management of vertical maxillary excess /certified fixed orthodontic courses by Indian dental academy


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management of vertical maxillary excess /certified fixed orthodontic courses by Indian dental academy

  2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education
  3. 3. CONTENTS Mixed dentition treatment approach 1. Habit breaking appliance 2. Myotherapy A. Appliance B. Exercise 3. Functional appliances 4. Orthodontic appliance a. High pull HG b. Vertical chin cup c. Bite block d. Bonded RPE and vertical chin cup e. Magnetic activator device IV f.. AVC Permanent dentition treatment approach Dental open bite – Draw bridge effect (extraction of 1st bicuspid and retraction of anterior ) Skeletal open bite – A. Questionable growth— MEAW, Bite block, Skeletal anchorage, Bite block, repelling magnet, spring loaded). B. Surgical
  4. 4. • Introduction: Vertical malocclusion results from interplay of many etiological factors during growth period. These growth factors include growth of maxilla and mandible, variations in rate of growth in both the maxillary suture and mandibular condyles and dentoalveolar development with the eruption of the teeth. The potential etiological factors other than unfavorable growth patterns are, digit sucking habits, lymphatic tissue, tongue and orofacial muscle activity, heredity, orofacial functional matrices, jaw posture, head position. • The correction of vertical dysplasia are more difficult and more challenging than the correction of anterior- posterior, transverse malocclusions, hence the need for proper diagnosis and treatment plan
  5. 5. • Depending on the growth status of an individual treatment mechanics to be considered. • Deciduous dentition • Mixed dentition—Orthopedic • Orthodontic approach • Myotherapy • Habit breaking appliance • Permanent dentition : • Dental open bite • Skeletal open bite • A. Questionable growth • B. Surgical
  6. 6. • Issacson (1971) and Worms et al believed that spontaneous correction occurs in upto 80% of mixed dentition open bite cases and suggested that interceptive treatment is of little or no value. Reasoned that Tongue thrust is the main mode of swallowing upto age of 10 yrs. After that age, marked decrease in this form of swallowing account for spontaneous correction. • Parker &Johnson (1993) believed that interceptive treatment should be carried out for the cases that do not self correct. • INTERCEPTIVE TREATMENT • 1) Altering mode of breathing. • 2) Myotherapy. • 3) Habit breaking appliance • 4) Functional orthopedic appliance • 5) Orthodontic appliance.
  7. 7. • ALTERING MODE OF BREATHING • Altering the mouth open breathing to mouth closed breathing respond to reduction in lower face height at an early age. • According to Linder - Aronson, Adenoidectomy must be performed at an early age • (6-8 yrs) to provide a post surgical growth. • Study by Linder-Aronson and Behltet on postadenoidectomy and post tonsillectomy for 5 yrs observation period, established hypothesis that change in mouth open breathing to mouth closed breathing reverses the symptoms.
  8. 8. • Adenoidectomy Reduced size of adenoids Increased nasal flow Change to nose breathing Tongue position and mandibular position raised Lips closed breathing • Increase width of maxillary arch • Increase inclination of maxillary and mandibular incisors. • Increase in depth of bony nasopharynx • Decrease lower anterior facial height.
  9. 9. • Contra Indication of Adenoidectomy • On clinical examination, if palate is observed to have a bifid uvula/ deep oropharynx which indicates palatopharyngeal insufficiency. Adenoidectomy is contraindicated in such cases because of the potential for creating hyper nasality/cleft palate speech.
  10. 10. • Study by WOODSIDE & HENRIKSON LATER, Confirms this hypothesis and reasoned that Change in incisor inclination due to • (a) Change in tongue and orbicularis oris pressure. • (b) According to Lowe et al. correlated between genioglossus muscle and overbite. They suggested that change in tongue postural activity exerts definite pressure on incisor tooth. • Decreased LAFH, due to autorotation and horizontal mandibular growth.
  11. 11. • MYOTHERAPY • According to Profitt myofunctional therapy is defined as any therapeutic approach that involves muscle exercises with appliance or not. He consider myofunctional therapy as an adjunct to orthodontic appliance therapy in patient's age 10 or older i.e. late mixed dentition or early permanent dentition with a treatment objective to alter resting tongue and lip posture. This approach takes advantage of function to adapt to form. Myofunctional therapy is not preventive measure. • Also A.P.Roger in 1906 suggested that muscle exercise be used as an adjunct tomechanical correction of malocclusion. • The principal purpose of myotherapy is creation of normal orofacial muscular function to aid growth and development of normal occlusion.
  12. 12. • Exercises • 1) Ask the patient to hold a piece of paper between the lips. • 2) Ask the patient to sip water and hold on tongue with the tip pressed hard against the spot, the patient swallows with biting teeth firmly together. • 3) The patient is instructed to practice correct swallowing pattern by placing the tip of tongue on the palate, close teeth, close lips and swallow with tongue in that position. After the new swallowing pattern learned on the conscious level, it is necessary to reinforce in subconsciously. Flat, sugarless fruit drops are used to reinforce subconsciously by asking the patient to hold fruit drops against the palate. • 4) Place the elastics in tip and dorsum of the tongue and ask the child to swallow. Child tends to hold the elastics by placing against palate in proper position. • 5) Thompson--- Ask the patient to squeeze teeth together as hard as possible for 15 secs, relax and repeat three times for total of one minute. This exercise should be done five times a day (Clenching exercises).
  13. 13. • • • • • • Myoappliance: 1. Lingual pearl 2. Scorpion appliance 3. Blue grass appliance MYO APLIANCE 1. Lingual Pearl (Jco -98,may) used when tongue is the only etiology factor responsible for malocclusion. Pearl, elevates the tongue against the palate. In most cases, the tongue will adapt to the new position of the dentition. However, to control the muscular forces of the tongue during space closing or bite opening, the Lingual Pearl can be attached to a transpalatal bar or a quad-helix • A Lingual Pearl can be used in the final phase of treatment of an open-bite case where vertical elastics were used to close the bite. Lingual retraining will help prevent reopening of spaces and subsequent relapse.
