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Biomechanics of open bite correction /certified fixed orthodontic courses by Indian dental academy
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Biomechanics of open bite correction /certified fixed orthodontic courses by Indian dental academy




The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call



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Biomechanics of open bite correction /certified fixed orthodontic courses by Indian dental academy Biomechanics of open bite correction /certified fixed orthodontic courses by Indian dental academy Presentation Transcript

  • MANAGEMENT OF OPEN BITE INDIAN ACADEMY DENTAL Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  • CONTENTS • • • • • What is an open bite ? Evolution of open bite Classification of open bite. Various treatment modalities. Biomechanics of treatment modalities. 1. Biomechanics of open bite correction before growth completion 2. Biomechanics of open bite correction after growth completion Conclusion. www.indiandentalacademy.com
  • Biomechanics of treatment modalities. 1. Biomechanics of open bite correction before growth completion biomechanics of – a) habit breaking appliance b) functional appliances - activator - bionator - FR-4 - twin block c) orthopedic appliance 2. Biomechanics of open bite correction after growth completion biomechanics of - a) fixed appliance mechanotherapy for open bitecorrection b) surgical management for open bite correction www.indiandentalacademy.com
  • WHAT IS AN OPEN BITE ? www.indiandentalacademy.com
  • OPEN BITE The Glossary of Orthodontic Terms defines open bite as a developmental or acquired malocclusion whereby no vertical overlap exists between maxillary and mandibular anterior or posterior teeth. www.indiandentalacademy.com
  • Evolution of open bite www.indiandentalacademy.com
  • • Open bite develops as result of the interaction of many etiologic factors. • In young children, digit habits and pacifiers are the most common etiologic agents. • In the mixed dentition years other than the normal transitional open bite, some openbites are probably attributable to lingering habits, where others are clearly skeletal in nature. www.indiandentalacademy.com
  • In the adolescent and the adult, it is difficult to assign singular causation. The influence of the tongue,lip, and airway on the development of malocclusion remains to be substantiated. Variations in growth intensity, the function of the soft tissues and the jaw musculature, and the individual dentoalveolar development influence the evolution of open bite problems. www.indiandentalacademy.com
  • SKELETAL FACTORS IN THE DEVELOPMENT OF AN OPEN BITE TYPE: 1. The combination of  excessive development of the upper mid-face heights (cranial base to molars)  a lack of development of posterior facial heights (S-Go) results in the downward and backward rotation of the mandible. www.indiandentalacademy.com
  • 2. The posterior half of the palate is tipped downward, carrying the molars further downward. This gives rise to a large palatomandibular plane angle. www.indiandentalacademy.com
  • 3. Because of the short ramus and the lower palate, the pharyngeal space is constricted. In order to breathe, these persons keep their tongues forward. Further enhanced by the dental open-bite, there is a tongue-thrusting tendencies. www.indiandentalacademy.com
  • 4. When enlarged tonsils are present, the tongue is further confined anteriorly. As the narrow palatal vault reduces the necessary space, there is a tendency towards tongue protrusion. This, in turn, may be a factor in the creation of bi-dental protrusion www.indiandentalacademy.com
  • CLASSIFICATION 1. Dento Alveolar Open Bite. 2. Skeletal Open Bite. www.indiandentalacademy.com
  • Dento Alveolar Open Bite  The extent of the dentoalveolar open bite depends on the extent of the eruption of the teeth. Eg: Supraocclusion of the molars and infraocclusion of the incisors can be primary etiologic factors. www.indiandentalacademy.com
  • 3. In vertical growth patterns the dentoalveolar symptoms include a protrusion in the upper anterior teeth with lingual inclination of the lower incisors. www.indiandentalacademy.com
  • 4. In horizontal growth patterns, tongue posture and thrust may cause proclination of both upper and lower incisors. www.indiandentalacademy.com
