Open bite (2) /certified fixed orthodontic courses by Indian dental academy


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Open bite (2) /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. INTRODUCTION Open bite is a condition or rather a malocclusion wherein there is a lack of overlap between the maxillary and mandibular dentition. It can also be called, the failure of tooth or teeth to meet its or their antagonists in the opposite arch. Open bite is a malocclusion in the vertical plane but may be either anterior of posterior or even both. Open bite causes significant problems such as: Difficulty is speech (Dysphonia) TMJ disorders Functional Imbalance Bad Aesthetics Alteration of Incisal guidance Reduction of normal functional activity (Mastication) The main features seen in open bite can be Increased lower facial height Clockwise rotation of the mandible Extrusion of
  3. 3. Hence, management of open bite should aim at striking a balance between the soft- tissues and the dento- alveolar and skeletal structures. So far various techniques have been tried both successfully and unsuccessfully, both surgically and orthodontically ( Even a combination of both), but Relapse, a thorn in the blood and sweat of any clinician has hampered as well as showed us the path to proper management. This seminar reviews the many aspects of such varied management paths of open bite.
  4. 4. CLASSIFICATION OPEN BITE IS CLASSIFIED 1.On the basis of region involved Anterior open bite Posterior open bite 2.On the basis of etiologic factors Skeletal open bite Dental open bite 3.On the clinical basis Simple open Bite (Confined to the teeth & alveolus process) Complex or Skeletal Open bite ( Based on primary vertical skeletal dysplasias) Compound Open Bite (or) Infantile Open Bite (Completely open including molass) Iatrogenic Open Bite (Consequence of either orthodonti or surgical theraphy) 4.On the basis of molar relationship Class I open bite Class II open bite Class III open
  5. 5. ETIOLOGY The Etiological factors of open can be grouped as 1. Epigenetics factors 2. Environment factors (or) can be grouped as 1. Disturbances in the eruption of teeth and alveloar growth (eg. Anylosed teeth) 2. Mechanical interference with emption and alvelor growth (eg. Thumb or digit sucking habit) 3. Vertical skeletal dysplastias.
  6. 6. EPIGENETIC FACTORS Posture, morphology and size of the (tongue) Skeletal growth pattern of the maxilla and mandible. Vertical relationship of the law bases. ENVIRONMENTAL FACTORS Abnormal function Improve respiration Thumb/digit sucking habit Tongue thrusting habit Mouth breathing habit. According to Leth Nielsen in 1991 vertical malocclusions develop as a result of interaction of diff etiologic factors, the most important one being mandibulars growth.
  7. 7. 1. There are two origins Dentoavelor Skeletal (Convex Profile, retrognathic mandible) 2. the growth of the mandibular condyle is directed posteriorly resulting in the increased lower facial height( “ Long face syndrome”) 3. Increase in anterior facial height due to the eruption of posterior teeth and the amount of sutural lowering of the maxilla.
  8. 8. ENVIRONMENTAL FACTORS THUMB/DIGIT SUCKING HABIT This is one of the most commonly seen habits in children. Till the age of 3 or 4 Years is quite normal. Beyond this age the habit becomes the cause of many a malocclusion. This habit has been due to various factors. 1. According to Dr. Sigmoid Freud, the child passes through various phases of physiological development of which the oral phase is seen in the 1st 3 Years of life. It is during this phase that the child has the tendency to place his fingers in the oral cavity and this act is normally for emotional security. 2. According to the oral Drive theory of Seans and Wise (1950) prolonged digit sucking lends to thumb sucking. 3. According to Benjamin‟s theory it is the rooting reflex that causes the movements of the infant‟s head and tongue towards anything touching its cheek, be it the mother‟s breast or a finger. This reflex disappears around 7 to 8 months of age. 4. Other factors are the physiological aspects such as, lack of parental love towards children and therefore the insecurity leading to the habit.
