full mouth rehabilitation / academy general dentistry

Part IV
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

Contents
Solving deep overbite problems
Solving anterior overjet problems
Solving anterior open bite problems
Treating end to end occlusions
Treating splayed or separated teeth
Treating the cross bite patient
Treating crowded, irregular, or interlocking
anterior teethwww.indiandentalacademy.com

Solving deep overbite
problems

Important considerations
A deep anterior overbite is only a problem if there are
no stable holding contacts.
The principal treatment objective is to establish a
stable stop for each tooth in centric relation.
Treatment considerations:
Care must be taken to maintain neutral zone
relationship of upper anterior teeth. Deep overbites are
almost always related to strong lip pressures and a
tight neutral zone.www.indiandentalacademy.com

Phonetic relationship of incisal edges is critical for
deep overbite patients.
Supraeruption of lower incisors often requires
correction. If lower incisors are shortened, stops must
be provided.
If stops cannot be provided, a removable substitution
may be needed to prevent supraeruption, or splinting
may be considered.

Misconception:
There is not a set amount of overbite for all patients.
 It is as normal and healthy to have a deep overbite as
long as there are definite stops to prevent
supraeruption.
Deep overbites with stable holding contacts are among
the most stable dentitions because posterior disclusion
is never a problem with a deep overbite.

Methods for correcting
Reshaping. This is often helpful in shortening lower
incisal edges in combination with restoring holding
contacts on upper teeth.
Orthodontics. Be careful not to move upper incisal
edges forward into lip closure path or in interference
with neutral zone.

Restorative procedures. Centric stops can often be
provided on upper anterior teeth. Lower incisal edges
can sometimes be restored forward to achieve centric
relation contact.
Surgery. Repositioning anterior segments is often a
good choice.

Applying the principles
A poorly made anterior fixed bridge
with no holding contacts.
The lower incisors erupted up to
impinge on gingival tissues.
The lower lip position is behind the
upper incisors because the tight
neutral zone prevented the lip from
fitting in front for a normal lip seal.
The result was very unaesthetic as
well as unstable.

The first goal of treatment is to
achieve stable holding contacts on
all anterior teeth.
The first treatment option:
Reshape
It is often necessary to reshape the
lingual of upper restorations to
provide a holding contour and
shorten the lower incisors if they
have erupted up too far to make
contact. www.indiandentalacademy.com

The second treatment option: Reposition
If the upper incisors have been wedged forward, they
can be moved back so lower incisor contact can be
achieved.
Changes the neutral zone as the lower lip will be able
to slide in front of the labial surfaces to hold them
back as the lips seal.
Improve the esthetics by getting rid of the
"buckteeth" appearance.

A simple but effective
appliance for moving the
anterior teeth back into a
predetermined position
against contoured slots in
the palatal part of the
appliance. A rubber band
directs the teeth into the
slots.

The complete lack of holding
contacts on the straight
lingual contours of the
original restoration.
The anterior teeth are
brought lingually, their
lingual contours has to be
recontoured to permit
anterior teeth contact into a
stop.

The third treatment option:
Restore
After the teeth have been
brought into an acceptable
alignment by reshaping and
repositioning.
Teeth are prepared and
provisional restorations are
used refine the anterior
guidance and esthetic concerns.

To achieve contact on all lower
anterior teeth, it is often
necessary to move one or more
teeth forward.
After the teeth have been
repositioned for centric
relation contact, the final
details are worked out in
provisional restorations.

Deep overbite with tissue contact
Lower incisors erupt up into soft tissue lingual to the
upper anterior teeth. It is not a problem if:
The upper lingual tissue has been unaffected by the
contact.
The contacted tissue is dense, firm, flat, and shows no
sign of inflammation.

The lower incisor tissue contact is simultaneous with
contact against the lingual surface of the cingulums of
the upper incisors.
The incisal edges of the lower incisors are smooth with
no sharp edges.
The incisal plane of the lower anterior teeth is
acceptable esthetically and must be in conformity with
the rest of the occlusal plane.