  • 5. A lateral open bite may be considered dentoalveolar in combination with infra-occlusion of molar teeth. www.indiandentalacademy.com
  • Skeletal Open-Bite www.indiandentalacademy.com
  • Skeletal Open Bite. 1. Skeletal Class I Open Bite 2. Skeletal Class II Open Bite 3. Skeletal Class III Open Bite www.indiandentalacademy.com
  • Positional Deviations Acc to Sassouni… 1. The four bony planes of the face are steep to each other, bringing the center 0 close to the profile. diagram www.indiandentalacademy.com
  • 2. The anterior arc, therefore follows the convexity of the profile. www.indiandentalacademy.com
  • 3. The posterior vertical chain of muscles is arcuate, and the masseter muscle is posterior to the buccal teeth, thus creating a mesial component of forces responsible for the dental protrusion. www.indiandentalacademy.com
  • 4. The cranial base angle and the gonial angle are obtuse. www.indiandentalacademy.com
  • Dimensional Deviations 1. The total posterior facial height (S-Go) tends to be half the size of the anterior total facial height (N-Me). www.indiandentalacademy.com
  • 2. The Lower Anterior Facial Height exceeds the Upper Anterior Facial Height. www.indiandentalacademy.com
  • 3 The facial breadths tend to be narrow, giving a long, ovoid appearance in the frontal view. www.indiandentalacademy.com
  • 5.The ramus is short with an antegonial notch at its lower border. 6. The mandibular symphysis is narrow antero posteriorly and long vertically. www.indiandentalacademy.com
  • • There is a lack of chin mental protuberance development. • According to the Sheldonian somatotyping, the open-bite type rates high in ecto-morphs. • The palatal vault is high and narrow. www.indiandentalacademy.com
  • SKELETAL CLASS II OPEN BITE 1. 2. In this type, in some instances, the rotation of the mandible may be purely positional. Often this is due to a downward and backward rotation of the mandible. This rotation is associated with excessive extrusion of the molars. If these interferences were removed, the mandible could be permitted to rotate in a closing direction, improving the Class II and the open-bite patterns simultaneously. www.indiandentalacademy.com
  • SKELETAL CLASS III OPEN BITE 1. This combination consists primarily of an open-bite with a palatal deficiency or a large mandible. www.indiandentalacademy.com
  • Among the facial deformities, these have probably the worst prognosis in terms of dentofacial orthopedics. If correction of this open-bite is attempted by rotating the mandible in a closing direction, the protrusion of the chin is increased. www.indiandentalacademy.com
  • On the other hand, the reduction of the mandibular protrusion is attempted by rotating the mandible downward and backward, the open-bite is increased. www.indiandentalacademy.com
  • VARIOUS TREATMENT MODALITIES OF OPEN BITE www.indiandentalacademy.com
  • 1. 2. 3. H abit therapy: A ppliance therapy: S urgical management: www.indiandentalacademy.com
  • BIOMECHANICS OF HABIT BREAKING APPLIANCE www.indiandentalacademy.com
  • TREATMENT IN THE DECIDUOUS DENTITION 1. Control of abnormal habits and elimination of dysfunction should be given top priority in the deciduous dentition. 2. The anterior open bite improves as soon as the habit is stopped. 3. Treatment with screening appliances is indicated in such open- bite cases. www.indiandentalacademy.com
  • Screening Appliance 1. Screening appliances intercept and eliminate all abnormal perioral muscle function in acquired malocclusions resulting from abnormal habits, mouth breathing, and nasal blockage. 2. Open bite created by finger sucking and retained visceral deglutition-pattern, tongue function can be helped with vestibular screens. www.indiandentalacademy.com
  • Mixed Dentition-treatment www.indiandentalacademy.com
  • Tongue Crib 1. A removal or fixed appliance can inhibit tongue thrust. 2. The crib used with a removable appliance for an anterior open bite consists of a palatal plate with a horseshoe-shaped wire crib. 3. The crib is placed in the area of local tongue dysfunction and resultant malocclusion. www.indiandentalacademy.com
  • NORMAL OCCLUSION www.indiandentalacademy.com
  • ANTERIOR TONGUE THRUST www.indiandentalacademy.com
  • TONGUE CRIB www.indiandentalacademy.com
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  • 5. The acrylic also can be interposed between the teeth, covering the occlusal surfaces of the upper molars, to prevent eruption of these teeth and enhance anchorage of the plate, which is especially beneficial in open-bite problems. www.indiandentalacademy.com