  9. 9. TONGUE THRUST HABIT The tongue is relatively large in the neonates, and is located in the forward suckling position for nursing. The tip of the tongue inserts through the anterior gum pad and assist in the anterior lip seal . This tongue position along with the coincident swallowing is termed Infantile/ Visceral swallow. With the eruption of the lower incisors the tongue starts to retreat and pattern of swallowing also changes to Adult mature Swallow. If the Visceral swallow persists well after the 4th Year of life, if is termed Tongue thrust (or) Retained Infantile Swallow.
  10. 10.
  11. 11. ETIOLOGY OF TONGUE THRUST 1. EPIGENETIC FACTORS: Specific anatomic or neuromusculars variations in the orofacial region can precipitate tongue thrust (eg) Hypertonic orbicularis oris activity. 2. LEARNED BEHAVIOUR: Improper bottle feeding, prolonged thumb sucking, prolonged Tonsillar and upper respiratory tract infections, prolonged duration of tendreness of gums ( or) teeth, can change the swallowing pattern, to avoid pressure on the tender areas. 3. MATURATIONAL FACTORS: The Infantile swallow changes to mature swallow once once the posteriors deciduous teeth bvegin erupting. Sometimes the maturation is delayed and thus Infantile swallow persists.
  12. 12. 4. MECHANICAL RESTRICTION: (a)Macroglossia, (b) Enlarged adenoids, predispose to tongue thrust habit. 5. NEUROLOGICAL DISTURBANCE: (a) Hyposensitive palate (b) moderate motor disability. 6. PSYHOGENIC FACTORS : Tongue thrust can occur as aresult of forced discontinuation of other habits like thumb sucking. Bohr & Holt classified tongue thrust activity into: I - Tongue thrust without deformation II - Tongue thrust causing anterior deformation (Anterior open bite termed simple open bite) III - Tongue thrust causing buccal segment deformation with a posterior open bite (Lateral tongue thrust) IV - Combined tongue thrust, causing both anterior and posterior open bite (Complex open bite)
  13. 13. SIMPLE TONGUE THRUST Normal tooth contact during swallowing Presence of anterior open bite Good intercuspation of Teeth Tongue is thrust forward during swallowing to establish anterior lip seal Abnormal Mental is activity. COMPLEX TONGUE THRUST Teeth are apart during swallowing Anterior open bite an be either Diffuse (or) Absent Absence of temporalis constriction during swallowing Contraction of circum-oral muscles during swallowing Occlusion of teeth may be poor.
  14. 14. MOUTH BREATING HABIT The mode of respiration influences the posture of the Jaws, the Tongue and to a lesser extent, the Head. Hence, mouth breathing can result in altered Jaw and Tongue posture which could alter the orificial equilibrium thereby leading to malocclusion. CLASSIFICATION OF MOUTH BREATHERS OBSTRUCTIVE HABITUAL ANATOMIC
  15. 15. CLINICAL FEATURES OF MOUTH BREATHERS Long and Narrow Face Narrow Nose and Nasal Passage Short and Faccid upper lip Contracted Maxillary Arch Flaring of the Incisors Anterior marginal gingivitis due to the drying up of the gingiva Lack of tonicity of the short upper lip. So, there is a decrease in the labial support to the max anterior teeth leading to labial flaring and open bite.
  16. 16. DIAGNOSIS CLINICAL 1.Overjet combined with an open bite less than 1mm- Pseudo open bite. 2.Open bite with more than 1 mm of space between opposing incisors, and with posterior teeth in occlusion - Simple open bite. 3.Open bite extending from the Pre- molar (or) deciduous molar on one side to the corresponding teeth on the other side – complex open bite. 4.Compound (or) infantile open bite is completely open including molars. 5.Latrogenic open bite is the consequences of orthodontic/ surgical theraphy. a. An Open activator with a high construction bite causes tongue thrust habit and resultant anterior open bite. Intrusion of posterior teeth creates a posterior open bite, especially in the deciduous molar areas. b. Expansion treatment: buccal segments tip buccally along with elongation of the lingual cusp. This creates a prematurity and open the bite. c. In distalization of the max. 1st molar with extras- oral forces, the molars are often tipped downwards and back, elongating the mesial cups. This creates open bite and therefore excesive anterior facial height.