Deep overbite problems
associated with an anterior slide
Such a problem calls for a three-step solution:
1. We must equilibrate to permit the mandible to close
without deflection from posterior teeth.
2. We must shorten the lower incisors to position the
incisal edges in an optimum relationship to
previsualized centric stops on the upper incisors.
3. We must restore the upper lingual contours to
establish stable centric stopswww.indiandentalacademy.com

Solving deep overbite problems
by splinting
Teeth that have supraerupted into the palatal tissue can
be shortened to relieve the pressure against the soft
tissues.
Splinting is often the most practical method of
stabilizing such lower anterior teeth.

Includes:
i. Full coverage
ii. Resin bonded lingual restorations
iii. Modifications in partial denture e.g. continuous
clasp splinting and Swing-lock design.

Bite planes to solve deep overbite
problems
Discomfort from tissue impingement and if future problems
are imminent.
Least complicated way of preventing supraeruption of the
lower anterior teeth.
Fabrication is carried out on centrically mounted models.
The appliance is most esthetically acceptable when it is made
of clear acrylic resin. It must provide stable centric contacts
for all lower teeth, and it should be equilibrated so that there
is no interference to any excursive movement.www.indiandentalacademy.com

Partial dentures to solve deep
overbite problems
When an upper partial denture is required, it can
sometimes fulfill a double purpose by serving as a
contact for the lower anterior teeth.
Palatal bar is designed to cover the tissues behind the
upper anterior teeth, the lower anterior teeth may be
permitted to contact the palatal bar to prevent
supraeruption.

The contour of the palatal coverage may be designed to
permit protrusive excursions of the lower anterior
teeth to slide smoothly from the palatal coverage onto
the lingual inclines of the upper anterior teeth.

Solving anterior overjet
problems

Overjet patients present the greatest difficulty for
providing centric stops on all the teeth.
Careful observation is important to make sure the
overjet relationship is not stable before attempting to
correct it.
The tongue is a common substitute for holding
contacts. Evaluate to see if it effectively stabilizes the
lower incisors

Evaluate the horizontal component of jaw function
before arbitrarily moving anterior teeth.
Problems with posterior teeth stability are common
with anterior overjet because of the difficulty of
providing anterior guidance with posterior disclusion .

It is essential to determine whether the overjet is
caused by maxillary protrusion, or by mandibular
insufficiency before a treatment plan is selected.
Overjet problems are common in children with airway
problems because the tongue must posture forward to
permit mouth breathing. Correction of the airway
problem is critical to correction of the overjet problem.

Extreme anterior overjet
treatment choices
Reshape. Some overjet problems can be corrected by
closing the vertical dimension of occlusion (VDO) to
permit the arc of closure to move the lower anterior
teeth forward into contact with the upper anterior
teeth.
Orthodontics. This is very often the best solution,
sometimes in combination with restorative dentistry.

Restorative dentistry to restore holding contacts or to
splint incisors to teeth that have contact in centric
relation.
Removable appliances to provide palatal bar stops for
lower incisors.
Surgery to move the maxilla back or the mandible
forward or to reposition the maxillary anteriors back
with an osteotomy.

The problems of anterior overjet
Lower teeth with no stabilizing contact with the upper
teeth either in centric relation or near centric relation
have tendency to supraerupt, drift out of alignment,
and frequently impinge on the palatal tissues.
Excessive overjet relationships make it difficult or
impossible for the anterior guidance to do its job of
posterior disclusion.

The classic bucktooth appearance has long been used
by cartoonists to depict stupidity. It is not a pleasant
appearance, and it is often the real reason why patients
seek treatment.
The resolution of anterior overjet problems
involves four considerations:
Stabilization of the lower anterior teeth

Providing the best possible anterior guidance for
posterior disclusion in protrusion
Providing the best possible relationship for disclusion
of the balancing inclines
Improving the position, alignment, or shape of the
upper anterior teeth for better esthetics

Overjet with lower incisor
contact on palatal tissue with
esthetic concerns.
The lower lip locks behind
the upper anterior teeth,
affecting speech and causing
exposure to unesthetic
drying of the incisors" labial
surfaces.

First treatment option:
Reshape. Need to narrow the
incisors to make room for moving
the incisor segment lingually.
Second treatment option:
Reposition. An appliance is
made with a lingual plate
contoured to receive the teeth into
their predetermined position as
they are moved lingually.

A rubber band attaches to the
appliance to move the teeth into
the contoured slots in the
lingual plate.
Improved incisal plane that
permits contact with the lower
incisors.
The appliance increases the
VDO to allow room to move the
upper teeth back.