  14. 14. • When used during finishing, the pearl can be bonded to the palatal sides of the premolars and remain there until tongue movement has been normalized. • A surgical patient is also a good candidate for the pearl, given the abrupt change in the amount of space available for the tongue --especially in an open-bite case.
  15. 15. Scorpion appliance 2. Scorpion appliance Tongue crib prohibits protrusive tongue activity during swallowing. However, the tongue may reach under the appliance and over the lower incisors to protrude anteriorly. The Scorpion is designed to provide a prohibitive response to low anterior tongue posturing during swallowing.Tongue movement is controlled in the vertical plane and is not limited anteroposteriorly.
  16. 16. • If the tongue ventures between the appliance and the lower incisors, the tongue is met by the spur. The next venture will then be above the spur and through the anterior "ring" of the appliance. The ring directs the tongue to the normal dentoalveolar contact. • This design can also be used on Hawley retainers during interceptive or retention therapy.
  17. 17. • HABIT BREAKING APPLIANCE • • • • Tongue crib appliance Vestibular screen with breathing holes. Bluegrass appliance. Pearl appliance
  18. 18. • 1. Tongue crib appliance • Act as inhibitory appliance, inhibits the thumb sucking habit and tongue thrusting habit. The appliance for the anterior open bite patients consists of a palatal acrylic plate with horse shoe-shaped wire crib and labial bow. The length of the crib is usually 6-12 mm and placed 3 to 4mm lingual to the upper incisors. If the crib is placed at the gingival third, a proper adjustment can stimulate the eruption of the anterior teeth, thereby useful in the correction of the open bite. The acrylic can also be interposed between the teeth, covering the occlusal surfaces of the upper molars, in order to prevent the eruption of the posterior teeth.
  19. 19. • Posterior tongue crib appliances are used to correct the unilateral (or) bilateral open bite, by preventing the lateral thrust of the tongue. • Fixed tongue crib is also used for the correction of open bite by banding to the abutment teeth [molars]. • Haryett reported that cribs were very effective in stopping the habit when they were worn for 10 months. • Cooper & Skewida reported that tongue crib appliance alone is not effective in closure of open bite.
  20. 20. • Vestibular screening appliance • This appliance extends into the vestibular sulci and eliminates pressure without creating tension in periosteum, to enhance bone in periosteum. This shield interrupts the contact between tip of tongue and lower lip, which leads to maturational deglutitionand indirectly influence tongue position. These appliances removes abnormal sucking habits, lipdysfunction and establishes proper oral seal.
  21. 21. • It is a screening appliance used to correct the mouth breathing habit. Construction: edge-toedge bite is taken without the consideration of the facial pattern. This bite does not predetermine a precise mandibular forward posturing but requires only that the mandible be moved forward to edge to edge relationship.
  22. 22. • The acrylic shield should extend vertically from the upper labial fold to the lower labial fold and extends to the distal margin of the last erupted molar. It should be in contact only with the upper and lower labial fold during the anterior positioning of the mandible. • If the crib is placed at the gingival third, a proper adjustment can stimulate the eruption of the anterior teeth, thereby useful in the correction of the open bite. The acrylic can also be interposed between the teeth, covering the occlusal surfaces of the upper molars, in order to prevent the eruption of the posterior teeth. Lip exercises should be advocated along with it. Lip exercises such as holding a piece of paper between the lips while wearing the vestibular shield is advocated
  23. 23. • It is effective in eliminating the mouth breathing habit, abnormal sucking habits and lip dysfunction in order, to achieve a proper lip seal, which is of prime importance. This lip seal will indirectly influences the posture of the tongue, and thereby leading to maturation of the deglutition cycle and creates a somatic swallowing pattern. • The appliance is usually worn at night and 2 to 3 hours per day when the child is not in school. • This appliance only eliminates the pressure. It cannot create a tension effect on the vestibular periosteum to enhance the bone formation in this region. The most important factor in treatment is to have a soft tissue seal of the screen with no strain in the peripheral portions.
  24. 24. • Modification of the vestibular screen are, vestibular screen with holes at the inter-incisor area for certain patients, who find difficult in the breathing, vestibular screen with the tongue crib, and vestibular screen with the acrylic tongue crib.
  25. 25. •BLUE GRASS APPLIANCE (Habit breaking and Tongue Retainer) • Haskell & Mink (in 1991) introduced easy to wear appliance called Bluegrass appliance. He used a hexagonal Teflon roller on a cross palatal wire. He claimed that appliance almost always ends a sucking habit within several days, if not immediately and begins training the tongue towards a normal posture. Normalizing facial growth and allowing proper speech. They did not recommend this appliance for pre-school age children.
  26. 26. • Chris baker (2000) modifiedthe Bluegrass appliance design to utilize4mm acrylic beads on the cross palatalwire. Advantage of modification • It encourages the maximum neuromuscular stimulation by using two or more beads • It reduced bulkiness of appliance, which results in less obstruction and more stimulation of tongue function. • Wire and beads cemented to second a deciduous molar that is not seen from outside mouth. A child quickly becomes comfortable with the Bluegrass and enjoys the sensation of the tongue playing with the beads.
  27. 27. • Chris baker claimed that there is a direct relationship between the age of child at the time of appliance placement and speed of correction. • Younger children show cessation of habit in first few days and quickly and completely tongue position becomes normalized. • Older children --- take few weeks. • Retention : • Appliance left in the mouth for six months after the habits has stopped. If the low tongue position persists after six months, leave the appliance in place to continue retraining.