  17. 17. CEPHALOMETRIC DENTOALVELOR OPEN BITE Depends on the extent of the eruption of teeth, Supra – occlusion of molars and infra – occlusion of incisors. IN VERTICAL GROWTH PATTERN: Protrusion of upper anteriors and lingual inclination of lower incisors. IN HORIZONTAL GROWTH PATTERN: Tongue posture and tongue thrust cause proclination of upper and lower incisors. LATERAL OPEN BITE: Is purely dentoaveolar with infraocclusion of molars. Etiology is cheek sucking, lateral tongue thrust and lateral tongue posture in the postural rest position.
  18. 18. II SKELETAL OPEN BITE Presents excessive anteriors facial height particulariy the lower third, but the posterior facial height is short. .MANDIBULAR BASE: Is usually normal . Antegonial notching is often present, symphysis is long and narrow, ramus is short, gonial angle is increased and the growth pattern is vertical. .MAXIALLY BASE: VERTICAL GROWTH PATTERN: Upward tipping of the forward end of the maxillary base. Downward tipping of the posterior end of the max. base.
  19. 19. HORIZONTAL GROWTH PATTERN Upward and forward tipping of the maxillary bone. According to David & Richard Smith (1988) in their study of lateral cephalograms of 250 pts. In the age group of 10-14 yrs, certain are useful in the diagnosis of open bite tendency. Steep mandibulars angle. SN : MP angle - 40 (or) greater OP : MP angle - 22 (or) greater PP : MP angle - 32 (or) greater PFH/AFH ratio - 58% (or) less UFH/LFH ration - 0.700 (or) less According to Eills and Mcnamara (1984)in their study of 302 adults with class III maloccusion to determine the frequency of open bite – 30% of the adult class III pts. Exhibited open bite.
  20. 20. Those who exhibited open bite had the following features. .Increased mandibulars plane angle. .Increased gonial angle. .Downward and backward positioning of the mandibulars ramus. .Increased mandibulars length .Decreased mandibulars protrusion .Posterior max. and mand. Dentoaveolar hyperplasia. .Anterior max. dentoaveolar hyperplasia. .Increase in total anterior facial height and lower ant. Facial height with no difference in the cranial base.
  21. 21. According to Thomas. J. Cangialosi (1984) in his study comparing the lateral cephalograms of 60 normal persons and 60 persons with open – bite the features exhibited by the open – bite were similar to the studies, but in addition. 1. In skeletal open , bite the anterior teeth were either normally erupted or over – erupted 2. In dento- alveolar open bite, the anterior teeth were under- erupted due to the presence of certain interference‟s such as tongue thrusting or thumb sucking. MANAGEMENT Treatment planning is based on the etiology and localization of malocclusion. IN DENTO-LALVEOLAR OPEN BITE CASES Habit control and elimination of abnormal perioral muscle function are the prime therapeutic approaches.
  22. 22. IN SKELETAL OPEN BITE CASES a) During active growth phase Redirection of growth is a possibility. b) After active growth phase Extraction and orthodontic tooth movement (or) orthognathic surgery. IN COMBINED DENTOALVEOLAR AND SKELETAL OPEN BITE CASES A combined therapeutic approach is needed to achieve better results. Management of open bite can be majorly divided into : 1) ORTHODONTIC CORRECTION 2) SURGICAL CORRECTION I. ORTHODONTIC CORRECTION 1. HABIT BREAKING APPLIANCES A) TONGUE CRIB B) REMINDER APPLIANCE C) VESTIBULAR SCREEN D) OTHER METHODS
  24. 24. HABIT BREAKING APPLIANCES TONGUE CRIB This can be either removable or fixed, and can be used to treat both anterior and posterior open bite cases. In anterior open bite : The appliance consists of a palatal acrylic plate with a horse-shoe shaped wire crib and labial bow. The crib is placed 3 to 4 mm lingual to the upper incisors. The crib can also be placed at the gingival third as to stimulate the eruption of the anterior teeth. The acrylic can cover the occlusal surfaces of the upper molars to prevent this eruption.