Third treatment option:
Restore. Teeth are prepared,
and a provisional restoration
are refined in the mouth
Tested for a smooth
functioning anterior
guidance, making sure that
immediate disclusion of the
posterior teeth is achieved.

The putty silicone index
communicates incisal edge
position and contour. The
custom anterior guide table
communicates the exact
lingual contours.
Finished restorations
showing improved
relationship to smile line.

Incisal edge contact on the inner
line of the lower lip during
pronunciation of V.
Post-op stabilization. Can be
accomplished with a Biostar
appliance made of flexible vinyl.
Adjusted for equal intensity
centric relation contacts. It is
also contoured to establish an
anterior guide ramp for
immediate posterior disclusion.www.indiandentalacademy.com

Solving anterior open
bite problems

The most important determination is what caused the
open bite.
Always evaluate the condition of the
temporomandibular joints (TMJs). Loss of condylar
height usually causes progressive anterior separation.
If a habit pattern caused the open bite, correction will
be unsuccessful unless the habit is eliminated.

Skeletal malrelationships can usually be successfully
treated.
There are many degrees of open bite depending on
tongue or lip habits that intrude teeth or prevent their
eruption.
Many anterior open bites are stable.
A major problem of anterior open bite is trauma to
posterior teeth.
A second major problem is lack of an anterior guidance
for posterior disclusion.

Treatment objectives
1. Maximize the number of equal-intensity occlusal
contacts on both sides of the arch.
2. Correct a "reverse smile line" on upper anteriors for
esthetic improvement.
3. If only one arch is malaligned, close the anterior
relationship by correcting the arch that is wrong.
4. If a habit pattern cannot be broken, the occlusion
must conform to the habit.

5. Achieve posterior disclusion in protrusive by
determining the anterior guidance as far forward as
possible.
6. If anterior guidance cannot be achieved for disclusion
of the balancing side, use group function of the
working side posterior teeth.
7. If condylar breakdown is progressive, correction of the
occlusion must keep up with it.

The major causes of anterior open bite in order of probable
frequency are as follows:
1. Forces that result from thumb or finger sucking, or use
of pacifiers.
2. Crowding. If anterior teeth are rotated. forward off their
basal bone, the forward inclination causes separation.
3. Airway obstruction:
a. Inadequate nasal airway creating the need for an oral airway
(mouth breather)
b. Allergies

c. Septum problems and blockage from turbinares
d. Enlarged adenoids or tonsils
4. Lip and tongue habits
5. Intracapsular TMJ deformations
6. Neurologic problems (such as cerebral palsy) lead to
tongue posture problems
7. Skeletal growth abnormalities, probably resulting
from the above problems as well as from pure skeletal
growth asymmetries.

Severe anterior open bites
Solving the problem of achieving a stable anterior
relationship may require a three-pronged attack:
1. Orthodontic correction of anterior tooth relationships
2. Occlusal equilibration to eliminate the need for
protective tongue or lip habits
3. Use of a retainer at night

Anterior open bite.
Contact in centric relation
is only on second molars.
Esthetics is a major
concern of the patient.

First treatment option:
Reshape Analysis of
mounted casts indicates
shortening the molars to
gain anterior contact.
1 mm of reduction of the
second molar results in 3
mm of closure at the
anterior teeth.

After equilibration of the
casts, a tentative wax-up of the
upper anterior teeth is
performed and an acrylic resin
overlay is made.
Completed restorations.
Contact in centric relation
establishes an anterior guide
with immediate posterior
disclusion.

Surgical option:
The first treatment option of
reshaping could only achieve
this much closure without
mutilating the molar teeth.
The upper dento-alveolar
segment should be
repositioned down to close the
space and gain contact with
the lower teeth.

Treating end to end
occlusions

Anterior end-to-end relationships
Important considerations:
Anterior end-to-end relationships may be very stable if
they are in harmony with centric relation. Lateral
anterior guidance is achieved by sliding sideways
against ,the flat incisal edges.
Condylar guidance can usually combine with flat
anterior guidance to disclude all posterior teeth.