  28. 28. Nanda found that the vertical pattern of development was established before the eruption of the permanent first molar and long before the adolescent growth spurt. Anterior vertical dimension is a key feature that is related to existing vertical growth patterns. VHA, is essentially a transpalatal arch with an acrylic pad. The VHA uses tongue pressure to reduce the vertical dentoalveolar development of maxillary permanent first molars Vertical holding appliance
  29. 29. ORTHOPEDIC APPROACH Functional appliance in growing patient Activator Principle Woodside viscoelastic properties of muscle contraction induces skeletal adaptation. Activator can be used for vertical malocclusion especially in open bite cases to eliminate tongue thrusting, finger sucking and facilitates eruption of anterior teeth, prevents eruption of posterior teeth and facilitates mandibular growth.
  30. 30. • Eschler (1952) says that if the bite opening with activator increases 4 mm beyond postural position, it will act as a muscle stretching method, works alternatively with isotonic and isometric muscle contractions. He describes the cycle as at the insertion of the appliance the mandible is elevated by isotonic muscle contractions and when the mandible assumes a static position with the appliance, isometric contract arise. Because the mandible cannot reach the postural rest position, the elevators remain stretched. When the fatigue occurs, the contracting muscle relaxes and the mandible drops. As soon as the muscle has recovered, the cycle begins again
  31. 31. • Bite registration : • The forward positioning of the mandible is not necessary, when this appliance is primarily used for the vertical problems. • Hence, the bite is opened 4 to 5 mm beyond postural rest position to develop sufficient elastic depressing force and load the molars that are in premature contacts. This appliance is used to achieve retroclination of the maxillary base with the restriction of the patient's vertical growth pattern. This will "close the V" between the upper and lower maxillary bases, depressing the posterior maxillary segment. If the divergent rotations of the jaw bases are present, the correction of open bite with activator is not possible.
  32. 32. • Weinback & Smith (AJO 1992) evaluated the effectiveness of appliance; found that there is decrease of 1.3mm in open bite and has less effect on lower molars . • Limitation- When divergent rotation of base is apparent, activator is not the choice of treatment.
  33. 33. • Intrusion of molars is performed by loading only the cusps of these teeth. The acrylic detail is ground away from the fossae and the fissures to eliminate any possible inclined plane stimulus to molar movement to achieve vertical depressing action. This will allow the activator to deliver greater amount of force. • Extrusion of the incisors requires loading their lingual surfaces above the area of greatest concavity in maxilla and below this area in the mandible. And the extrusion can be enhanced by placing the active labial bow above the area of greatest convexity (gingival third).
  34. 34. Vertical Control with a Headgear-Activator Combination • The rigid acrylic activator consists of two parts: an upper “ horseshoe” splint covering all the teeth up to the gingiva, and a lower portion adapted lingually to the mandibular arch and alveolar process, with lower wings as long as possible. Labial coverage of the incisal edges can be added to prevent proclination of the incisors.
  35. 35. High angle cases are particular domain of this combination since, unlike the use of activator only treatment, vertical control is optimal. • In vertically critical cases the force vector of the headgear is adjusted so that even pressure is distributed between the incisal and molar regions, i.e. through the centre of resistance of upper dentition. No acrylic is removed in the lower molar region. The amount of force should not be less than 400 gm. • By changing the direction of the outer facebow, it is possible to achieve different biomechanical effects on both the alveolar and skeletal units. Moments can be positive, negative, or nonexistent, resulting in clockwise rotation, counterclockwise rotation, or pure translation, according to treatment objectives.
  36. 36. • Lowering the outer facebow enhances the tipping effect of the activator, thus increasing anterior overbite and reducing posterior facial height. This effect should be avoided in brachyfacial cases, but can be used to advantage in mesofacial or dolichofacial types with tendencies to anterior open bite .
  37. 37. Since the outer facebow was bent downward so the direction of force passed behind both the alveolar and skeletal centers of resistance. Thus, positive moments and clockwise rotation were generated • Clockwise rotation of the palatal plane, • Downward tipping of the occlusal plane without eruption of the upper molars. • Eruption and retroclination of the upper incisors, resulting in correction of the overjet and anterior open bite. • Closing of the facial axis and anterior mandibular rotation, with forward displacement of pogonion. • Inhibition of forward maxillary growth, combined with forward mandibular growth, resulting in correction of the Class II skeletal relationship.(disadvantage in class 3 cases ) • Backward displacement of the upper dentition and forward displacement of the lower, without tilting of the incisors, resulting in correction of the Class II malocclusion.
  38. 38. • Bionator • Bionator mainly used to correct abnormal posture and function of tongue. • Principle • 1) According to Balter, equilibrium between tongue and circumoral muscles is responsible for shape of dental arches and intercuspation. The functional space or the tongue is essential to the normal development of the orofacial system. • 2)Not to activate muscles but to modulate muscle activity, thereby enhancing normal development of inherent growth pattern and elimination abnormal and potentially deforming environmental factor. • 3) Construction bite is as low as possible with slight opening for posterior bite block to prevent extrusion of posterior teeth. • 4. To inhibit tongue movement, the acrylic portion of lower lingual part extends into upper incisor region as a lingual shield closing the anterior space without touching upper teeth.
  39. 39. • The palatal bar is used to position the tongue more posterior (or) into caudal position. • The labial bow should run between the incisal edges of the upper and lower incisors. The labial part of the labial bow is placed at the height of the correct 'lip closure, thereby stimulating the lip to achieve a competent lip seal and relationship. The vertical strain on the lip tends to encourage the extrusive movement of the incisors, after eliminating the adverse tongue pressures
  40. 40. Weinback et al (AJO-92) concluded that openbite bionator is not useful in severe open bite cases and useful in mild case were posterior eruption would be undesirable due todivergent skeletal pattern.
  41. 41. Frankel FR- IV • Out-to be matrix'-Allows muscle to exercise to adapt. The working principle of R, establishes the mandible forward rotation with posterior edges of buccal shields as rotational centers. Anteriorly the force of anterior vertical muscle chain being strengthened by lip seal exercise raises the mandible. • Appliance effectively changes dentoalveolar structures without producing skeletal changes.
