Applied anatomy of maxilla and mandible

Contents
Introduction Anatomy of maxilla Anatomy of Mandible Applied aspects Skeletal malocclusion Anchorage Cleft plate Oral asymmetry

Introduction
As orthodontist are heavily involved in the treating abnormalities in the development of not just the dentition but the entire dentofacial complex, should be able to manipulate facial growth for the benefit of the patient.

 Bones of head and neck include somatic bones, the skull, seven cervical vertebrae and the hyoid developed from the second and third brachial arches. The skull cap is formed by frontal , parietal, squamous temporal and a part of occipital bones, develop by intramembranous ossification being a quicker one stage process. The base of the skull in contrast ossifies by intracartilaginous ossification which is a two stage process (membrane-cartilagebone)

 The skeleton of the head is called as skull. It consists of several bones that are joined together to form the cranium. The term skull also include mandible (the lower jaw). Skull can be divided into two main parts a) The calvaria or brain box b) The facial skeleton constitutes the rest of the skull and includes the mandible.

Bones of the skull

Skull consist of 22 bones The calvaria or brain case is composed of 8 bones 2 PAIRED 4 UNPAIRED

1) Parietal
2) Temporal

1) Frontal
2) occipital 3) Sphenoid 4) Ethmoid

 The facial skeleton is composed of 14 bones 6 paired and 2 unpaired

Maxilla Zygomatic bone Nasal bone Lacrimal bone

Mandible Vomer bone

Palatine bone Inferior nasal concha

 Norma Frontalis

 Norma lateralis

 Norma occipitalis

 Norma verticalis

 Norma basalis

anterior

middle

posterior

 Anterior part of norma basalis:1) Alveolar arch:-bears socket of the roots of the upper teeth 2) Hard palate:- formation anterior two third by the palatine

process of the maxillae and posterior one third by the

horizontal plates of the palatine bone. Sutures :- cruciform sutures made up of intermaxillary interpalatine and palatomaxillary sutures.

 Greater palatine foramen:- One on each side is situtated just below the lateral part of the palatomaxillary sutures. The lesser palatine formamina:- Two or three in number on each side is situated behind the greater palatine foramen. Posterior border of the hard palate is free and presents the posterior nasal spine in the median plane. The palatine crest is a curved ridge near the posterior border. It begins behind the greater palatine foramen and runs medially.

 Middle part of norma basalis:- The middle part extends from the posterior border of hard palate to the arbitary transverse line passing through the anterior margin of the foramen magnum

Maxilla
The term maxilla was derived from a Latin word Mala which means cheeks Its the second largest bone of the face

The two maxillae form the whole of the upper jaw, and each
maxilla enter into the formation of face, nose mouth orbit the infratemporal and pterygopalatine fossae

Features
Each maxilla has a body and four process Body of maxilla:- The body of maxilla is pyramidal in shape with its base directed medially at nasal surfaces and the apex directed laterally at the zygomatic process. It has four surface and encloses a large cavity the maxillary sinus. The surfaces are 1) 2) 3) 4) Anterior or facial Posterior or infratemporal Superior or orbital Medial or nasal

 Maxilla contributes a large share in the formation of facial skeleton. The anterior surface of the body of the maxilla presents a) nasal notch medially b) the anterior nasal spine

c) Infraorbital foramen
d)Incisive fossa e)The canine fossa lateral to the canine eminence

 The frontal process articulates anteriorly with the nasal bone, posteriorly with the lacrimal bone and superiorly with the frontal bone. The zygomatic process of the maxilla is short and articulates with zygomatic bone The alveolar process of maxilla bears sockets. The palatine process

Anterior or facial surface:-

 Anterior or facial surface:- Directed forward and laterally Above the incisor teeth there is a slight depression the incisive

fossa which gives orgin to depressor septi.