The principal problem is failure to disclude the
posterior teeth in excursions, so care must be taken to
make sure the occlusal plane and fossae contours are
correctly related for disclusion by the condylar path on
the balancing side.
This typically requires flatter occlusal contours for
disclusion on the working side because working side
disclusion is achieved solely by the lateral anterior
guidance.

Changing an anterior end-to-end occlusion to an
overlap relationship steepens the anterior guidance
and will probably cause a bruxing wear problem on the
anterior teeth.
A nighttime bruxing appliance is in order whenever
the envelope of function is restricted.
Even though restriction of the anterior guidance

causes wear, etc., it is not usually uncomfortable for the
patient as long as there are no interferences to centric
relation closure.
The ideal solution is to maintain the anterior guidance
as flat as possible if esthetic goals can be met without
an anterior overbite relationship.

Restoring end- to-end anterior teeth
Minimal changes in incisal edge position can effect
gross improvements in anterior function.
Moving the upper incisal edges forward and the lower
incisal edges inward can extend the protrusive contact
by a couple millimeters or more.
Even a horizontal zero-degree guidance can fulfill all
the disclusive needs of the posterior teeth if occlusal
contours are also kept flat enough and the occlusal
plane is correct.www.indiandentalacademy.com

Restorative recontouring of teeth in an end-to-end bite
an cause special problems if the stresses are moved off
the direction of the long axis.
The stresses are so confined to the long axis that the
periodontal fibers and the bone trabeculae are not
aligned to resist lateral stress.
Suddenly changing a tooth's contour to subject it to
lateral forces may produce unwanted effects of
tenderness or hypermobility until the fibers realign and
the bone becomes more resistant to the lateral forces.

The choice that must be made is between increasing
the vertical dimension of occlusion (VDO) or
endodontically treating the teeth and maintaining the
VDO.
The VDO should be increased no more than is
necessary to provide room for the restorative materials
on the incisal edges. 1.5 mm increase should usually
provide the needed space.

Special considerations
The decision to alter the occlusal relationship should
be based on a careful evaluation of the following
factors:
Stability
Whether an end-to-end occlusion is stable depends
principally on two factors:
1. Harmony with the neutral zone
2. Noninterference with the envelope of function

Function
It is rare for a patient with a stable end-to-end
relationship to complain of inadequate function.
Esthetics
The irony of an anterior end-to-end occlusion is that
although many dentists believe it should be
"corrected," most patients believe it is the ideal
relationship.

Skeletofacial profile
Evaluation of skeletofacial profile problems requires
cephalometric analysis as well as mounted diagnostic
casts.
The purpose of the cephalometric evaluation is to
determine whether the end-to-end relationship is
caused by an underdeveloped maxilla or an
overdeveloped mandible, or some combination of
both.

Neutral zone
If an end-to-end relationship occurs posterior to the
facial plane or the McNamara plane, it results in a
"pushed-in" appearance as a manifestation of
bimaxillary deficiency
This type of occlusal relationship should be treated
with caution because it is usually accompanied by a
very strong buccinator-orbicularis oris limitation on
arch size.

Posterior end-to-end relationships
1. Are all teeth stable or unstable?
2. Can the anterior guidance disclude the posteriors? If
so, an end-to-end occlusion is not a problem.
3. If anterior guidance cannot disclude the posterior
teeth in lateral excursions, correct the posterior
relationship by the best choice of:

• reshaping
• repositioning
• restoring (with centralized cusps)
• surgery
The goal is posterior disclusion of the balancing side
either by the anterior guidance or by the posterior
teeth on the working side.
4. Anterior guidance can sometimes be steepened if it is
not steeper than the lateral path originally found
during excursions dictated by posterior teeth.

Restoring end-to-end
posterior teeth
The goal is to provide as much stability as possible in
centric relation and as much relief as possible in
excursions.
Lower Cusp Tip to Upper Flat Surface
Provide almost normal lower posterior occlusal form,
with slight modifications to flatten and broaden upper
cusp tips to serve as stops for the more rounded lower
cusps.

Overjet can be provided to hold the cheek away from
the contacts.
Adequate as long as the teeth are positioned in
harmony with the cheeks and tongue.
 Centralization of the Lower Cusps
By converging the lower buccal and lingual cusps into
single centralized cusps, it is practical to place them in
the central fossae of the upper teeth.

