[MUSIC] Hi, I'm Dr. Sam Kedan. I'm an orthodontist in private practice, as well as a member of the faculty at the Department of Orthodontics at the University of Pennsylvania School of Dental Medicine. Today, I'm going to be discussing the specialty of orthodontics and the scope of the cases that we work with. Orthodontics is considered to be dentistry's first specialty. It deals with the diagnosis prevention and treatment of disharmonies of facial and dental relationships. There is a misconception that orthodontics deals only with aesthetic alignment of the teeth. Where as this is true, orthodontics also deals with the underlying facial structures to guide, restrain, p promote and modify facial growth in growing individuals. The term malocclusion means bad bite. The reason for bad bite, or malocclusion is multifactorial. Most of the time, genetic factors are involved in cases, such as cleft lip and palate, missing or extra teeth, disproportionate size of jaw and teeth, dental habits, such as thumb sucking and many other factors including caries, periodontal disease, mouth breathing, amongst others. For the sake of discussion today, I'm dividing the Timing of Orthodontic Treatment into two categories. First one is early treatment and/or adolescent treatment and the second category is adult treatment. In adults, teeth can be moved at any age as long as the teeth and the gums are healthy. However, modification of facial structures cannot be done without involving surgical procedures to correct the jaw disharmonies in adult. We have here an eight year old child and he suffers from an upper jaw that's positioned way behind the lower jaw, what is called anterior crossbite. The issue here is that his midface is deficient, he has maxillary hypoplasia. And because he is young, we are able to somehow mold his facial structure to correct the developing malocclusion. In this case, we use face mask therapy to promote the forward movement of the midface and the upper jaw. As the lateral cephalometric x-ray or the profile x-ray shows, the upper jaw is clearly sitting behind the lower jaw and the following slide shows the effect of the therapy that we instituted on this patient. You can see clearly that the upper teeth now are sitting ahead of the lower teeth and on the profile picture of this child, you can see that the upper jaw is forward and is more rounded. This is a lateral cephalometric x-ray of the same individual following the treatment. And you can see that the upper jaw is sitting ahead of the lower jaw, which is the normal position for this age for a normal bite. This is a side by side comparison of before and after the treatment and it shows clearly that the upper jaw moved forward of the lower jaw. This is a side by side comparison of before treatment and after treatment on a facial profile of the same patient and you can see to the right that the profile is rounder, that the midface if more full and this is the typical profile you want to see on a child this age. This is another case where the lower jaw is receded and this is again a younger patient about 11 years of age, you can see there is crowding on the upper jaw, there are teeth sticking to the side. And the main issue here is that the lower jaw is receded and we wanted to promote the forward growth of the lower jaw. On this patient, we used functional appliance that promotes the forward growth of the lower jaw and the reason for this is because this patient is growing. You can see the results on this slide with the chin protruding much better than before and the occlusion in good shape. This is a before and after comparison of the same patient showing that the lower jaw is receded at the beginning of the treatment and how the lower jaw has come forward as a result of the treatment. This is another case again, a growing child about 11 years of age. The main issue here is the receded lower jaw and the protruding upper teeth. This image shows the functional appliance used. The function of this functional appliance is to promote the forward growth of the lower jaw. This is the final result after the fixed appliances have been removed and you can see how the lower jaw has moved forward. There is a balanced profile and very acceptable occlusion. This is a side by side comparison of before and after showing on the left how the profile started out and on the right how we ended up and you can see clearly that the lower jaw has moved forward and the occlusion is in Ideal form. This is a side by side comparison of the before and after treatment. Notice on the left side how the lower lip is everted and incompetent, meaning that patient at rest cannot get their lips together without straining the chin muscles. On the right hand side, you can see that the lips rest easily and the profile is acceptable. This is a side by side comparison of the case before treatment before treatment and after treatment, showing the reduction of the overbite with treatment. This is another case, a young child about 10 years of age and the main issue here is that the upper jaw is small and is in cross. We call this cross bite, meaning that the upper teeth sit inside the lower teeth, which is contrary to the normal occlusion where the upper teeth should be whiter than the lower teeth. This image shows the expansion that was done to the upper jaw and the reason we were able to do that is because of the young age. At a younger age, the upper jaw is two separate pieces of bone and there is a suture right in the middle that fuses once the individual matures. If the patient is treated before that suture matures, then we can easily do parallel expansion without