Lateral to the canine eminence there is a larger and deeper depression, the canine fossa which gives orgin to anguli oris

 Above the canine fossa there is infra orbital foramen which transmits infraorbital nerve and vessels. Lecator labi superioris arises between the infraorbital margins and infra orbital foramen. Medially the anterior surface ends in a deep concave border, the nasal notch which terminates below into process with the corresponding process of maxilla forms the anterior nasal spine. Anterior surface bordering the nasal notch gives orgin to nasal depressor septi

Infratemporal surface

 Convex and directed backwards and laterally . Forms anterior wall of infratemporal fossa separated from anterior surface by zygomatic process .

Near the centre of surface open two or three alveolar canals for
posterior superior alveloar nerve and vessels.

 Posterioinferiorly there is a rounded eminence the maxillary tuberosity which articulates superiomedially with pyramidal process of palatine bone and gives origin laterally to superficial head of medial pterygoid muscle. Above the maxillary tuberosity the smooth surface form the anterior wall of pterygopalatine fossa and is grooved by maxillary nerve.

Superior or orbital surface

 It is smooth ,triangular , and slightly concave and forms the greater part of the floor of orbit. Anterior border forms a part of the infraorbital margin. Medially it is continuous with the lacrimal crest of frontal process.

Posterior border forms anterior margin of the inferior orbital fissure,in the middle it is notched by infraorbital groove.

 Medial border presents anteriorly the lacrimal notch which is converted into nasolacrimal canal by decending process of lacrimal bone. Behind the notch,the border articulates from before backwards with the lacrimal ,ethmoid, and the orbital process of palatine bone.

 Surface presents infraorbital groove leading forwards to infraorbital canal which opens on anterior surface as infraorbital foramen. Inferior oblique muscle of eyeball arises from depression ;lateral to lacrimal notch at the anteromedial angle to the surface.

MEDIAL OR NASAL SURFACE

 Forms a part of lateral part of nose. Posterosuperiorly displays large irregular opening of maxillary sinus. Above sinus, there are parts of air sinuses which are completed by ethmoid and lacrimal bones.

 Below hiatus ,smooth concave surface forms a part of inferior meatus of nose. Behind hiatus ,surface articulates with perpendicular plate of palatine bone. Front of hiatus; nasolacrimal groove which is converted into nasolacrimal .

MAXILLARY PROCESSES
ZYGOMATIC PROCESS FRONTAL PROCESS ALVEOLAR PROCESS PALATINE PROCESS

ZYGOMATIC PROCESS

 Is a pyramidal lateral projection on which the anterior , posterior, and superior surfaces of maxilla converge. In front and behind it is continuous with the corresponding surfaces of the body, but superiorly it is rough for articulation with the zygomatic bone.

FRONTAL PROCESS

 Projects upwards and backwards to articulate above with nasal

margin of frontal bone ,in front with nasal bone and behind
with lacrimal bone. Lateral surface is divided by a vertical ridge ,the anterior lacrimal crest , into smooth anterior part and a grooved posterior part.

 Medial surface forms part of lateral wall of nose. a) Uppermost area is rough for articulation with ethmoid to close the anterior ethmoidal sinuses. b) Ethmoidal crest is a horizontal ridge about the middle of the process. Posterior part of crest articulates with middle nasal concha ,and anterior part lies beneath the agger nasi.

. The anterior smooth area gives origin to the orbital part of orbicularis oculi and levator labii superioris. Posterior grooved

area forms anterior half of floor of lacrimal groove.

 The area below the ethmoidal crest is hollowed out to form the atrium of middle meatus. Below the atrium is the conchal crest which articulates with

inferior nasal concha.

ALVEOLAR PROCESS

 Forms half of the alveolar arch, and bears sockets for the roots of upper teeth. Buccinator arises from posterior part of its outer surface up to

the first molar tooth.

A rough ridge ,the maxillary torus ,is sometimes present on inner surface opposite the molar sockets.

PALATINE PROCESS

 Is a thick horizontal plate projecting medially from the lowest part of the nasal surface. Inferior surface is concave and the two palatine processes form

anterior three-fourth of bony palate. It presents numerous

vascular foramina and pits for palatine glands. Posterolaterally it is marked by two antero-posterior grooves for greater palatine vessels and anterior palatine nerves.