Stress direction is ideal for both upper and lower teeth,
and function is excellent.
With centralized lower cusps, the upper working
inclines can be used to disclude the balancing inclines
on the opposite side, and it can be accomplished
within the limits of the normal neutral zone.

Treating splayed or
separated teeth

Some splayed anterior teeth with spaces are healthy
and have stable holding contacts. If the teeth are
stable and the supporting structures are healthy, the
decision is based on the patient's esthetic desires.
1. Why are teeth splayed? Find the cause.
2. Can the spaces be closed by constricting the arch
without interference to the anterior guidance?

3. Will constricting the arch size interfere with the
tongue?
4. Can the teeth be moved together if the lingual
contours are reshaped to make new holding contacts?
5. If the teeth have stable holding contacts, can the
spaces be closed restoratively or with bonding?
6. Is the problem related to an arch size discrepancy?

Observation
Splayed anterior teeth are usually in a definite neutral
zone corridor. They can be moved or reshaped within
that corridor, but movement toward either the tongue
or the lips usually results in interference with the
musculature and eventual instability.

The patient presented with
the primary concern of
improving the esthetics of
his smile. The teeth were
splayed, separated, and
inclined forward.
All teeth were firm with no
sign of wear or fremitus.

Maximal intercuspation.
There is a long slide from
the first contact at the
most closed position.
Centric relation. The true
arc of closure to anterior
contact in centric relation
can then be determined
on mounted casts.

Equilibration of casts. Posterior
deflective interferences can be
eliminated without mutilating
the posterior teeth. Is it possible
to achieve anterior contact in
centric relation.
Anterior guidance. Can only be
achieved after all interferences
to centric relation closure have
been eliminated.www.indiandentalacademy.com

Diagnostic wax-up.
Neutral zone
considerations. Splayed
anterior teeth are usually
in the most balanced
relationship between
tongue and lip pressures.

The diagnostic wax-up
completed.
Prepared teeth

Matrix used as reduction
guide and for direct
fabrication of provisional
restorations.
Provisional restorations in
place.

Provisionals tested for
appearance, phonetics,
and function.

Treating the cross bite
patient

IMPORTANT CONSIDERATIONS
Never treat an anterior crossbite without first
analyzing the tooth-to-tooth relationships at the
selected vertical dimension in centric relation.
1. Is the anterior crossbite the result of mandibular
prognathism or maxillary deficiency?
2. What is the anterior relationship in centric relation? If
it is end to end in centric relation, how much vertical
displacement of the condyles is there in maximal
intercuspation?

3. Do the anterior teeth need to be restored because of
wear or appearance?
4. Is the crossbite an esthetic problem? Can the anterior
teeth be restored end to end?
5. The importance of vertical dimension in crossbite
problems is critical. Class III patients often respond
unfavorably to increasing the vertical dimension of
occlusion (VDO).

6. Anterior guidance is not a problem, as anterior
crossbite patients do not protrude. They have vertical
envelopes of function.
7. Disclusion of the balancing side should be achieved
by group function of the working side posterior teeth.
8. Orthognathic surgery is often the treatment of choice
for correction of facial profile problems and can result
in good occlusal relationships.

Problems with anterior crossbites
Esthetics
The most common reason that patients seek treatment
is to improve their appearance.
Elimination of the "bulldog look" of prognathism can
be accomplished in several ways, but surgery seems to
be the only practical method if the prognathism is
severe.

No centric contact on anterior teeth
The upper lip substitutes for the contact and holds the
lower anterior teeth in place.
 The tongue prevents the upper teeth from
supraerupting.
Providing of centric contact through surgical
correction of the arch relationship, by orthodontic
repositioning of the teeth, by restorative reshaping, or
by splinting to teeth that have centric contact.

No anterior guidance
Most prognathic patients limit their function to
vertical "chop chop" movements
Provide balancing incline disclusion.
The necessary lift can usually be provided by the
working-side inclines.
Group function of the working inclines is usually the
occlusion of choice.

Why increasing the VDO works?
Increasing the VDO is often the best treatment plan
for anterior crossbites for the following reasons:
I. If the increased VDO at the anterior teeth is offset by
upward movement of the condyles from maximal
intercuspation to centric relation, the interference
with elevator muscle contracted length may be
minimal or none.
Thus converting an anterior crossbite to an end-to-end
relationship may result in a stable occlusion.