  25. 25. VESTIBULAR SCREEN It is a screening appliance used to correct the mouth breathing habit. It consists of an acrylic shieled extending vertically from the upper labial fold to the lower labial fold and horizontally from the distal margin of the last enpted molar on one side to that on the other side. It is constructed on a registered edge to edge bite. It is effective in eliminating mouth-breathing, abnormal sucking habits and lip dysfunction, by achieving a proper lip seal. The lip seal influences the posture of the tongue thereby leading to maturation of the deglutition cycle and creates a somatic swallow pattern. The appliance is usually worn at night and for 2-3 hours during the daytime, everyday. Lip exercises should also be advocated along with the appliance for achievement of proper lip seal.
  26. 26. Modifications of the vestibular screen are : 1. Vestibular screen with Breathing holes. 2. Vestibular screen with tongue crib. OTHER METHODS PSYCHOOGICAL APPROACH 1) Parent (counselling) 2) Patient counselling and motivation to discontinue the habit. 3) Dunlops „Beta Hypothesis‟ according to which, the best way to break a habit is by its conscious purposeful repetition. The child is asked to sit in front of a mirror and observe himself/herself as he/she indulges in the habit.
  27. 27. REMAINDER APPLIANCE This appliance is used to correct anterior open bites caused by tongue thrusting thumb or finger sucking. It consists of an acrylic plate in which a ball (plastic) or a wire mesh is embedded. Whenever the child goes back to the habit, the appliance reminds him/her not to do so. CHEMICAL APPROACH The use of a bitter tasting or foul smelling preparation placed on the thumb or digit to make the habit distasteful. 1) Pepper dissolved in a volatile medium and 2) Quinine Are some of the preparations
  28. 28. MYOFUNCTIONAL APPLIANCES a) THE ACTIVATOR The activator was devised by Viggo Anderson in 1908. It used to correct Anterior open Bite Cases. This is a loosely fitted appliance. It increases the salivary secretion swallowing activity, muscle contraction and the amount of intermittent force applied to the tooth structure. The forward positioning of the mandible s not necessary. The dentoalveolar open-bite can be corrected by selective trimming of the acrylic. Intrusions f the molars is achieved by loading only the cusps and by grinding acrylic in the fossas and fissures. Extrusion of incisors is achieved by loading their lingual surfaces, above the area of greatest concavity, and also by placing the active labial bow above the area of greatest convexity (the gingival third). In surgical open bite cases the activator is used for impaction of the posterior segments, thereby allowing autorotation of the mandible.
  29. 29. The Elastic activator similar to Stockfish‟s Kinetor, a modification of the Anderson‟s Activator has been used in the treatment of anterior open bite by. A Stellzig, Steegmayer – Gilde and E.K. Basdra in 1999. The intermaxillary acrylic of the lateral occlusal zones is replaced by elastic rubber tubes. By stimulating orthopaedic gymnastics, the E.activator intrudes upper and lower posterior teeth. An appreciable counter clock-wise rotation of the mandible was accomplished. Some of the advantages are : 1. Relatively simple fabrication. 2. Uncomplicated replacement of the elastic rubber tubes. 3. Enhancement of compliance due to the chewing gum (Orthopaedic gymnastics) effect. 4. Possibility of early treatment, even in mixed dentition phase.
