick thin Orientation of symphysis Facing up and backwards Facing up and forward Inclination of incisors / symphysis angulated ≈ same axis Anterior Facial height reduced increased 53 ASSOCIATION BETWEEN FRONTAL AND LATERAL ATTRACTIVENESS ? Gu JT et al. Association of Frontal and Lateral Facial Attractiveness JAMA Facial Plast Surg. 2018 Jan; 20(1): 19–23. 54 ASSOCIATION BETWEEN FRONTAL AND LATERAL ATTRACTIVENESS ? Gu JT et al. Association of Frontal and Lateral Facial Attractiveness JAMA Facial Plast Surg. 2018 Jan; 20(1): 19–23. 55 Gu JT et al. Association of Frontal and Lateral Facial Attractiveness JAMA Facial Plast Surg. 2018 Jan; 20(1): 19–23. 56 DEVIATION FROM NORMALITY 57 DEVIATION FROM NORMALITY Hypotelorism Hypertelorism 58 CRANIO-FACIAL SYNDROMES OF THE MIDLINE Solitary median maxillary central incisor, a clinical predictor of hypoplastic anterior pituitary, ectopic neurohypophysis and growth hormone deficiency https://craniofacial.org/en/content/craniofrontonasal-dysplasia 59 Daniel T. Ginat&Caroline D. Robson CT and MRI of congenital nasal lesions in syndromic conditions January 2015 Pediatric Radiology 45(7) 60 Solitary median maxillary central incisor syndrome (SMMCI) with congenital nasal pyriform aperture stenosis: literature review and case report with comprehensive dental treatment and 14 years follow-up N. N. Lygidakis, K. Chatzidimitriou, +1 author N. LygidakisPublished 2013MedicineEuropean Archives of Paediatric Dentistry 61 62 DEVIATION FROM NORMALITY 63 64 65 66 DEVELOPEMENTAL CAUSES OF FACIAL ASYMMETRY • Facial clefts • Hemifacial Microsomia • Craniosynostosis • Torticolis • Facial Hemi-hypertrophy • Neurofibromatosis • Vascular malformations 67 AQUIRED CAUSES OF FACIAL ASYMMETRY • Ankylosis of temporo-mandibular joint (trauma, infection) • Facial tumors • Childhood radiotherapy • Condylar hyperplasia (hemimandibular elongation or hyperplasia) • Progressive Hemi-facial Atrophy 68 CRANIO-SYNOSTOSIS (PLAGIOCEPHALY) 69 70 Hemifacial hyperplasia: a case series and review of the literature A. DattaniA. Heggie International Journal of Oral and Maxillofacial Surgery 2020 71 Hemifacial hyperplasia: a case series and review of the literature A. DattaniA. Heggie International Journal of Oral and Maxillofacial Surgery 2020 72 FACIAL HEMI-HYPERPLASIA (HEMI-HYPERTROPHY) • Prevalence : rare Isolated or associated with malformation syndromes 2/1 female to male ratio • Definition: Asymmetric overgrowth of one or more body parts Some Malformation syndromes associated with hemihyperplasia (more often on the rigt side according to Neville and al.) Beckwith-Wiedeman syndrome Proteus syndrome Features : • Unilateral macroglossia with prominent tongue papillas • Dental crowns can be larger, precocious maturation & eruption on the affected side • Can be associated with tumors (abominal ultrasounds, risk of nephroblastoma etc…) Neurofibromatosis McCune Albright syndrome 73 74 Proffit W Contemporary orthodontics 5th ed. Elsevier Loderer et al. Surgical Management of Progressive Hemifacial Atrophy Oral and maxillofacial surgery 2017 Yadav N et al. Progressive facial deformity from childhood to adulthood in a patient of Parry-Romberg syndrome. J Cleft Lip Palate