  • The bite-block here can be 3 to 4 mm, which is usually beyond the postural vertical dimension in open-bite patients. In such cases a stretch reflex is elicited from the closing muscles that enhances the depressing action on the buccal segments and helps close the anterior open bite. www.indiandentalacademy.com
  • Activator 1. The bite is opened 4 to 5 mm to develop a sufficient elastic depressing force and load the molar that are in premature contact. 2. Properly constructed activators that follow this principle can influence the vertical growth pattern in these cases. www.indiandentalacademy.com
  • To “close the V” between upper and lower dental arches by depressing the posterior maxillary segments with the activator in a manner analogous to that of orthognathic surgery www.indiandentalacademy.com
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  • Bionator 1. Used to inhibit abnormal posture and function of the tongue. 2. The construction bite is as low as possible, but a slight opening allows the interposition of posterior acrylic bite blocks for the posterior teeth, to prevent their extrusion. 3. To inhibit tongue movements, the acrylic portion of the lower lingual part extends into the upper incisor region as a lingual shield. Closing the anterior space without touching the upper www.indiandentalacademy.com teeth.
  • 4. The palatal bar has the same configuration as the standard bionator, with the goal of moving the tongue into a more posterior or caudal position. www.indiandentalacademy.com
  • 5. The labial bow differs from the standard appliance, that the wire runs approximately between the incisal edges of the upper and lower incisors. www.indiandentalacademy.com
  • 6. The labial part of the bow is placed at the height of correct lip closure thus stimulating, the lips to achieve a competent seal and relationship. The vertical strain on the lips tends to encourage the extrusive movement of the incisors, after eliminating the adverse tongue pressures. www.indiandentalacademy.com
  • FRANKLE IV The working principle of the FR in establishing the mandibular forward rotation with the posterior edges of the buccal shields as a rotational center. Anteriorly, the mandible is raised by the force of the anterior vertical muscle chain being strengthened by lip seal exercises. www.indiandentalacademy.com
  • 1. Normally, anterior open bite problems show protracted tongue posture with incompetence of lips. The tongue tooth contact replaces the lip seal during deglutition to create negative atmospheric pressure. 2. FR IV along with lip exercises cause lip contact, reducing tongue protrusion and cause the tongue to move back into its normally raised position in proximity with palate, during deglutition. www.indiandentalacademy.com
  • TWIN BLOCK • Maintain occlusal contact to intrude the posterior teeth www.indiandentalacademy.com
  • PITFALLS • Do not allow the second molars to over erupt • Extend occlusal cover or occlusal rests distally to second molars. www.indiandentalacademy.com
  • • Do not trim the upper block in open bite cases. • This will allow the lower molars to erupt and again popping the bite open. www.indiandentalacademy.com
  • BIOMECHANICS OF HEAD GEAR www.indiandentalacademy.com
  • Centers of resistance in midfacial complex. 1. Alveolar process. 2. Maxilla. www.indiandentalacademy.com
  • Direction of force passes behind both alveolar and skeletal centers of resistance, producing clockwise rotation of maxilla and maxillary dentition. www.indiandentalacademy.com
  • Direction of force passes between alveolar and skeletal centers of resistance, producing clockwise rotation of maxilla and counterclockwise rotation of maxillary dentition. www.indiandentalacademy.com
  • Direction of force passes above both alveolar and skeletal centers of resistance, producing counterclockwise rotation of maxilla and maxillary dentition. www.indiandentalacademy.com
  • Lloyd E Pearson Describes seven different procedures for treatment of open bite with backward rotating mandible www.indiandentalacademy.com
  • OCCIPITAL HEADGEAR WITH CHIN CUP www.indiandentalacademy.com
  • 1. In the mixed dentition open-bite patient we could intrude the upper first permanent molars and then remove the remaining deciduous teeth, permitting open-bite closure. 2. occipital headgear with a transpalatal arch to control the inclination of the molars as they are intruded. 3. After the molars have been intruded perhaps 3 mm the deciduous teeth are removed, the mandible is hinged closed, and the anterior open-bite is closed. www.indiandentalacademy.com
