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1 s2.0 1073874602800445 Main PDF
1 s2.0 1073874602800445 Main PDF
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Growth
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Figure 2. An example of a
patient with an excessive
lower facial height.
o p m e n t in both the maxilla and mandible.
Bjork is-21 and Bjork and Skieller 2:~,24 have perf o r m e d n m n e r o u s studies that have shown that
the most c o m m o n direction of condylar growth
is vertical, with some anterior c o m p o n e n t . Patients with a p r o n o u n c e d short lower anterior
facial height (Fig 4A and B) generally exhibit
upward and forward condylar growth (Fig 5).
These individuals generally have a d e e p vertical
overbite with a d e e p mentolabial sulcus and a
strong overclosed appearance. 25 In contrast, pa-
Figure 3. An example of a
patient with a diminished
lower facial height.
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Figure 4. A patient with a pronounced short lower anterior facial height. (A) The cephalometric radiograph is also shown. (B)
radiation exposure. Advances in imaging technology may, in the future, p e r m i t the clinician to
use these m e t h o d s for diagnostic purposes with
greater safety.
An understanding of the maxillomandibular
growth rotation of the patient would be most
helpful in the diagnosis of vertical variations.
Bjork u8 has contributed information that offers
some guidelines for the clinician to assist in the
determination of the growth rotation of the
mandible so that the c o n c o m i t a n t vertical
changes are m o r e easily understood. Bjork's
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the backward rotator exhibits (1) a straight inclination of the condyle, (2) a relatively straight
mandibular canal, (3) the symphysis slopes forward and, (4) lower anterior facial height is
long.
Isaacson, 29 Isaacson et al, 3 and Schudy, ~ following on Bjork's reports, studied jaw rotation
caused by vertical condylar growth. A succinct
summary of the findings of these investigators is
that a forward mandibular rotation occurs when
vertical condylar growth exceeds the sum of the
vertical growth of the maxillary sutures and the
maxillary and mandibular alveolar processes. If
growth of the maxillary sutures and the maxillary/mandibular alveolar processes exceeds vertical condylar growth, a backward rotation
occurs, and the face becomes longer. An understanding of the effect of condylar growth on
mandibular position is fundamental if the clinician is to adequately and appropriately diagnose
a vertical dimension abnormality.
Dentoalveolar Development
Issacson et al 3~ studied dentoalveolar developm e n t in three groups of subjects--those with
Fo~t~ard Pvotator
Backward Rotator
Straigbt or slopes u p
Straight
Notchcd
Slopes fi)iveard
Acute
Acute
Tall
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Diagnostic Considerations
Steep Excess Vertical Pattern:
The Backward Rotator
During differential diagnosis of the high-angle
patient, two questions must be asked. First,
where should the teeth be positioned? For the
patient with long anterior facial height, the mandibular anterior teeth are most often positioned
in a m o r e retracted posture over basal bone. Lip
p r o c m n b a n c y can be best resolved if the mandibular anterior teeth are upright. T h e a m o u n t
of uprighting that must be achieved is a matter
of (1) clinical preference and must be determ i n e d during the t r e a t m e n t p l a n n i n g phase of
the t r e a t m e n t protocol or (2) the dictates of the
malocclusion. If indeed the facial profile of the
patient with excess vertical dimension is long, a
vertical reduction genioplasty can be effective
for facial esthetics. It is f u n d a m e n t a l for the
clinician to be able to visualize the posttreatm e n t positions of the m a n d i b u l a r anterior teeth
during t r e a t m e n t plan preparation. Secondly,
will extractions be necessary? For m a n y patients
with excessive lower anterior facial height, extractions may be necessary. T h e question of
which teeth should be extracted can be answered only after a t h o r o u g h and accurate differential diagnosis.
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Treatment Concerns
During the diagnosis of the vertical dimension
problem, the clinician must be attentive to the
force systems that are p l a n n e d for treatment and
understand that undesirable reactions to incorrectly applied fbrce systems are disastrous. Posterior facial height must be carefully controlled
for the high-angle patient because an increase in
posterior facial height will result in an increase
in anterior facial height. 434~ An increase in anterior facial height of high-angle patients is calamitous.
An important mechanical tooth manipulation
that must be accomplished during the treatment
of the patient with excess vertical dimension is
prevention of extrusion of the mandibular posterior teeth, assuming that the maxillary posterior vertical dimension is controlled by intrusive
forces (ie, headgear or other methods). Extrusion in the molar areas will prevent successful
correction of the malocclusion with excess vertical dimension and long lower anterior t:ace
height. It is important for the clinician to understand these concepts during diagnosis and treatm e n t planning so that extraoral traction can be
planned to help control the vertical dimension
during treatment. There should be intrusive
forces to the posterior segments of both arches.
Additionally, Class II elastic wear can be one of
the most detrimental force applications that is
applied to a patient with long lower anterior
facial height. If Class II elastics are used indiscriminately on the high-angle patient, the mandible drops down and back and increases the
sagittal discrepancy. Therefore, Class II elastic
use, or the absence of it, must be planned for
during diagnosis and treatment planning.
Pearson 4~ has published his results using vertical pull chin cups and has provided evidence
that their use can create some effective skeletal
changes for the long-face patient. A thoughtful
diagnostician nmst consider the use of whatever
means is necessary to impact treatment and prevent the lengthening of lower anterior facial
height during the course of treatment.
Summary
The orthodontic clinician must make a careful
differential diagnosis for each patient who seeks
his or her care. The diagnosis must analyze all
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