 Superior surface is concave from side to side, and forms greater part of floor of nasal cavity. Medial border is thicker in front than behind. It is raised

superiorly into nasal crest.

Posterior border articulates with horizontal plate of palatine bone. Lateral border is continuous with alveolar process.

ARTICULATIONS
Superiorly articulates with 1) nasal 2) frontal 3) lacrimal bones. Medially, with 1) Ethmoid 2) inferior nasal concha, 3) vomer, 4) palatine 5) opposite maxilla. Laterally, 1) zygomatic bone

Growth
The attachment of facial skeleton anterioinferiorly to the

calvarial bone determines the chondracranial influence of

facial growth. The site of attachment are clearly defined by the pterygomaxillary fissure and the pterygopalatine fossa between the sphenoid bone of the clavarial bone and the maxillary and palatine bone of the posterior aspect of the face.

 Zygomatic bone is attached to the calvarial skeleton at the temporozygomatic and frontozygomatic sutures. The maxillary and nasal bones of the anterior aspects are attached to calvaria at the fronto maxillary and frontonasal sutures
The nasal cavity and the nasal septum have considerable influences in determining facial form.

Direction of growth and resoption of facial bone at various sites. The overall effect if the combination of these growth sites is a downward and forward displacement of face and vice versa for the cranial base

 The frontomaxillary, frontozygomatic, frontonasal, ethmoidomaxillary, and frontoethmoidal sutures are the sites of bone growth in a largely vertical direction as a result of eyeball and nasal septal expansion. If the nasal septum is defective, the height of the middle third of the face is less affected than its anteroposterior dimension resulting in concavity of the face. Sutures function mainly as sites of fibrous union of the skull bones, allowing for adjustments brought by surface apposition and remodeling.

GROWTH FIELDS
All surfaces, inside and outside, of every bone are covered by an irregular pattern of growth fields comprised of various soft tissue osteogenic membranes or cartilages. The genetic component for bone growth resides in the bones investing soft tissues muscles, integument, mucosa, blood vessels, nerve, connective tissue, the brain, etc.

The growth fields have either depository or

resorptive activity. The varying activities and rates of growth of

these fields are the basis for the differential

growth processes that produce bone of irregular shapes.

The soft tissue acts as a functional matrix to

control bone growth whereas the bone itself only reports via a feedback mechanism which

is connected to the connective tissues when the

shape, size and biomechanical aspects coincide with the functional requirements.

Mandible

 The word mandible came from the latin word mandibula meaning chew. The mandible ,or the lower jaw, is the largest and the strongest bone of the face. It develops from the first pharyngeal arch. It has a horseshoe-shaped body which lodges the teeth, and a pair of rami which project upwards from the posterior ends of the body. The rami provide attachment to the muscles of mastication.

 BODY Each half of the body has outer and inner surfaces, and upper and lower borders. The outer surface presents the following features. 1. symphysis menti 2. mental protuberance and mental tubercles. 3. mental foramen. 4. oblique line 5. incisive fossa.

Inner surface

1) Mylohyoid line 2) Submandibular fossa 3) Sublingual fossa 4) Posterior surface of symphysis menti 5) The mylohyoid groove

RAMUS
The ramus is quadrilateral in shape and has two surfaces, lateral and medial, four borders, upper, lower, anterior and posterior, and the coronoid and condyloid processes.

The medial surface presents the following: Mandibular foramen and mandibular canal. Lingula The mylohyoid groove Mandibular notch. Coronoid process Condyloid process

 The lower border is the backward continuation of the base of the mandible. Posteriorly, it ends by becoming continuous with the posterior border at the angle of the mandible. The anterior border is thin, while the posterior border is thick.