  30. 30. THE BIONATOR The Bionator was introduced by Balters in 1956. He stated that the equilibrium between the tongue and the circum-oral muscles is responsible for the shape of the dental arches and intercuspation. The functional space of the tongue is essential for the normal development of the orofacial system. Any change in position of the tongue leads to certain malocclusions such as Openbite. Winders, in 1958, stated that the tongue exerts 3 to 4 times the force that the buccal and labial musculature does on the dentition. The Open-bite bionator is used to inhibit abnormal posture and function of the tongue. The construction bite is as low as possible, but a slight opening allows the interposition of the posterior acrylic bite blocks to prevent extrusion of the posterior teeth. The palatal bar has the same configuration as in the Standard Bionator, with the function of moving the tongue into a more candal or posterior position. The labial bow should run bet‟n the incisal edges of the upper and lower incisors, and at the height or correct lip closure, thereby stimulating the lip of achieve a competent lip seal. The encourages the extrusion of the incisors.
  31. 31. THE FRANKEL FUNCTIONAL REGULATOR IV (FR IV) The FR was introduced by Rolf Frankel in 1966, and was aimed at establishing an artificial matrix that allows the muscles to exercise and adapt, by keeping away the buccinator mechanism and the orbicularis oris complex. The FR IV is used in the treatment of Skeletal Open bite and maxillary protrusion cases. It has 2 buccal shields, 2 lower lip pads, upper labial wire and four occlusal rests. The occlusal rests present on the maxillary permanent 1st molars and the deciduous 1st molars prevent the eruption of the posterior teeth. Lip seal exercises should be advocated along with the FR IV to achieve a proper lip seal. The FR-IV can be combined with the extra-oral chin cap therapy to close the bite by virtue of a positive depressing action on the buccal segments. KARUS suggested a modification of the FR-IV by adding lingual crib spurs to discourage anterior tongue posture and compensatory tongue function.
  32. 32. THE TWIN BLOCK APPLIANCE It was introduced by William .J. Clark in 1977. It consists of simple upper and lower bite blocks that engage on occlusal inclined places and modify them effectively. In treating patients with anterior open bite and increased lower facial height, the contact between the occlusal bite blocks and the posterior teeth should be maintained to prevent the eruption of the posterior teeth. Headgear tubest can be attached to the maxillary molars and a high pull traction can be applied to a modified face bow )Concorde face bow) to intrude them. Vertical elastics can also be used along with the twin block as demonstrated by Mills. The elastic are applied intra orally, and pass from the upper arch to the lower arch in the premoalr region. Repelling rare earth magnets can also be used in the bite blocks to reduce the anterior open bite. A palatal spinner can be added to the upper appliance which is effective in controlling the anterior tongue thrust. JASPER JUMPER The Jasper Jumper was devised by J.J. Jasperin 1987 and was used to jump the bite in Class II div. I malocclusions. Robert. G. Cash in 1991 described the non-extraction Rx of an adult with a bilateral Class II with an open bite using a Jasper Jumper. He used the Jasper Jumper to distalize and intrude the maxillary molars, thereby correcting the open bite.
  33. 33. MULTILOOP EDGEWISE ARCHIWISE TECHNIQUE(MEAW) Young H.Kim in 1987 described the MEAW technique in correcting Anterior Open-bite. This technique is considering to be one of the more effective treatment modalities for anterior open-bite malocclusions as per the study conducted by Young Chang and Cheol Moon in 1999. The MEAW technique lowers the load deflection rate and allows the tooth to move independently. It used double edgewise brackets with 0.018 inch slots with an auxiliary vertical slot. The loops are L-shaped and consist on one vertical loop segment for horizontal control and one horizontal loop segment for vertical control. The amount of wire sued is 21/2 times more than ormal, and hence provides a ten-fold reduction in the load/deflection rate. The Arch-wire used is 0.016” x 0.22” rectangular SS wire and there are 5 loops on each side. The vertical loop components should be centered at the interproximal areas and the horizontal loop components should be directed mesially. Tip back bends are incorporated into the archwire last, according to the degree of axial inclination. The completed Maxillary MEAW shows a marked curve of Spee, and the Mandibular MEAW a marked reverse curve, thereby applying intrusive forces on the incisors further worsening the openbite. This is counteracted by using anterior vertical elastics worn full-time. The completed wire must be treated for several minutes in a furnace at about 900 F (475 C), to increase resiliency and stiffness. The wire is then polished in an acid bath. In addition, Kim says that, the extraction of second and third molars in open-bite cases offers a feasible diagnostic and therapeutic situation by eliminating the dynamic blocking effect and also most of the cortical bone that resists the uprighting of the molar mesial to it.