  • 4. The lower molars will often tend to extrude in this type of situation. Unless mechanics are designed to control their eruption. 5. An addition of a vertical pull-chin cup to the occipital headgear and transpalatal arch would intrude the upper molars, while preventing the eruption of the lower molars. 6. As the open bite closes the mandible hinges upward, reducing the height of the lower face. www.indiandentalacademy.com
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  • Extraction of first premolars and use a vertical pull-chin cup www.indiandentalacademy.com
  • 1. Extraction of first premolars and use a vertical pull-chin cup with (16 ounces of forces) 2. This can close the mandibular plane angle, reduce the lower facial height and close anterior open bites. 3. Approximately 40 of closure of the mandibular plane angle was found in his study. www.indiandentalacademy.com
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  • possible mechanisms of action at work a) maxillary sutures are pressure sensitive and some intrusion of the maxilla could occur. b) The posterior teeth tend to move forward mesially. c) A retardation of eruption of the posterior teeth. www.indiandentalacademy.com
  • Mandibular bite- block therapy www.indiandentalacademy.com
  • 1. Mandibular bite- block therapy, augmented with vertical pull-chin cup therapy, can produce a favorable holding of the vertical height throughout the growth period, intrusion of posterior teeth, The hinging of the mandibular plane in a counterclockwise direction and closure of anterior open bites. www.indiandentalacademy.com
  • AFTER CORRECTION www.indiandentalacademy.com
  • Magnetic bite blocks. www.indiandentalacademy.com
  • 1. Magnetic bite blocks. 2. Although we get rapid results, two difficulties arise with bite blocks a. Extreme mouth opening which is difficult to tolerate the appliance by the patient. b. lateral movement of the mandible, that can cause some temporomandibualr joint strain. www.indiandentalacademy.com
  • MAGNETIC BITE BLOCKS www.indiandentalacademy.com
  • MAGNETIC BITE BLOCKS www.indiandentalacademy.com
  • MAGNETIC BITE BLOCKS www.indiandentalacademy.com
  • vertical reduction genioplasty. www.indiandentalacademy.com
  • 1. One advantage, is that it does not involve the temporomandibular joints, 2. It can be done after non-surgical treatment as an adjunct to bring the chin up and forward, to improve facial balance, and to achieve competency www.indiandentalacademy.com
  • The Extrusion Arch www.indiandentalacademy.com
  • 1. The extrusion arch is a term coined to describe the reverse action of already existing and well established intrusion arch. 2. Wire used is  16 x 22 SS or 17 X25 TMA with 900 offset bend at the molars. www.indiandentalacademy.com
  • Mode Of Action AT THE MOLAR:1. A second order couple is generated at the molar with crown tipping mesially and root tipping distally. 2. The equilibrium is achieved because the anterior end of the wire extrudes the incisors and posterior end intrudes the molars. 3. Relatively very minimal buccal flaring of the molar is seen. www.indiandentalacademy.com
  • MODE OF ACTION AT MOLAR www.indiandentalacademy.com
  • MODE OF ACTION AT MOLAR www.indiandentalacademy.com
  • PROXIMAL VEIW www.indiandentalacademy.com
  • • AT THE INCISORS:• Extrusion can involve single teeth or group of teeth. • When a group of teeth are to be extruded ,a segment of heavy arch wire may be used in the brackets of the anterior teeth, and the teeth are extruded as if they were one big tooth. • Whether the extrusion arch is tied segmentally or to continuous arch wire or placed directly into the brackets the effect is the same www.indiandentalacademy.com
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  • Low transpalatal arch 1. It is considered that the transpalatal bar interferes with the normal vertical descent of the upper molars, and therefore retards maxillary vertical alveolar development. www.indiandentalacademy.com
  • 2. It is believed that, tongue pressure against the transpalatal arch during swallowing, especially when the transpalatal arch is placed low in the palate, will inhibit maxillary alveolar vertical growth. www.indiandentalacademy.com