FACIAL MUSCLES
1) Muscle of the scalp 1) occipitofrontalis 2) Muscle of auricle 1) auricularis anterior 2) auricularis superior 3) auricularis posterior 3) Muscles of the eyelids 1) orbicularis occuli 2)Corrugator supercilii 3)Levator palpebrae superioris

4 ) Muscles of the nose 1) procerus 2) compressor naris 3)dilator naris 4)depressor septi 5) Muscle around the mouth 1) Orbicularis oris 2) Zygomatic major 3) Levator labii superioris 4) Levator angli oris 5) Zygomatic minor 6) Depressor anguli oris 7) Mentalis 8) Risoris 9) buccinaor

MUSCLES OF MASTICATION

MUSCLES OF MASTICATION
Masseter muscle Temporalis muscle Medial pterygoid muscle Lateral pterygoid muscle

 COMMON CHARACTERISITICS: 1. All are inserted to the mandible 2. All are innervated by the mandibular division of the trigeminal nerve 3. All are concerned with biting and chewing FUNCTIONS: 1. To move the mandible 2. To secure then stabilize the mandibular positions 3. To determine the direction of mandibular movements

Masseter muscle
It is a flat quadrangular muscle, partly tendinous, partly fleshy. It overlies the lateral surface of the mandibular ramus. ACTION: elevate the jaw, with the superficial fibers causing protraction

Deep part Superficial part

TEMPORALIS MUSCLE
It is a large, fan-shaped muscle at the sides of the head.

ACTION: anterior fibers elevate the mandible, while the posterior fibers retract the mandible Blood supply: Deep temporal branches of maxillary artery.

LATERAL (or EXTERNAL) PTERGOID MUSCLE

It is a thick and triangular muscle with two heads. It is the muscle of mastication that occupy primarily a horizontal position.
Action: acting together they protrude and depress the mandible; acting alone and alternatively they produce side to side movements of the mandible.

Medial pterygoid muscle

It is almost a mirror-like image of the masseter muscle. It is rhomboidal and runs practically in the same direction on the inner surface of the mandible

Action: assets in elevating and protrusion of the mandible acts together with lat. Pterygoid of the same side in rotating the mandible

Temporomandibular joint

 The temporomandibular joint is an example of ginglymoarthrodial articulation and its movements are combination of gliding movements and loose hinge movements. GINGLYMOARTHROIDAL: The TMJ offers hinging movements in one plane, therefore it is considered as ginglymoid. It also provides for gliding movement, hence arthroidal.

The temporomandibular joint is made up of the following A. BONY COMPONENTS 1. Condylar head 2. Glenoid fossa 3. Articular eminence B. SOFT-TISSUECOMPONENTS 1. Joint capsule 2. Articular disk 3. Ligaments C. MUSCLES ASSOCIATED WITH THE TMJ
Muscles of mastication Muscles attached to the joint Muscles of facial expression Muscles of the neck

MAXILLARY ARTERY

 The larger terminal branch of the external carotid artery given off behind the neck of the mandible. It has a wide territory of distribution and supplies 1) the external and middle ears and the auditory tube 2) the dura mater 3) The upper and lower jaws 4) The muscles of the termporal and infra temporal regions 5) The nose and paranasal air sinuses 6) The palate 7) The root of the pharynx

Branches

 Applied aspects of maxilla and mandible

ROTATION OF JAWS
Studies of growth were carried out in the 1960s primarily by Bjork and coworkers in Copenhagen, the extent to which both the maxilla and mandible rotate during growth.

Forward rotation of the mandible with the center (type I) at the joints (a) With the center at the incisal edges of the lower incisors (type II) (b) With the center at the premolars (type III) (c)

Backward rotation of the mandible with the center at the joints (a) and with the center at the last occluding molars Type I:Bite is raised increased Anterior facial height Flattening of cranial base Middle cranial fossa is raised in relation to anterior Incomplete development of middle cranial fossae Type IIOccurs in relation with growth in the saggital direction at the mandibular condyles Because of position of the center of rotation at the molar the symphysis swung backward and the chin may not follow this movement and a characteristic double chin can occur