  42. 42. OWEN s modification of a function regulator differs from other Frankel appliances in the addition of posterior acrylic bite blocks to arrest molar eruption through the function of the elevator muscles. The vertical dimension or anterior facial height (ANS-Me) decreased through the holding or intrusion of the upper molars.
  43. 43. It also has headgear tubes that accept a facebow for an occipital pull headgear, which provides the appliance with positive control of the posterior maxilla The construction bite was taken 3-4mm protrusive, with 3-4mm posterior (molar) clearance to allow for the bite blocks and headgear tubes
  44. 44.
  45. 45. • Study by Erbay et al (AJO-95) showed that this appliance produce favorable mandible rotation with extrusion of upper and lower incisors thereby correcting malocclusion. As a result of treatment with the FR-4 appliance and lip seal training, the growth and development pattern of the mandible was altered. The spontaneous downward and backward growth direction of the mandible which was observed in the control group was changed to an upward and forward direction by FR-4 therapy, allowing the skeletal anterior open bite to be successfully corrected through upward and forward mandibular rotation.
  46. 46. • Reduction in total anterior facial height growth was due to successful inhibition of lower anterior facial growth by the FR-4 appliance. It appears most likely that this reduction in mandibular plane angles was the result of differential increase between total posterior and anterior facial height (4.5 and 3.9 mm, respectively). Greater posterior vertical growth would result in a lowering of the gonial region and subsequent upward and forward mandibular rotation. Theoretically, Fränkel and Fränkel explained this rotation mechanism with the possible effect of the function regulator's buccal shields and lip seal exercises. They hypothesized that the posterior edges of the buccal shields are deeply positioned in the vestibular sulcus and provoke pressure sensation in this area. This could cause the inferior translation of the posterior part of the mandible with a compensatory translative growth at the condyles, leading to an increase in ramus length. They suggested that, concomitant with the lowering of the posterior part of the mandible, its anterior part could be raised with the posterior edges of the FR as a rotational center.
  47. 47. • They concluded that such a forward rotation of the mandible was brought about by the force of the vertical muscle chain being strengthened by lip seal exercises. This hypothesis is supported by the findings of Ingervall . They found considerable anterior mandibular rotation in children with longface structure during muscle training with chewing gum. However, Ingervall suggested the anterior mandibular rotation could be explained by reduced midfacial vertical growth due to increased masticatory muscle strength, instead of increased mandibular condylar growth. • The occlusal rests of the FR-4 appliance on the upper first molars appear to restrict the rate of growth in upper posterior dentoalveolar structures.
  48. 48. • Twin blocks • Twin blocks with modification can be used to achieve vertical control and includes posterior & also erupts anterior, which aid in correction of excess vertical height malocclusion especially in mixed dentition. The principle of this appliance is to correct the malocclusion by correcting the unfavorable cuspal contacts and maximize the growth potential of the jaws. Rapid correction of the malocclusion is achieved by transmitting favorable occlusal forces to the occlusal inclined planes covering the posterior teeth. In treating the patients with vertical growth pattern associated with 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.
  49. 49. • Modifications : • 1.A palatal spinner comprising of a bead which rotates on a transpalatal wire ositioned in the palate which encourages the tongue to curl upward and backward instead of thrusting between teeth. • 2. Twin block with headgear to upper 1st molar • (Intrude and corrects VME) • Headgear tubes can be attached to the upper molar and high pull extra-oral traction can be applied to a modified face bow worn at night to intrude the upper molars. • 3. Concord face bow is a unique way to deliver an intrusive force to upper molar and protrusive force to the lower molar. • In the Concorde face bow, the outer bow should be slightly above than the inner bow, producing an upper component of force, to stabilize the upper appliance. This upward force is balanced by the horizontal elastic attached to the recurved labial hook and the vertical component of orthopedic force is applied to the upper molars by cervical headcap (or) headgear.
  50. 50. Concord face bow twin block
  51. 51. • 4. Vertical elastics used to twin blocks to upper and lower posterior premolar regions which helps in intruding posterior teeth thereby altering vertical dimension. They intrude the posterior teeth especiaIIy the upper molars, by encouraging the patient to bite into the appliance consistently and producing more amounts of intrusive forces on the opposing molars. This effect is useful to the patients with vertical growth pattern and weak musculature and so they do not close consistently on the appliance. • 5. Use of repelling rare earth magnets in the occlusal bite blocks to reduce the vertical dimension.
  52. 52. • JASPER JUMPER • This appliance produces both sagittal and intrusive forces like Herbst bite jumping mechanism, but affords the patients much more freedom of mandibular movement. • The Jasper Jumper is relatively new auxiliary capable of producing rapid change in occlusal relationships. It is flexible fixed appliance that delivers light continuous force. It can be used to move single teeth, most of teeth or an entire arch. It can deliver functional bite jumping forces, or a combination of these. • Its modular system can be attached to most commonly use fixed appliances. • This system is composed of two parts, the force module and the anchor units. • ROBERT G.CASH57, 1991 had described the non-extraction treatment for on adult patient with a bilateral Class II malocclusion and an open bite, using a Jasper Jumper appliance to distalize and to intrude the maxillary molars.
  53. 53. • ORTHODONTIC APPROACH to limit vertical dimension, in growing patient are: • High pull headgear with/without splint • Extraction therapy • Bite blocks (passive/active) • Vertical pun chin cup • Combination of these.
  54. 54. • High pull headgear • Used to treat hyperdivergent open bite, by effectively holding maxillary sutural rowth and vertical dentoalveolar development (Armstrong, Woodside and Baumrind). • Study by Creekmore and Pearson, showed that high pull headgear alone modifies maxillary growth but compensatory eruption of mandibular molars prevents autorotation of mandible and control of anterior facial height. • Study by Melsen and Caldwell, showed that high pull headgear attached to a splint more effectively modifies maxillary growth to a more posterosuperior direction and this is an effective approach for vertical maxillary excess
  55. 55. Maxillary traction splint: • Caldwell (AJO-84) used acrylic splint With headgear (high pull) showed that, this approach produce a superior and distal displacement of maxilla, reduction in SNA angle, clockwise rotation of palatal plane and relative intrusion of upper molar with increased lower molar eruption, decreased mandibular growth and increased SNB angle.