Craniofac Anomal 2020;7:121-4 75 Yadav N, Gupta DK, Utreja A, Garg AK. Progressive facial deformity from childhood to adulthood in a patient of Parry-Romberg syndrome. J Cleft Lip Palate Craniofac Anomal 2020;7:121-4 76 PROGRESSIVE FACIAL HEMI-ATROPHY (PARRY ROMBERG SYNDROME) 77 PROGRESSIVE FACIAL HEMI-ATROPHY (PARRY ROMBERG SYNDROME) Prevalence : Rare Definition : Degenerative condition with atrophic changes affecting one side of the face, dermatome of one or two branches of the trigeminal nerve (muscles, bone, teeth) Evolution : • progressing slowly for 2-20 years and becomes stable • Features similar to localized form of scleroderma Etiology : non elucidaded history of trauma, infection –Lyme disease-, hereditary 78 Keogh, I. J., Troulis, M. J., Monroy, A. A., Eavey, R. D., & Kaban, L. B. (2007). Isolated Microtia as a Marker for Unsuspected Hemifacial Microsomia. Archives of Otolaryngology–Head & Neck Surgery, 133(10), 997–1001. https://doi.org/10.1001/archotol.133.10.997 79 80 81 HEMIFACIAL MICROSOMIA- OAV SPECTRUM Prevalence : 1:5500 live births Definition : Broad spectrum of disorders ; varying degrees of hypoplasia or aplasia of the components of face derived from 1st and 2d branchial arches : OMENS • Right more affected than Left • Boys more affected than girls • Etiology : ischemia in the area of stapedian artery hematoma in utero (30-45 days IU, according Poswillo) Teratogenic agents (disruption of neural crest migration) Thalidomide, Accutane, alcohol exposure 82 Jackson, I.T. Analysis and treatment of hemifacial microsomia. Eur J Plast Surg 27, 159–170 (2004). https://doi.org/10.1007/s00238-004-0633-y 83 HEMIFACIAL MICROSOMIA O M E N S CLASSIFICATION 84 HEMIFACIAL MICROSOMIA O M E N S CLASSIFICATION 85 HEMIFACIAL MICROSOMIA O M E N S CLASSIFICATION CONDYLAR HYPERPLASIA CONDYLAR HYPERPLASIA NORMAL CONDYLE TYPE I CONDYLAR HYPERPLASIA In coronal view ondyle appears more rounded Thinned disc Starts during puberty Histology: normal cartilage (more vascular, thicker) Head Neck Corpus increased length Normal shape Type Ia : bilatéral (+/- asym) cl III Type Ib : unilatérale(cl III unilat controlateral crossbite CONDYLAR HYPERPLASIA TYPE I • Most frequent type, 60% females • Can be bilateral • Condyle can grow up to 25 years • Self limiting, spontaneously stops CONDYLAR HYPERPLASIA TYPE IIA vertical unilatéral facial growth, Increased head, neck, ramus, corpus (can devaite to the other side) Posterior Open bite On the affected side or unilateral compensatory growth of the maxilla Occurs 2/3 around 20 Histology : ostéochondroma ( mésenchymal indifferenciated cells, hypertrophic cartilage irregular and thick trabecular bone). ENDLESS GROWTH, rythm can be slow, moderate or rapid. , Disc deplacement controlateral side Osteoarthrosis. 