Schudys concept of growth rotation

Schudys concept of growth rotation

Cockwise rotation

Conterclockwise rotation

Jaw bones or mandible grows downwards and backwards

Bone grows upward and forwards

More posterior gorwth and less anterior growth

More anterior growth and less posterior growth

Results in long face called as high angle cases

Results in short face called as low angle cases

Proffits description of rotation

Rotation depending upon the location of growth

Internal rotation (IR) rotation occurs in the core of the jaw bone Core is the portion that covers the inferior alveolar nerve

External rotation (ER) Rotation due to surface changes)

Remaining parts of mandible like alveolar process the muscular processes condylar process

Two types of internal rotation

Rotation around condyle or matrix rotation

Rotation centered within mandible or intramatric rotation

11-12degree external rotation

15 degree of internal rotationa

Total rotation

 Bjork and Skieller distinguished two contributions to internal rotation (which they called total rotation) of the mandible: (l) matrix rotation, or rotation around the condyle (2) intramatrix rotation, or rotation centered within the body of the mandible

 Bjork also named 7 structural signs of extreme growth rotations.

1. Inclination of the condylar head.

2. Curvature of the mandibular canal.

3. Shape of the lower border of the mandible 4. Inclination of the symphysis. 5. Inter Incisal Angle. 6. Inter premolar, Inter molar Angle.

7. Anterior lower Facial height.

FACIAL DEFORMITIES RELATED TO MAXILLA

Facial Clefts: are among the most common congenital malformation in humans. Fetal Alcohol Syndrome: caused by very high blood alcohol levels during the first trimester of pregnancy. Hemifacial Microsomia: is a microstomia is a congenital defect characterized by a lack of tissue on the affected side of the face.

FACIAL DEFORMITIES RELATED TO MANDIBLE

Agnathia: mandible may be grossly deficient or absent. Occurs due to deficiency of neural crest tissue in the lower part of the face.

Micrognathia: characteristic for many syndromes

like Pierre Robin Syndrome, Downs Syndrome.

Macrognathia: causes prognathism

 Hemifacial hypertrophy: evident at birth tends to be prominent at puberty. Unilateral enlargement of the mandible, the mandibular fossa and the teeth. Bifid or Double Condyle: results from the persistence of the septa dividing the fetal condylar cartilage.

Skeletal malocclusion

CLASS II MALOCCLUSION
Components of class II malocclusion:-

Maxilla

mandible

Maxillary skeletal position

Maxillary dentoalveolar position

Dental position

Skeletal position

maxilla
mandible

Normal mandible

Retrognatic mandible

Normal maxilla

Prognatic maxilla

 Deficient in mandibular size Mandible well defined but still class II due to posterior

positioning of glenoid fossa

A deficiency in the anteroposterior position of the mandible is a common finding in class II A decrease in vertical dimension cause the mandible to rotate upward and forward

These patients have a low mandibular plane angle deep bite

with a strong chin point or flared maxillary incisors

Increased vertical dimension

A patient with increased lower anterior facial height often is characterized by Retruded mandible Poorly defined chin point with a hyperactive mentalis muscle. Anterior open bite The ratio between anterior to posterior facial height is increased Maximum advancement of chin point is desired as the goal of treatment increase in the vertical dimension of patient during treatment should be minimized

Treatment
Once the component has been identified one or more specific

treatment protocols can be used.

MAXILLA :1) Maxillary skeletal position

Protrusion

Retrusion

Protrusion The most common treatment for true maxillary skeletal protrusion is extraoral traction. Extraoral traction appliances are divided arbitrarily into two types 1) Face-bow 2) Head gear

Retrusion
There are a significant number of class II patients whose malocclusions are characterized in the part, by maxillary skeletal retrusion

. This condition tends to be found in patients who have a long lower face height, a steep mandibular plane angle and a retruded position of the chin point.