II. Even if increasing the VDO cannot be offset
completely by upward condylar repositioning, the
increased VDO can be well tolerated as the muscles
return it to their original contracted length.
If all teeth are in contact in centric relation, the
corrected occlusion will be maintained with minimal
adjustments required.

Anterior crossbite at maximal
closure. At this most closed
position, the condyles are
displaced down and forward
The end-to-end relationship
occurs in centric relation
when the condyles have
moved up their eminentiae.

An existing removable partial
denture was used to increase the
VDO at the anterior end-to-end
relationship.
Based on the analysis on the
mounted casts, the anterior teeth
were narrowed a predetermined
amount to facilitate moving them
into a better alignment that was
pre-established on the diagnostic
wax-up.

A continuous clasp was
cast to fit the repositioned
teeth on the diagnostic
wax-up.
The clasp is bonded to the
canines on each side. The
canines and central
incisors are in the neutral
zone and will not be
moved.

Small rubber bands are
used to pull the lateral
incisors into the slots
designed to receive them.
Alignment of the teeth
progresses.

After the lateral incisors
are aligned, direct
composite buildup is used
to develop contacts and
contours.
It is copied in provisional
restorations that serve as a
retainer until final
preparation and
completion.

The conservative approaches for resolving anterior
cross bite problems can be summarized as follows:
1. Selective shaping and occlusal equilibration
2. Orthodontic repositioning of the teeth within the
present bone framework
3. Restorative reshaping
4. A combination of the above procedures

The above option of opening the bite is a logical choice if:
1. An acceptable end-to-end relationship can be achieved at
the incisors in harmony with centric relation.
2. The required increase in VDO is acceptable.
3. The posterior segments require restoration for other
reasons

There seem to be only two practical choices:
1. Live with the prognathism with fairly good assurances
that the dentition can be maintained.
2. Select a surgical correction.

Surgical Correction of Anterior
Crossbite
There are three methods for correcting an anterior
crossbite surgically:
1. Resection through the ramus so that the body of the
mandible can be moved distally into alignment with
the maxilla.
2. Horizontal resection of the maxilla so that it can be
moved forward into alignment with the mandible.

3. Sectional osteotomies so that an anterior segment can
be repositioned. This is not ideal if there is a severe
skeletal discrepancy.

Posterior crossbite
Three questions to ask before "correcting" a posterior
crossbite:
1. Are the teeth ideally situated in the alveolar process?
2. Would a change in tooth position benefit tooth-to-
muscle harmony, or is the relationship in harmony
with the tongue and the perioral musculature?
3. Can the lower posterior teeth disclude as they move
toward the tongue (balancing-side disclusion)?

Determining the best treatment choice for posterior
crossbite. In most instances, it is "leave it alone" unless
there are interferences to centric relation or excursions.
Analyzing cusp/fossae relationships in crossbite cases.
The lower lingual cusp and the upper buccal cusp become
the stamp cusps.
Treatment objective
Cross bite occlusions follow the same rules as normal
occlusions with regard to the requirements for stability.
They just use different cusps for holding contacts.

Evaluating Posterior Crossbites
Tooth-to-bone relationship in the same arch
Are the teeth ideally situated in the alveolar process?
 Would the tooth-to-bone relationship be improved if
the mandibular teeth are moved lingually or the
maxillary teeth bucally?
If the teeth are properly positioned within their
alveolar bone, which in turn is harmoniously aligned
with basal bone.www.indiandentalacademy.com

Relationship of the teeth to the tongue and cheeks
Are the teeth in harmony with normal tongue and cheek
pressures, or have they been moved into the crossbite
relationship by abnormal muscle patterns or habits?
 If deviate tongue or cheek patterns have moved the
teeth into a malrelationships, is it possible to correct the
abnormal habit pattern?
Would a change in tooth position or contour benefit the
tooth-to-muscle harmony or the overall stability?

Occlusal relationship
Upper-to-lower tooth relationships should be
evaluated for direction of stresses, distribution of
stresses, and stability.
 If the occlusal relationship causes stresses to be
directed favorably up or down the long axes, the first
requirement of stability has been fulfilled.
 If the occlusal contours permit favorable distribution
of lateral forces in excursive movements, the second
requirement of stability can be fulfilled.