  • Low Mandibular Lip Bumper 1. Cetlin and Hoeve advocated the use of a lip bumper for the development of the lower dental arch. 2. They suggested that if the lip bumper were adjusted low, the cheek and lip mucosa would rest above the appliance, and this will inhibit vertical mandibular molar dentoalveolar development. www.indiandentalacademy.com
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  • 3. But there is no further explanation or evidence that a lower lip bumper can be used to prevent eruption of the mandibular molar teeth. www.indiandentalacademy.com
  • Wedge Principle Coupled With The Extraction Of Teeth Two major approaches of applying the wedge principle by extraction of teeth to control the vertical dimensions. 1.Loss of posterior anchorage so that the anchor teeth move mesially and are located farther anteriorly in the arch in an area of greater vertical dimension. 2. Extraction of first or second molars in both arches to decrease the posterior dentoalveolar height. www.indiandentalacademy.com
  • Garlington and Logan found that enucleation of mandibular second premolars is beneficial,    To control the vertical dimension. Increased in forward rotation of the mandible. Significant decrease in lower anterior face height.  The criteria selection :a. b. c. d. Minimal lower arch discrepancy (6 to 10mm). A mandibular plane angle greater than 380. A hyperdivergent skeletal pattern. Increased lower anterior facial height. www.indiandentalacademy.com
  •  Pearson stated that after the extraction of premolar teeth, there is some mesial drift of the posterior teeth (out of the wedge) and this permits the mandible to hinge closed. www.indiandentalacademy.com
  • High Angle Begg Cases 1. In high angle begg cases we avoid class II elastics to avoid open bite and accentuation of present class II . 2. We give mild class I elastics in such cases. www.indiandentalacademy.com
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  • Bracket Position 1. The placement point for incisor brackets may vary in cases of infraocclusion. 2. In cases of open bite, placing anterior brackets I mm more towards the gingival side. www.indiandentalacademy.com
  • Triangle Elastics 1. Triangle elastics aid in the improvement of class I cuspid intercuspation and increasing the overbite relationship anteriorly by closing open bites in the range of 0.5 to 1.5 mm. 2. They extend from the upper cuspid to the lower cuspid and first bicuspid teeth. www.indiandentalacademy.com
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  • Anterior Vertical Elastics  Class II orientation.  Class III orientation www.indiandentalacademy.com
  • Avoid Intermaxillary Elastics 1. Intermaxillary elastics from the posterior teeth have a vertical force vector which extrudes these teeth and can further open the posterior vertical dimension. 2. Class II elastics from 6 - 6 should not be utilized until these teeth are well anchored in buccal cortical bone . www.indiandentalacademy.com
  • How To Use Class II Or Class III Elastics 1. If class II or III elastics are required, they should be attached posteriorly to premolars rather than molars. 2. These ‘short elastics minimize the extrusive effect on the back of the arch www.indiandentalacademy.com
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  • ACTIVE VERTICAL CORRECTOR 1. AVC is a simple removable or fixed orthodontic appliance that intrudes the posterior teeth of both the maxilla and mandible by reciprocal forces. www.indiandentalacademy.com
  • Active vertical corrector www.indiandentalacademy.com
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  • 3. By effective intrusion of posterior teeth, the mandible is allowed to rotate in upward and forward directions. 4. The uniqueness of this appliance is that, it corrects anterior open bite problems by actually reducing anterior facial height. 5. Problems formerly thought to require orthognathic surgery, can now be treated successfully with AVC. www.indiandentalacademy.com
  • Method of Action :1. Force system -- generated by repelling magnets, 2. AVC is considered superior to a static bite block appliance energized only by the intermittent force from the muscles of mastication. 3. The constant force system of the AVC results in greater rapidity of tooth movement. www.indiandentalacademy.com