 Maxillary skeletal retrusion is extremely difficult to treat directly. Occasionally retrusion may be treated indirectly by using such appliances as posterior bite block or the veritcal-pull chin cup that may produce a slight upward and forward movement of the maxilla and a counterclockwise rotation of the mandible

MANDIBLE
mandible

Mandibular skeletal position

Mandibular dentoalveolar position

Mandibular dentoalveolar position

Many of the techniques described in the treatment of tooth size/ arch length. Lip bumber can be used effectively for mandibular dentoalveolar retrusion Mainly indicated in individuals who have very tight cheek and lip musculature and a defined mentolabial sulcus. Mild to moderate deficiency in mandibular arch length a removable mandibular schwarz appliance can be used.

Mandibular skeletal position: Mandibular skeletal retrusion is most common

Functional jaw orthopedic appliances may be indicated.

All functional jaw orthopedic appliances have one aspect in

common they induce a forward mandibular posturing as part

of the treatment effect

Treatment options
1) 2) 3) 4) FR-2 of frankel Twin block appliance Herbst appliance Bionator The first two are primarly indicated in mixed dentition. Herbst in early permanent dentition.

Condylar light bulb analogy:

Condyle acts like a light bulb on a dimmer switch Lights up during advancement, dimming back to near normal levels during retention. Growth potential diminishes with age while remodeling potential last long into adulthood.

LIGHT BULB ANALOGY

Improved clinical use of Twin-block and Herbst as a result of radiating viscoelastic tissue forces on the condyle and fossa in treatment and long-term retention: Growth relativity AJO DO 2000

 Light bulb analogy of condylar growth and retention. When the growing condyle is continuously advanced, it lights up like a light bulb on a dimmer switch. When the condyle is released from the anterior displacement, the reactivated muscle activity dims the light bulb and returns it close to normal growth activity. In the boxed area, the upper open coil shows the potential of the anterior digastric muscle and other perimandibular connective tissues to reactivate and return the condyle back into the fossa once the advancement is released. The lower coil in the box represents the shortened inferior LPM. The open coil above the yellow condylar light bulb represents the effects of the stretched retrodiskal tissues.

Biodynamic factors involved in condylar-glenoid fossa (C-GF) growth modification during orthopedic mandibular advancement in treatment and retention. Metabolic action describes the pump-like influx and expulsion of nutrients and other chemicals from the engorged blood vessels of the proliferating retrodiscal tissues (dark blue region) extending between the condyle and the fossa. This biodynamic action (light blue circle) occurs in the retrodiskal tissues and fibrocartilage during condylar displacement. The expulsion of these accumulated metabolites occurs during reseating of the protracted condyle and is clinically evident as relapse of the previously observed condition.

VERTICAL EXCESS
Skeletal open bite Long face syndrome Elongation of maxillary and mandibular posterior teeth

Long face syndrome

Low muscle activity
Long face syndrome Increased anterior facial height Decreased posterior facial height Hight mandibular plane angle High gonial angle

Low bite forces

Decreased masticatory mucle thickness and volume

Muscle fiber type slow

Obliquely placed masticatory muscles

Rx OF VERTICAL EXCESS
HIGHPULL HEADGEAR TO MOLARS Maintain vertical position of maxilla Inhibit eruption of maxillary posteriors

Rx OF VERTICAL EXCESS
HIGHPULL HEADGEAR TO A MAXILLARY OCCLUSAL SPLINT Gummy smile Excessive incisal show (increased ant. dental height) Disadvantage: allows mandibular teeth to erupt freely

TRANSVERSE DIMENSION
The transverse dimension of maxilla can be widen and this temporary defect in the mid palatal suture region remodels with osseous tissue.

 Suture is formed by the junction of the three opposing pairs of bones namely premaxillae,maxillae and the palatines but often for practical purposes they will be treated as single entity called as a Midpalatal suture.

 The suture starts to ossify posteriorly (Davida 1926) and always shows a greater degree of obliteration posteriorly then anteriorly, while ossification comes very late anterior to Incisive foramen.

Cleft plate
The simplest definition of a cleft is that Its an opening in an anatomical part that is normally not open. Orthodontist plays a major role in the management of the Cleft patient. Palatal integrity is essential at birth to enable feeding. The orthodontist helps in designing and fabrication of the following appliances that may be used for the Cleft palate patient management: Feeding plate for the neonate. Orthodontic correction plate for the gum pad.