  56. 56. 1. High pull HG short and high outer bow: Line of HG force is mesial to Centre of resistance. • Moment tends to flatten the OP. • Distal and intrusive force component. 2. HG force passing through center of resistance. Intrusive and distal component of force. No moment. 3.High pull with long outer bow: • • • Moment at center of resistance tends the steepen the OP. Force with distal and intrusive component. Indication : Class II open bite patients.
  57. 57. Vertical chin cup • Pearson used vertical chin up in mixed and permanent dentition to reduce the Mpa and limit in increase in anterior facial height. • Haas used vertical chin cup with Kloehn cervical headgear, and showed that appliance inhibit upper molar eruption and descent of maxilla, while mandibular growth was redirected toward a more horizontal direction. • Cups have ben used during active RPE therapy to minimize the vertical displacement of the maxilla and control the opening of MPA. • Eren studied the effect of vertical chin cup alone and found a decrease in Mpa, posterior rotation of maxilla, increase in upper facial height, a decrease in total anterior and lower anterior facial height, an increase in lower post dentoalveolar height and an increase in overbite.
  58. 58. • Study by Iscan (AJO-2002) effect of vertical chin cup on mandibular morphology in treating Skeletal open bite. Concluded that Mpa decreased significantly. Gonial angle closed, ramal inclination angle decreased, corpus inclination increased all indicating anterior rotation of mandible. Anterior rotation of mandible occurred as a result of inhibiting vertical growth in mandibular post dentoalveolar region. Eruption of mandibular incisors played an important role in correcting open bites in vertical chin cap therapy. • Study by Pearson, showed that mandibular plane angle decreased to 3.9°, with all 4 extractions and a vertical pull chin cup for 9 months of treatment. • Study by Nanda, showed that high pull chin cup prevents increase in anterior facial height and mandibular plane angle in hyperdivergent individual during maxillary expansion.
  59. 59. Passive posterior bite block Do not contain any active elements like springs/magnet. According to Kuster et al bite blocks are like functional appliances, with interocciusal space of 3-4 m beyond rest position, which inhibit extrusion of buccal segments effectively. This is most effective prior to growth completion of jaws. Modification of bite blocks 1.Removable spring loaded - Kuster & IngeNal (AJO-90) It shows greater reduction in ANB angle and molar intrusion than passive bite block. 2. Repelling magnet - Iscan et al (AJO-97) 3. Active vertical corrector (AVC) - Dellinger(AJO-86) -Tooth borne appliance -Fixed/ Removable type Advantage Rate of tooth movement is greater than conventional appliance such as high pull headgear, bionator, activator (or) conventional bite block therapy. Correction of LAFH range from 0.9 - 2.4 mm
  60. 60. • BITE BLOCK • DELLINGER (1986) proposed the use of occlusal bite blocks containing repelling magnets, the effect of the force of the magnets was reported to cause intrusion of the posterior teeth, allowing the mandible to rotate upward and forward. • Michael G. Woods and Ram S. Nanda (1988) in their experiment in growing baboons found magnetic bite blocks are effective in intrusion of posterior teeth. There was significant eruption of anterior teeth. This dentoalveolar compensation was greater in animals wearing magnetic appliances than bite blocks without magnets. Bone remodeling changes at the gonial angle wear also marked with magnetic appliances.
  61. 61. • Study by Thilander & Dellinger, showed that a bite block is effective in controlling anterior facial height. • Study by McNamara and Dellinger, showed that magnetic bite blocks produce significant treatment effect with the disadvantage • a) Creating asymmetric mandibular posture and subsequent unilateral cross bites due to shearing forces created by repelling magnets. • b) Increased root resorption due to excessive intrusive force for extended periods.
  62. 62. • Kalra and Nanda (AJO 1989 ) • A fixed magnetic appliance was designed that hinged the mandible open and exerted an intrusive force on the teeth. Treatment with this appliance resulted in: • An increase in length of the mandible ( age group 8 – 10 yrs ) • Intrusion of teeth • Upward and forward autorotation of the mandible • Reduction of A-B to occlusal plane • Improvement in the angle of facial convexity • Creation of temporary buccal crossbite caused by the shearing force of repelling magnets
  63. 63. • The MAD IV Appliance • M. ALI DARENDELILER (JCO) • The Magnetic Activator Device IV (MAD IV) uses anterior attracting magnets as well as posterior repelling magnets. The anterior magnets guide the mandible into a centered-midline position, add an anterior closing effect, and enhance the anterior rotation of the mandible. • The MAD IV consists of removable upper and lower plates, each of which contains three cylindrical neodymium (Nd2Fe17B) magnets coated with stainless steel. The four posterior magnets, embedded in a repelling configuration, generate an intrusive force of 300g each, with a bite opening of 5.5-6mm at the first molars. The two midline magnets apply an attracting force of 300g.
  64. 64. • 1. The MAD IV-a is used in cases where the anterior segment of the maxilla is vertically correct or overdeveloped (gummy smile). Because posterior intrusion and mandibular autorotation are needed, the posterior and anterior magnets are placed in full contact
  65. 65. • 2. MAD IV-b is used when an additional extrusive effect is needed in the maxillary anterior region. The anterior magnets are positioned with a vertical opening of 2-3mm, while the posterior magnets are placed in full contact. These selective anterior and posterior effects can be accentuated by dividing the upper plate in two and joining the two sections with a hinge.
  66. 66. • . The MAD IV-c is used when only anterior extrusion is needed. The posterior magnets are omitted, and the anterior magnets are placed with an opening of 1-2mm, depending on the severity of the anterior open bite.