  • Multiloop Edgewise Arch Wire 1. Multiloop Edgewise Arch Wire was developed by Kim to achieve these goals :A, Correcting the inclination of the occlusal planes. B, Aligning the maxillary incisors relative to the lip line. C, Uprighting the axial inclinations of the posterior teeth. www.indiandentalacademy.com
  • 1. The MEAW contains horizontal and vertical loops fabricated from a 16 x 22 ss wire in an L shape fashion 2. The vertical loops act as a break between the teeth, lowers the load deflection rate and provides horizontal control. 3. The horizontal loops further reduces the load deflection rate and provides vertical control. www.indiandentalacademy.com
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  • 4. Typical tip back bends of 3-5degrees are given on each tooth. 5. Elastics are placed between the loops that lie mesial to opposing cuspids. 6. Recommended elastic size is 3/16 inch heavy, with a force approximately 50 gms when the jaw is closed. www.indiandentalacademy.com
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  •  KIMS technique was later modified by AYHAN ENACAR et.al, using 16 x 22 reverse curve NiTi arch wires with heavy intermaxillary elastics applied in the canine region www.indiandentalacademy.com
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  • Skeletal Anchorage System 1. Skeletal anchorage system was developed for tooth movements. 2. SAS consists of titanium miniplates, that are temporarily implanted in the maxilla or the mandible as an immobile anchorage. 3. These miniplates are fixed at the buccal cortical bone around the apical regions of the lower first and second molars on both the sides. www.indiandentalacademy.com
  • 4. Elastic threads are used as a source of orthodontic force to reduce excessive molar height. 5. The lower molars were intruded about 3 to 5 mm, and open-bite was significantly improved with little if any extrusion of the lower incisors, with counter clockwise rotation of the occlusal plane . www.indiandentalacademy.com
  •  SAS is an effective adjunctive biomechanical procedure for correction of skeletal open-bite malocclusion with out unfavorable side-effect. www.indiandentalacademy.com
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  • Conclusion Surgical management: www.indiandentalacademy.com
  • • One method of surgical correction is to extract second and/or third molars if they are the only source of centric contacts. • Glossectomies have been used to correct open bite problems associated with abnormal tongue habits. Their effectiveness in closing anterior or posterior open bite problems has not been substantiated. www.indiandentalacademy.com
  • • Surgical procedures to improve the patency of the airway must be undertaken with caution. Documenting the amount and location of the obstruction is a prerequisite. • In many cases, a more conservative medical approach may serve the same purpose when the obstruction is related to allergies www.indiandentalacademy.com
  • • This is especially important because it is recognized that a reduction in tonsilar and adenoid tissue occurs near adolescence, and other children appear to "outgrow" certain allergies. • Severe skeletal open bites in patients who are not growing are often treated by combined orthodonticsurgical approach. • Superior repositioning of the maxilla, via total or segmental maxillary osteotomies, is indicated in skeletal open bite patients with excess vertical maxillary growth. www.indiandentalacademy.com
  • • Maxillary impaction allows forward and upward rotation of the mandible, therefore decreasing the lower face height and eliminating anterior open bite. • This upward and forward autorotation often makes mandibular reduction or reduction genioplasty necessary as well. • Superior repositioning of the maxilla is one of the most stable orthognathic surgical procedures. www.indiandentalacademy.com
  • conclusion The treatment of open bite remains a challenge to the clinician, and careful diagnosis and timely intervention will improve the success of treating this malocclusion. www.indiandentalacademy.com
  • REFERENCES 1. Subtelny, J. D.: Open-bite: Diagnosis and treatment, Am.J.orthod. 42; 337, 1964. 2. Hellman, M.: Open bite, Am J. orthodont. 17: 421, 1931. 3. Robert J Issacson, Closing anterior open bite :the extrusion arch. Seminars in orthodontics. 7.34 – 41 .2001 4. Vertical Control with a Headgear- Activator CombinationCLAUDE CHABRE, DCD, DSO JCO 1990 OCT 618 - 624 www.indiandentalacademy.com
  • DOUBTS www.indiandentalacademy.com
  • Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com