Orthodontic cum prosthetic plate used in deciduous and permanent dentition.

Fixed Orthodontic appliance.

Rapid palatal expansion appliance in the pre-puberty growth

period. Headgear for pre-maxillary fragment.

ANCHORAGE: Orthopeadic correction-

Two methods for obtaining the Skeletal anchorage:-

Intentionally Ankylosed teeth.

Endosseous Implants.

Anatomy of Maxilla and TADS

Knowing the anatomy and density of bone helps in identifying the ideal place to insert the Implants.

 Bone density and Misch classifications Stationary anchorage failure often occurs because the TAD was placed in a region of low bone density with inadequate cortical thickness

 D1 (> 1,250 HU) is dense cortical bone primarily found in the anterior mandible, buccal shelf and midpalatal region . D2 (850-1,250 HU) is porous cortical bone with coarse trabeculae found primarily in the anterior maxilla, the midpalatal region and the posterior mandible. D3 (350-850 HU) is thin (1 mm), porous cortical bone with fine trabeculae,found primarily in the posterior maxilla and mandible. D4 (150-350 HU) is fine trabecular bone, found primarily in the tuberosity region

 Stedmans medical dictionary symmetry may be defined as equality or correspondence in form of parts distributed around a center or an axis, at the two extremes or poles or on the two opposite sides of the body

CLASSIFICATION.
Asymmetries can be classified according to the structures involved into dental, skeletal and functional. Dental asymmetries Skeletal asymmetries

Muscular asymmetries
Functional asymmetries

 Dental asymmetries: These can be due to local factors such as early loss of deciduous teeth, congenitally missing tooth or, and habits such as thumb sucking. Lack of exactness in genetic expression affects the teeth on the right and left sides causing asymmetries in mesiodistal crown diameters. Skeletal asymmetries: The deviation may involve one bone such as the maxilla or mandible, or it may involve a number of skeletal and muscular structures on one side of the face, e.g. hemifacial microsomia

 Muscular asymmetries: Facial disproportions and midline discrepancies could be the result of muscular asymmetry, as might occur with hemifacial atrophy or cerebral palsy. Sometimes muscle size is ill-proportioned as in masseter hypertrophy." Abnormal muscle function often results in skeletal and dental deviations. Functional asymmetries: These can result from the mandible being deflected laterally or antero-posteriorly, if occlusal interferences prevent proper intercuspation in centric relation. These functional deviations may be caused by a constricted maxillary arch (even if the constriction, in itself, is symmetrical), or a more localized factor such as a malposed tooth. The abnormal initial tooth contact in centric relation results in the subsequent mandibular displacement in centric occlusion.

The association of anatomical entities as applied to clinical orthodontics

Vertical and horizontal growth has an important effect on vertical overbite as were as over jet The type of terminal growth will indicate the best retention procedures Facial esthetics is significantly affected by the rotation of the mandible and the degree if facial divergence.

Conclusion
One should have a thorough understanding of the basic anatomy constitution of the tissue structure and anatomy of the area before intervening or indulging in deciding treatment plans.

REFRENCES
Contemporary Orthodontics William R Profit. Text Book of Craniofacial growth Sridhar Premkumar Colour atlas of dental medicine Orthodontic diagnosis- Rakosi Orthodontics and dentofacial orthopedicsJames A McNamara

 Text Book Of Anatomy- Grays Anatomy Human Anatomy- B.D. Chaurasia Facial growth Geoffrey H. Sperber

 Janusz Skrzat et al., The morphometry of the human palatine sutures(Folia Morphol., 2003, Vol. 62, No. 2) Improved clinical use of Twin-block and Herbst as a result of radiating viscoelastic tissue forces on the condyle and fossa in treatment and long-term retention: Growth relativity AJO DO 2000

 Age related differences in mandibular ramus growth: a histologic study- Mark G. Hans, Donald H. Enlow, Regina Noachter