  67. 67. • THE ACTIVE VERTICAL CORRECTOR (AVC ) • Active Vertical Corrector (AVC) is a simple removable or fixed orthodontic appliance that intrudes the posterior teeth in both the maxilla and mandible by reciprocal forces. AVC is a tooth borne appliance. • By the use of effective posterior intrusion of teeth, the mandible is allowed to rotate in upward and forward directions. The uniqueness of this appliance is that it allows the clinician to correct anterior open bite problems by actually reducing anterior facial height. • It is an adaptation of present-day bite block therapy .
  68. 68. • The AVC works as an energized bite block. The energy system is obtained by the repelling force of samarium cobalt magnets. Because samarium cobalt is a highly reactive, rare earth material and therefore best kept isolated from the oral environment, these magnets are hermetically sealed in a stainless steel capsule. Stainless steel was selected over epoxy as the material for encasing the magnets because epoxy tends to crack and abrade from occlusal contact.
  69. 69. • The method of action is reciprocal intrusion of the maxillary and mandibular teeth This movement results in autorotation of the mandible and open bite correction. The force system presently used in this appliance generates 700 g of force per magnetic unit. The magnets are placed immediately over the teeth to be intruded. The placement is viewed as a pure vector problem and varies from case to case. One or two magnets per distal quadrant are used, depending on the force required.
  70. 70. • Method of action • The AVC force system generated by repelling magnets is considered superior to a static bite block appliance energized only by the intermittent force from the muscles of mastication. The constant force system of the AVC results in greater rapidity of tooth movement. It has been shown that increased cellular activity occurs when tissues are subjected to an intermittent electromagnetic field. Saliva is an electrolyte and the magnets are at times in motion. The possibility of microcurrent flow in the periodontium should be considered a positive tissue stimulator.
  71. 71. • The rate of tooth movement is considerably greater than conventional approaches such as high-pull headgear, Bionators, activators, or conventional bite block therapy. • The impressions for constructing the dental casts are critical because the taking of the working bite demands a precise clinical technique and is an absolutely essential element in the correct functioning of the AVC. Another extremely important factor is the placement of the magnets because the appliance is a direct reciprocal vector appliance between the maxilla and mandible. A specially designed headcap and chin strap is worn during sleep and at all other times deemed socially fitting by the patient. • The appliance has been successfully used in both adults and children, growing children experience more rapid correction than the skeletally mature adult. • Study by Ingervall showed that AVC produce quicker response in dental and skeletal vertical relationship in growing individuals. i.e. an average of 3mm of anterior open bite closure over a 8 months treatment period.
  72. 72. OPEN BITE CORRECTION IN INDIVIDUALS WITH NO POETENTIAL FOR GROWTH MODIFICATION • Dental open bite • Wiseman (AJO-95), provides a guideline to treat dental open bite. • 1) Prociined maxillary/mandibular incisors, • 2) Normal craniofacial pattern • 3) Little/no gingival smile • 4) 2-3 mm of incisor exposure at rest. • His approach is extraction and retraction of incisor, commonly involved teeth for extraction is 1st premolar . Mechanics of treatment aimed at changing angulations and extrusion of anterior teeth (Draw bridge effect). The limiting factor in this type of treatment is relationship of upper incisor to upper lip.
  73. 73. • YOUNG H.KIM 1987 has described the multi loop edgewise Archwire • (MEAW) technique in the treatment of the Anterior openbite. The MEAW technique • 16x22 SS archwire + heavy anterior elastics - to achieve molar intrusion and simultaneous incisor extrusion. • 1. ELIMINATE all rotations, spaces and crowding before treatment. • 2. Double edgewise brackets with .018 slots, preferably auxilIary vertical slot are used. • 3. Two types of loop components, vertical and horizontal. Vertical loop provides’ horizontal control and horizontal loop provides vertical control. • 4. Individual loops are in the form L shape.'• 5. Using 2 1/2 times (30 cm) more than the normal span of wire, it provides ten-fold reduction in the load/deflection rate over a typical ideal archwire.
  74. 74. • 6. Requires 5 loops on each side. • 7 Vertical loops centered at the interproximal areas horizontal loops should be directed mesially. • 8. Typical tip back bends 3° to 5° should be incorporated. • 9. Upper MEA W has deep curve of spee and lower reverse curve; this will apply intrusive forces on incisors further worsening the open-bite. So this force is counteracted by anterior vertical elastic force. The elastics must be in a place for full-time. • He concluded that the MEAW technique is very effective in the treatment of the open-bite. In addition he says that the extraction 2nd or 3 rd molar in open-bite cases offers feasible diagnostic and therapeutic situation and while treating the open bite, individual occlusal plane should be corrected, teeth must be uprighted to occlusal plane for stability and function.
  75. 75. • • • • • • • • Effect Increase upper anterior alveolar height No effect on upper posterior alveolar height. Reduction in lower posterior dentoalveolar height Distal movement of entire dentition. Increase in inter incisal angle. Alters the occlusal plane by preventing upper molar extrusion and intrudes lower molar. MEAW influence dentoalveolar changes with minimal effect on skeletal pattern. Limitation - Patients with gingival show.
  76. 76. Implants • As Stationary Anchorage • Prosterman et al (AJO-95) used Osseo integrated implants to intrude/at least prevent extrusion of posterior segment in correction of vertical facial height and anterior open bite. • Umemori at al (AJO-98) used titanium miniplates in buccal cortical bone in apical region of 1st & 2ndmolars and produce 3-5 mm of intrusion and counter clockwise rotation of occlusal plane without unfavorable side effect.
  77. 77. Leibinger miniplates, screws, and screwdriver. The plate should be positioned so that only the last loop on the vertical (most occlusal) leg of the plate projects through the mucosal incision into the oral cavity. This loop should be several millimeters apical to the brackets on the molars and adjacent to the teeth requiring the greatest amount of intrusion. Two self-tapping screws are placed to secure the plate to the bone.