  34. 34. THE TIP-EDGE TECHNIQUE Kesling in 1986 designed the tip-edge brackets which ar dynamic in action and upright individual teeth easily and automatically. Kuniaki Miyajima and Tetsuo Lizuka in 1996 used Kim‟s MEAW Philosophy but employed Tip-edge brackets and anteriorly placed Class III elastics to correct a case of class III open bite malocclusion. UNIQUE CHARACTERISTICS OF THE TIP-EDGE BRACKETS .The archwire slot can become 0.028” when teeth are tipped distally and return back to 0.022” when uprighted. 1. The degree of final crown tipping is pre-determined. 2. Inter-bracket distance is 100% and hence loops are not required. 3. Tip-ede brackets through auxiliaries achieve the following effect with no-lops (a) uprighting (b) torquing (c) adjustment of occlusal plane (d) space gaining.
  35. 35. HEADGEARS AND ELASTICS Headgears have been used to correct open-bite through molar intrusion. Most of the authors advocate the elimination of the causative factors such as mouth-breathing, tongue thrusting, etc. before starting comprehensive treatment. Galletto in 1990, used posterior bite-blocks in conjunciton with high pull headgear and arch-wire mechanics to reduce the lower facial height through molar intrusion and upward and forward rotation of the mandible. Lucaine Closs and Kulbersh in 1996, used a high-pull headgear in combination with a bionator to treat a 10 year old female patient who presented with a skeletal open bite. Roy Sabri in 1998, used a high-pull headgear with class II and vertical elastics to achieve proper antero-posterior occlusal interdigitation in patients with class II div I malocclusion and ant. Open- bite.
  36. 36. BITE – BLOCKS AND HEADGEARS Hocevar et al. 1996, treated a patients with class II open bite malocclusion using daily clenching and chewing exercise with resilient posteriors bite- blocks for 13 months followed by: 1. Extraction of upper 1st premolars. 2. Placing a 0.22 inch appliance with 0.014 inch Australian SS archwires. 3. Reinstitution of hard acrylic posteriors biteplane. 4. Light class II elastics 5. Archwire size increased to 0.018 inch SS wire by 5th month of treatment. 6. Using a torquing auxilary for 10 months. 7. Using a J-hook anterior high – pull headgear for 2yrs 8. Using 0.021” x 0.16” SS ribbon arches for finishing
  37. 37. BITE - BLOCKS: Posteriors bite are used in the early treatment of skeletal open bite to produce a forward and upward mandibular rotation, by transmitting the masticatory muscle forces to the buccal dento-alveolar regions and preventing their vertical growth. Passive acrylic bite blocks act as functional appliances hinging open the mandible by approx. 3 to 4mm and maintaining pressure on the neuromuscular system supporting the mandible. Spring-loaded bite blcoks are activated from time to time and they supply additional force within the neuro muscular system besides the forces applied by the passive bite- blocks. Magnetic bite-blocks provide continuous pressure on the occlusal surface o the buccal teeth means of repelling magnets. (Dellinger).