having to involve surgical procedures. This is showing in the same individual after the fixed appliances have been removed and you can see that the crossbite has been resolved and the occlusion is ideal. This is a before and after image before treatment to the left and after treatment to the right and it demonstrates the crossbite that I just described. To the right, you can see that a crossbite has been resolved and that the occlusion is in good form. This is another case, also adolescent. I wanted to show you this case, because sometimes we cannot modify the jaw growth to fit all our needs. In this instance, you can see that the patient has moderate to severe crowding. And due to that, we were able to treat this case by extracting four permanent premolars. This image demonstrates the occlusion after the fix up lines has been removed and that the collision is ideal. This is a before and after images of the same patient showing how the canine teeth were blocked out on the left how everything is seated and the occlusion after the treatment has been completed. This is an adult case and as you can see from the profile, the upper jaw or the midface is completely pushed back behind the lower jaw. There's also a posterior crust bite. There's also an anterior open bite. In this case, the individual is an adult, we cannot modify the facial structures. And this case will have to be a combination of orthodontics treatment and surgical correction of the underlying jaw discrepancy. This lateral ceph demonstrates how the upper jaw is pushed back compared to the lower jaw. It also demonstrates that there in an anterior open bite presence. This case was treated surgically. There are two steps in this surgical treatment of this case. First, the braces would go on along with the palatal expander that you can see on the palate and then the surgeon releases the upper jaw to create or recreate the suture that has already fused and the upper jaw would have to be released from other points as well, then the palatal expander gets to be activated. In this image, you can see that there are fixed appliances placed already. The expansion has already taken place and we're in the process of repairing this patient to get ready for the second stage, which would be to promote the forward position of the upper jaw surgically. This is another case where the patient is an adult. This patient had undergone orthodontic treatment previously with extraction of permanent teeth. However, the underlying jaw discrepancy has not been corrected. If you look at the left side upper jaw image, you can ascertain the V shape of upper jaw. The upper jaw is meant to be in a U shape. You could also see that the upper jaw is more narrow than the lower jaw, we call that a crossbite. This patient has an anterior and a posterior crossbite, indicating that the upper jaw is also pushed back behind the lower jaw. So this case would have to be treated surgically. This is a two-step surgical procedure along with orthodontic treatments. The first step would involve surgically, expanding the upper jaw. We call that surgically assisted expansion of the maxilla and then the second step would involve also surgical repositioning of the upper jaw to bring it forward of the lower jaw. In this image, you can see that the expansion of the upper jaw has already started. You can see that there are orthodontic braces placed on the teeth, on the upper ones and that there is a gap opening between the two front teeth indicating the expansion of the upper jaw. In this image, you can see that the expansion has been complete. Please note the shape of the arch on the upper jaw on your left. How it changed from V shape to a more oval shape. This is after the expansion has been completed and we are now ready to do the second stage surgical procedure to promote the forward position of the upper jaw. This is an adult case, as well. This was not a surgical procedure. This is a case that presented with an interior and posterior cross bite. However, the patient declined the surgical option and you can see it's a mutilated, crowded position of the teeth. This is the finished result showing ideal occlusion and proper relationship between the upper and lower teeth. This image shows the before and after position of the teeth. And as you can see on the right-hand side, the occlusion is in the proper relation. Finally, I'm showing you an adult case that was not done surgically. This is a mutilated occlusion with a condition of altered passive eruption that I will describe later. As you can see, there are rows of teeth in front of and behind each other. There are retained primary teeth and there are impacted teeth, as well. This is once the treatment has started, you can notice that there are auxiliary appliances placed to help with the surgically exposed canines that we have to go after. These are called temporary anchorage devices and they help out with the orthodontic treatment. This is treatment progressing and this is the way the bite looked on the day the braces came off. If you notice that the front teeth don't look even at the gum level and that is because the gums are enlarged and the patient has a condition where the gums do not peel away from the teeth evenly, it's called altered passive eruption. And this is a condition that can easily be treated by the periodontist by removing some gingival tissue, as well as some bone. This is the results after the gingival surgery was done and you can see the occlusion is in very good shape. I hope this was helpful in shedding the light on the variety of cases that we deal with in the exciting field of orthodontics.