  78. 78. • Since the intrusive force is buccal to centre of resistance , molar buccal flaring can occur. Lingual crown torque was applied to the lower molars with Burstone’s precision lingual arch to avoid buccal flaring during intrusion . In the upper arch TPA can be used.
  79. 79. SURGICAL TREATMENT When the severity of vertical deformity is so great that reasonable correction cannot be obtained by growth modification/camouflage, a combination of orthodontics and orthognathic surgery is the viable treatment option. Ways to counteract this malocclusion: 1) Superior repositioning of the maxilla (or) at least posterior part of the maxilla by total/segmental maxiiiary osteotomy. This indirectly repositions the mandibie in an upward and forward direction. Care taken not to elevate anterior maxilla and may be indicated to rotate downward so that an esthetic smile arc is maintained. 2). Mandibuiar surgery to bring lower jaw forward and upward, in a open bite cases, by fitting he body of mandibie up after a ramus osteotomy (this approach indicated when problem is largely in mandible and no alteration in maxilla is required). 3).Superior repositioning of chin by mandibular lower-border osteotomy. This procedure is useful adjunct to above approaches, but it is not adequate to solve severe discrepancy.
  80. 80. 4).Double jaw procedure - Maxillary surgery is the primary procedure. After maxilla repositioned vertically, mandibular ramus osteotomy is recommended only as a secondary procedure. 5) Glossectomy In cases where abnormal large tongue is the causative factor in excess vertical facial height, partial glossectomy procedure is recommended. And also where tongue is large to small mandible, either functional orthopedic appliance/jaw advancement surgery is indicated (Bite jumping). Primary focuses on maxilla, for two reasons • Usually the maxilla has excessive vertical development with influence on mandible rotation down and backward. • Stability - moving maxilla up produces stable surgical correction, whereas mandibular ramus osteotomy in a counter clockwise rotation stretches soft tissue posteriorly resulting unstable.
  81. 81. • INDICATIONS • 1. Cases where normal mandibular length, rotated to Class II pattern, superior repositioning of maxilla alone will bring mandible to Class I. • 2. Cases where small mandible and rotated backward, superior repositioning of maxilla and mandibular ramus osteotomy indicated(For advancement of mandible). • 3. Cases where large mandible and rotated backward, i.e. (ClassIII to Class I), superior repositioning of maxilla and mandibular ramus osteotomy indicated (to shorten mandible
  82. 82. • Presurgical Consideration • 1) Lefort-1 osteotomy has tendency of gingival stripping during healing process, scar contractions pulls gingival attachment gingivally. When gingival attachment is questionable. gingival attachment should be augmented by placing gingival grafts in doubtful areas atleast 2-3 months before surgery (esthetic problem). • 2) In anterior open bite planned for segmental maxillary osteotomy with anterior and posterior dentoalveolar segments, it is important not to level upper arch during presurgical orthodontics.If upper arch is leveled presurgicalty,in severe open bite cases. produce a relapse tendency, i.e. primarily leveling occurs by elongating upper incisor. When appliance removed post surgically the incisors tend to relapse apically to some extent and would lead to opening of bite anteriorty.
  83. 83. • 3) Transverse, If arch requires expansion orthodontically, do at the very beginning of presurgical orthodontic procedure and maintain as long as possible before the expansion appliance is removed. If arch expansion planned at surgery, orthodontic expansion should not be carried out in presurgical procedure.
  84. 84. • ANTERIOR MAXll,LARY AND MANDIBUULAR SUB APICAL OSTEOTOMY • This surgery is mainly executed for the extrusion of the anterior segment of maxilla (or) mandible (or) both to close the anterior open bite. • Indication for anterior maxillary sub-apical osteotomy: • 1..A small open bite associated with the minimal tooth exposure (or) none,lip competence, a good naso labial angle, and adequate lower anterior facial height • 2.The relationship between the upper lip and concealed maxillary incisors of rest,speech and smiling produces an unaesthetic edentulous appearance. • Indication for anterior mandibular sub-apical osteotomy: If the open bitemanifests in the anterior portion of the mandible as a reverse curve in the mandibular archwith transverse maxillomandibular harmony and good esthetic balance between upperlip and maxillary anterior teeth. Relapse potential is very minimal.
  85. 85. KOLE MODIFICATION OF MADIBULAR SUB-APICAL OSTEOTOMY Indications : Mandibular prognathism associated with anterior open bite, severe reverse curve, and excessive chin height along with the patient should have a functional posterior occlusion, no transverse deficiency problem in maxilla and a satisfactory lip to tooth relationship in maxilla. . The main objective of this surgery is the close the open-bite by elevating the lower anterior segment and reducing the chin height it includes horizontal sub-apical bone incision and vertical ostectomies in the premolar (or) molar extraction sites. The choice of extraction site depends on the magnitude of the anterior open bite and location of the reverse curve in the mandibular occlusal plane. .The principle disadvantage of the surgery relates to unpredictable soft tissue profile and chin height changes. So that a well placed pressure dressing for 7 days minimizes the soft tissue changes.
  86. 86. • LEFORT I MAXILLARY OSTEOTOMY FOR THE CORRECTION OF THE VME • This surgical procedure is indicated in cases with high and constricted palatal vault, excessive curvature of the maxillary occlusal plane, lip incompetence high mandibular plane angle and a long distance between the palatal roof apices and the nasal floor. • This down fracture Le fort I osteotomy is more useful when interdental osteotomies are indicated to level the maxillary occlusal plane, widening the maxillary arch, less problematic, more versatile and easier to execute than anterior (or) posterior maxillary osteotomies.
  87. 87. • Post-surgical orthodontics • The most difficult part in post-surgical orthodontic in long face is maintaining transverse maxillary expansion, particularly surgical expansion. To stabilize transverse expansion, Heavy labial auxiliary wire in headgear tube along with light working archwire. • Transpalatal lingual arch.