  38. 38. MAGNETS Since the introductionof rare earth magnets such as Samarium Cobolt by Becker in 1970, their use in the field of Orthodontics has become increasingly popular. Eugene Dellinger in 1986 was the first to use them to correct anterior open-bite in his Active Vertical Corrector. The AVC consists of upper & lower bite blocks with Samarium Cobalt magnets in stainless steel cases embedded in them. The method of action is reciprocal intrusion of the maxillary& mandibular posterior teeth leading to the autorotation of the mandible, closure of the open-bite & reductiono f lower anterior facial height. Ali Darendeliler in 1995 used the MAD IV Magnetic Activator Device IV to correct anterior open-bite. The MAD IV consists of anterior attracting & posterior repelling magnets. It consists of removable upper & lower acrylic plates, each containing 3 cylindrical Neodymium magnets coated with stainless steel. The attracting force of the anterior magnet is 300 gm & the repelling force of the posterior magnets is also 300 gm. In the mixed & permanent dentition, the plats are retained mechanically but, in the late mixed dentition, modified Adams clasps & Torquing springs give added retention.
  39. 39. IMPLANTS Beth Prosterman et al. In 1995 described the use of implants for correction of open bite. They concluded that since osseo integrated titanium implants show remarkable resilience to pressure they can prevent extrusion of mandibular post. Teeth thereby preventing increase in ant. Facial height. They advocated the use of implants in conjunction with fixed appliances to correct ant. Open bite. TCA Viazis in 1993 described the Thumb sucking / tongue thrusting / tongue posturing correction appliances. The TCA consists of a palatal wire that is inserted in the upper lingual molar sheaths & carries over to the lower incisors ending 1-2 mm. Above the labial surface. The TCA prevents the habits by blocking the tongue from the ant. Teeth. The TCA should be worm for atleast 3 months.
  40. 40. SAS SKELETAL ANCHORAGE SYSTEM Mikako U,e,pro et al/ in 1999 described the Skeletal Anchorage System (SAS) for open bite correction. The SAS consists of a titanium mini plate implanted in the maxilla or mandible. The mini plates were fixed in the buccal aspect of a the bone sides Elastic threads were used as a source of orthodontic force for intrusion intrusion of 3-5 mm. Achieved with SAS. Advantages of SAS : No serious side effects Simplified treatment mechanics Shortent treament period Minimum discomfort Control of the level of occlusal plane. THERA SPOON Bennett et al. In 1999 described the efficacy of open bite treatment with Thera spoon. Compared to the Tongue crib where there is complete closure of ant. Open bite & significant extrusion of the incisors, the Thera spoon does not shown remarkable results.
  42. 42. SURGICAL CORRECTION Hulliten in 1849, was the first to surgically correct bite. Ant. Mand. Sub-apical Osteotomy. The present – day surgical techniques to correct open bite involves, Max. surgery for ant. Extrusion & post. Intrusion, and Mand. Surgery to elevate the incisor segment. The choice of the appropriate surgical technique requires careful diagnostic evaluation. ANTERIOR MAX. & MAND. SUB-APICAL OSEOTOMY INDICATIONS FOR MAXILLARY ASO A small bite with minimal tooth exposure, lip incompetency, good naso-labial angle & adequate lower ant. Facial height. An unaesthetic edentulous appearance due to concealed maxillary incisors. INDICATIONS FOR MAND. ASO Ant. Open bite due to reverse curve in the mandibular arch. Transverse max.mand. harmony & good aesthetic balance between upper lip & max ant. Teeth. After surgery the max & Mand. Ant. Segment are immobilised for 5-6 weeks. Relapse potential is very minimal.
  43. 43. KOLE MODIFICATION OF SUB-APICAL OSTEOTOMY INDICATIONS Mandibular prognathiam with ant. Open bite. Severe reverse curve Excessive chin height Functional post. Occlusion Satisfactory lip-tooth relationship & no transverse deficiency in maxilla. The principle disadvantage here relates unpredictable soft tissue profile changes & chin height changes. SAGITTAL SPLIT RAMUS OSTEOTOMY This surgery can be performed in both extraction & non-extraction cases. It is indicated in open-bite cases with severe mand. Deficiency or prognathism. It is usually done along with maxillary osteotomy to minimize relapse. It performed separately, posterior overcorrection with an interocclusal splint, supra-hyoid myotomy and cervical collar should be considered to prevent relapse.