75% CONDYLAR HYPERPLASIA TYPE IIB exophytic growth of condylar head Occurs 2/3 around 20 Histology : ostéochondroma ( mésenchymal indifferenciated cells, hypertrophic cartilage irregular and thick trabecular bone). ENDLESS GROWTH, 94 Sergio Olate, Henrique Duque Netto, [...], and Márcio de Moraes Int J Clin Exp Med. 2013; 6(9): 727–737. Published online 2013 Sep 25. CONDYLAR HYPERPLASIA TYPE II • 76% females • 68% start in their twenties • Unilateral vertical growth (head and neck of condyle) • NOT Self limiting 96 CONDYLAR HYPERPLASIA TYPE III • Other benign tumors of the temporomandibular joint • Osteoma • Neurofibroma • Fibrous dysplasia • Not any specific age 97 25 years old male 98 99 https://www.oralhealthgroup.com/features/treatment-fibrous-dysplasia-utilizing-digital-planning/ by Jeffrey W. Chadwick, DDS; Garry Toor, DDS; Marco Caminiti, DDS, MEd, FRCD(C) Toronto 100 Biopsy of right mandible Fibrous dysplasia https://www.oralhealthgroup.com/features/treatment-fibrous-dysplasia-utilizing-digital-planning/ by Jeffrey W. Chadwick, DDS; Garry Toor, DDS; Marco Caminiti, DDS, MEd, FRCD(C) Toronto 101 CONDYLAR HYPERPLASIA TYPE IV • Malignant tumors of the temporomandibular joint • Chondrosarcoma, • osteosarcoma, • Ewing Sarcoma, • osseous metastasis… • Not any specific age 102 OTHER CONDITIONS & SYNDROMES AFFECTING GROWTH Primary & secondary cartilages Sutures (premature fusion …) Bone components & metabolism Muscles Teeth Inner organs (Moss theory) Scars Cranial base Cranial vault (cranio-synostosis) Facial derivatives of the Neural Crest Cells 103 PHARYNGEAL ARCHES, NEURAL CREST TERRITORIES Netter’s head and neck Anatomy for entistry 104 105 TREACHER COLLINS SYNDROME Variable expression of the phenotypic clinical features of Treacher Collins syndrome ranging from mild to more severe (left to right). Plomp RG Clinical Implications of Treacher Collins Syndrome 2015 106 PIERRE ROBIN SEQUENCE Lafontaine V. Devenir des enfants porteurs d'une séquence de Pierre Robin : étude comparative 2018 107 ACHONDROPLASIA https://www.digitalspy.com/tv/ustv/a866543/game-of-thrones-nikolaj-coster-waldau-tyrion-lannister-tattoo/ DIAGNOSIS OF THE ORTHODONTIC PROBLEM • Problem list diagnosis • Intra-arch Skeletal (Dental & Periodontal) (3D Shape, Growth) Diagnosis Inter-arch (Qualitative & Quantitative) Soft tissues (Esthetics) 108 SKELETAL CLASSE I DENTAL CLASS I SKELETAL CLASSE I DENTAL CLASS II SKELETAL CLASSE I DENTAL CLASS II SKELETTAL CLASSE II DENTAL CLASS II SKELETTAL CLASSE II DENTAL CLASS I (DENTOALVEOLAR COMPENSATION) SKELETTAL CLASSE II SKELETTAL CLASSE II SKELETTAL CLASSE III EXAMPLE OF MAXILLARY DEFICIENCY Prognathisme 117 DIFFERENTIAL DIAGNOSIS… • Is the problem dentoalveolar or skeletal ? • Anterior interferences and anterior shift ? • Multiple teeth in anterior cross bite ? • Compensations (lingually inclined lower incisors ? • Diastemas in the upper jaw ?) DENT415 2020 118 DENT415 2020 Hugo J. De Clerck and William R. Proffit. Growth modification of the face: A current perspective with emphasis on Class III treatmentAm J Orthod Dentofacial Orthop 2015;148:37-45. 119 DENT415 2020 120 DENT415 2020 121 DENT415 2020 HORIZONTAL REFERENCES S Na Po Or SAGITTAL EVALUATION SNA angle : 80 +/- 2 SNB angle : 78 +/- 2 ANB angle: 2 +/AoBo (Wits) SAGITTAL EVALUATION Convexity angle Facial Angle Dental compensations (sagittal) 126 Mittal G et al.: The Art of Genioplasty- An Insight VERTICAL EVALUATION Qualitative (Bjork) Convergence of horizontal reference planes MMA (maxillary-mandibular plane) FMA (Frankfort Mandibular plane angle) Occlusal plane Angle Anterior and posterior facial heigths & Ratios