  88. 88. Surgical management of the growing patient • Surgical management of the growing patient remains controversial. Growing patients can present to the clinician with maxillary dentofacial deformities that require combined surgical and orthodontic correction. • Around 12 years of age, most transverse maxillary growth is complete.Anteroposterior (AP) growth of the maxilla is basically complete by about the age of 14 years. Normal vertical maxillary growth, however, continues into adulthood. • Early surgical correction may be beneficial in some patients for functional, esthetic, and psychosocial reasons.If surgery is performed during growth, the patient and parents must be informed that future surgery will probably be necessary. Surgery is often undertaken with the expectation that additional treatment, including more surgery, may be required after the completion of growth.
  89. 89. • Le Fort I maxillary osteotomy. The Le Fort I osteotomy , when performed during growth, effectively inhibits further anterior growth of the maxilla. Vertical maxillary growth, however, can be expected to continue postoperatively at the same rate as before surgery. • In patients with normal mandibular growth, the occlusion should remain stable.
  90. 90. • Horseshoe maxillary osteotomy (dentoalveolar osteotomy). • With the horseshoe maxillary osteotomy procedure the nasal septum remains attached to the stable palate, and only the dentoalveolar structures are mobilized. Thus, some AP maxillary growth may be expected to occur postoperatively. The overall growth rate, however, will remain deficient. • Vertical maxillary growth remains unaffected and continues at the same rate as before surgery • Tunnel procedure -- risky • Flap-- Raised labialy and buccaly
  91. 91. • The most predictable results will be obtained if surgery is performed after age 14 in girls and age 16 in boys. If done at an earlier age (12 years in girls and 14 years in boys), there is a possibility of the excessive vertical maxillary growth rate recreating a vertical maxillary excess after surgery, although to a lesser extent than would occur if surgery was not performed. The occlusion will usually remain stable • Either procedure can be performed before the patient reaches age 10, provided sufficient space exists above the apices of the developing permanent teeth to place the osteotomies and apply fixation. Damage to developing tooth roots may result in dento-osseous ankylosis, and localized dentoalveolar growth impairment.
  92. 92. • Orthognathic surgery for the correction of vertical maxillary hyperplasia can be performed with corrective mandibular surgery for retrognathia or prognathism, if the preoperative rate of mandibular growth is normal, and the TMJs are healthy. The Le Fort I osteotomy will inhibit further AP maxillary growth while allowing vertical maxillary growth to continue.
  93. 93. • Sagittal split ramus osteotomy. • The sagittal split ramus Osteotomy is more difficult to perform on younger patients because of greater bony elasticity, the thinness of the cortical bone, the presence of unerupted molar teeth, and the relatively shorter posterior vertical mandibular body height, as compared with adults. It does have the advantages of easy application of rigid fixation as well as better positional control of the proximal segment. SSRO is best reserved for patients over the age of 12 years—that is, after the eruption of the permanent second molars, so that damage to these teeth during surgery can be avoided.
  94. 94. • Vertical ramus osteotomy. • The vertical ramus osteotomy (VRO) can be used to advance the mandible and vertically lengthen the ramus with appropriate bone or synthetic bone grafting as indicated to control the positional orientation of the proximal segment and fill bony voids. • The amount of mandibular advancement and vertical lengthening possible with this technique is limited by the temporalis muscle attachment and interference of the coronoid processes on the zygomatic arch.
  95. 95. • Inverted “L” osteotomy. ( Subsigmoid osteotomy ) • Alternate to BSSO • 5 mm advancement or retraction can be done--Limitation The inverted “L” osteotomy (ILO) can be used to advance the mandible and vertically lengthen the ramus, but it may require bone or synthetic bone grafting to control the positional orientation of the proximal segment and to fill the bony voids between segments. The use of rigid fixation is recommended.
  96. 96. With any of the above mandibular ramus procedures, the preoperative rate of growth can be expected to be maintained after surgery. Mandibular growth should not be affected by any of these techniques, provided that the condylar head is not damaged during surgery. The vector of facial growth, however, may be altered by a change in the orientation of the proximal segment and thus the condyle, similar to moulding of regenerate in D.Og. The use of rigid fixation will improve long-term stability
  97. 97. • TMJ & VME • The TMJs are the foundation for orthognathic surgery. If the TMJs are not stable and healthy, orthognathic surgical results may be unstable, with increased TMJ dysfunction and pain as a result. The TMJs must be appropriately evaluated before surgery. The most common TMJ disorder seen in orthognathic surgery patients is the displaced articular disk. Significant problems can occur when orthognathic surgery is performed in the presence of untreated disk displacement. • Pullinger et al demonstrated a higher prevalence of open bite in DD with reduction and DDN . Out of 614 patients with TMJ disorders 32 had anterior open bite and 27 / 32 had disk displacement. • Riolo et al ( AJO 1987 ) suggested that open bite was positively associated with TMD and muscle tenderness.
  98. 98. • Kerstens et al ( J cranio Max S ) studied 480 OS patients both pre and post operatively and found that retrognathic patients with low and normal angle MPA were more likely to have preoperative TMJ signs and showed improvement of signs and symptoms postoperatively.High angle patients with mandibular retrognathism had highest post surgical incidence of TMJ signs and symptoms. ( Surgery done BSSO and LF –I). • Stringert and Worms ( AJO 1986 )compared cephalometric data from a group of 62 subjects with documented internal derangements with a sample of 102 subjects from normative sample. Results indicated an increased proportion of subjects with "high plane" characteristics and a decreased proportion of subjects with "low plane" characteristics in the experimental sample.
  99. 99. Relapse Tongue will adapt to new environment to both orthodontic treatment Copey (AJO-85) and surgical treatment Denison (AngIe-89). Tongue habit should be corrected by Myotherapy. Fixed retainer Use tongue crib during treatment-to alter tongue posture and after treatment. Placing retainer that cover occlusal surface.
  100. 100. Thank you Leader in continuing dental education