  44. 44. LE FORT-I MAXILLARY OSTEOTOMY This surgery is indicated in open-bite cases with : High & constricted palatal vault. Lip incompetence High mand. Plane angle. Increased distance between the palatal root apices & the nasal floor. ADJUNCTIVE SURGICAL PROCEDURES Adjunctive surgical procedures have to be performed to combat, either a large tongue or a tongue with abnormal function which causes open- bite , or, even its recurrence. To correct True, Relative or Functional Macroglossia the following procedures are performed: 1. The “V” excision for partial glossectomy 2. Keyhole procedure for partial glossectomy 3. Deep lingual frenectomy.
  45. 45. 1.THE “V” EXCISION: A “V” shaped excision is made from the front of the tongue, lateral to the midline & extending posteriorly in nearly a striaght line, converging at the midline at about 4mm from the Circumvallate papillae. 2.THE KEYHOLE PROCEDURE: A keyhole shaped mass of muscle is excised when the tongue is too large in the molar area and the ant. Fourth is nearly normal. 3.DEEP LINGUAL FRENECTOMY: Deep lingual frenectomy with”Z” plasty is indicated in Ankyloglossia or Functional macroglossia where the tongue does not adapt after ortho. Or surgical treatment.
  46. 46. GENIOPLASTY: Fridrich et. Al. In 1997 described various Genioplasty strategies for Anterior facial vertical dysplasias. Different Types of Genioplasty: Sliding advancement genioplasty Genioplasty with parallel ostectomy Genioplasty with down graft Genioplasty with anteriorly tapred ostectomy Sliding seetback genioplasty Fridrich stated that failure to recognise vertical dysplasia of the mandible will lead to post- op mentails strain. He concluded that, in vertical dysplasias, genioplasty given good esthetics results with functional harmony.
  47. 47. TMJ CONSIDERATIONS: The status of the TMJ is of great importance before surgery, because the movements associated with surgery increase pressure in the joint until the muscles, soft tissues & dento- osseous structures readapt. Hence, if pre-existing TMJ disorders are carefully assessed and appropriately managed, the TMJ is stable after the surgery is performed.
  48. 48. RETENTION & RELAPSE The main etiological factors responsible for relapse after ortho correction are: Latent vertical growth of the face. The role of the tongue The main etiological factors responsible for the relapse after surgical correction are: Mandibulars musculature Incompletely understood biomechanical factors influencing the Elevators group & Suprahyoid group of muscles. The success of Treatment depends upon the ratio: Success = Magnitude of improvement ______________________ Magnitude of relapse
  49. 49. Wick Alexander stated that retention begins with Diagnosis & Treatment planning. “Begin with the end in mind” should be the philosophy of treatment. John Sheridan in 1997, described the Force Amplified System for corrected open- bite. It involves the use of conventional max. & mand. Cuspid to cuspid bonded lingual retainers, low- profile bonded lingual Caplin hooks and intraoral elastics. The retainers are bonded to each tooth to distribute the elastic forces. RETENTION AFTER SURGICAL CORRECTION Upper & lower border wiring of the mandile Steinmann pins to stabilize the maxilla Skeletal wire fixation(Cicumzygomatic & Circummandibular wires) Rigid fixation.
  50. 50. CONCLUSION In any field of dentistry, the dreaded loom of Relapse hangs over the dentist, and the Orthodontist and the Oral surgeon are the most vulnerable.They have come up with many answers to combat Relapse and ascertain Stability in their respective fields, but have met with negligible success. The recent trend of combining Orthodontic and Surgical methods to manage Open bite, which is a multi- factorial problem, has had enough success for Orthodontists and Oral Surgeons to be proud. Let‟s hope this Combination asserts enough Stability in the management to Open bite and similar condition.
  51. 51.