When both of these requirements have been satisfied,
neither stability nor function needs to be slighted.
Optimum function with excellent stability is just as
practically attained in a posterior cross bite
relationship as it is with normal intercuspation.

Restoring Posterior Crossbite
The most common treatment mistake in crossbites:
Confusing balancing side disclusion.
Upper inclines that face the cheek or lower inclines
that face the tongue should never contact in lateral
excursions.
This rule should be followed regardless of the arch
relationship.
All inclines should disclude when the lower teeth
move toward the tongue.

When posterior crossbites are being restored, the
lower lingual cusps become the functioning cusps.
They fit into the same upper fossae and function
against the same inclines as the lower buccal cusps do
in a normal relationship.

If posterior group function is desired, the lower lingual
cusps contact the lingual inclines of the upper buccal
cusps in working excursions (laterotrusion). This
working incline contact can be used very effectively to
disclude the opposite-side balancing inclines.
The lower buccal cusp is a nonfunctioning cusp in
crossbite relationship, and its lingual inclines should
never contact; so it should be shortened slightly from
the normal contours so that it does not interfere in
balancing excursions (mediotrusion).

Treating crowded,
irregular, or interlocking
anterior teeth

1. Can the temporomandibular joints (TMJs) seat
comfortably in centric relation?
2. Is load testing negative?
3. Determine if the occlusion is stable.
a. Are the anterior teeth stable?
b. Are the posterior teeth stable?
c. Always check all teeth for signs of stability or instability?

4. If the teeth are stable
a. Is esthetics a problem that needs correction?
b. Is function a problem?
c. Is cleanability a problem (from crowding)?
5. If the occlusion is unstable or if correction is required for
other reasons
a. Is there room in the arch for correction?
b. Is there a discrepancy between tooth size and arch size?
c. Honor the neutral zone.

6. Can the alignment of the anterior teeth be corrected
without major changes to the posterior occlusion?
7. Do the posterior teeth interfere with complete closure
to anterior contact in centric relation?
a. Do the anterior teeth contact in maximal
intercuspation?
b. If not, determine if a tongue or lip habit is the reason.
c. Can the tongue or lip habit be broken?
d. Will it be necessary to work with the habit?

8. On mounted diagnostic casts, analyze all five options for
a. Getting the back teeth out of the way
b. Correcting anterior tooth alignment and position
c. Establishing stable holding contacts on anterior teeth
d. Establishing stable holding contacts on posterior teeth
e. Posterior disclusion

Methods of Correcting
anterior interlocking bites
Cases with interlocked anterior teeth can be divided
into two categories:
1. Cases that have sufficient room in the arch to
accommodate the anterior teeth when they are
properly aligned.
2. Cases that have insufficient room for the anterior
teeth to be aligned without changing posterior arch
form.

Five possible ways of solving the space problem:
1. We can narrow the teeth so that they will fit into the
available space.
2. We can widen the space by reshaping the adjacent teeth.
3. We can reduce the number of teeth that must fit into a
given space.
4. We can increase the space by changing the shape 0f the
arch.
5. We can change the axial inclination of the anterior teeth.

Narrowing crowded teeth
Several techniques that can be used for moving teeth
into their predetermined correct position in the arch:
Finger pressure
Ligatures and rubber bands
Removable appliances
Bands
Cemented brackets
Vinyl repositioners

Invisible retainers
Flexible ethylene vinyl acetate (EVA) polymer joined to
a semi rigid polycarbonate material.
Invisalign
It utilizes a series of computer-generated sequences for
tooth movement to achieve an ideal alignment of teeth
in both arches.

Patient with
upper-left lateral
and canine locked
behind lower
teeth.

A centric relation bite is
made using bilateral
manipulation with load
testing to verify centric
relation.
Casts are mounted in
centric relation with an
earbow for location of
centric relation condylar
axis.

A silicone index is made
to relate the casts to
centric relation at first
point of tooth contact.
The index is used in the
computer-generated jaw
relationship to which the
teeth will be aligned

Series of Invisalign
overlays to be used in
sequence.
Computer-generated
image of starting point.
Image of projected
treatment goal.

Laminates for final
esthetic position and
contour on right and left
laterals and canines.
Teeth prepared for
laminates.

Crowded anterior teeth with
severe posterior interferences

For more details please visit

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