Mangement of openbite in orthodontics


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Mangement of openbite in orthodontics

  1. 1. MANAGEMENT OF OPEN BITE DrRavikanthLakkakula 1
  2. 2. CONTENTS 1.Introduction. 2.Classification. 3.Etiology. 4.Management. 5.Conclusion. 6.References. DrRavikanthLakkakula 2
  3. 3. INTRODUCTION The openbite malocclusion is one of the most difficult dentofacial deformities to treat. The complexity of this malocclusion is attributed to a combination of skeletal , functional and habit related factors. Accurate diagnosis is essential for proper treatment planning , which in combination with patient specific mechanics, is needed to achieve stable results. Incidence of anterior openbite varies among the races and with dental age. It is more common in african americans (6.6%) than in caucasians (2.9%). chronologically as children develop dentally , the incidence of anterior openbite decreases, as it tends to self correct during mixed dentition phase. DrRavikanthLakkakula 3
  4. 4. 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. Open-bite must be considered as a deviation in the vertical relationship of the maxillary and mandibular dental arches. DrRavikanthLakkakula 4
  5. 5. In an open-bite there should be a definite lack of contact, in the vertical direction, between opposing segments of teeth. The degree of openness can vary from patient to patient, but an edge-to-edge relationship or some degree of overbite cannot be rightfully categorized as an open-bite. The loss of contact in the vertical direction of segments of teeth can occur between the anterior segments or between the buccal segments. DrRavikanthLakkakula 5
  6. 6. Open bite creates significant problems such as 1. Difficulty in speech (dysphonia). 2. TMJ disorders. 3. Functional imbalance. 4. Bad aesthetics. 5. Alteration of incisor guidance. 6. Reduction of normal functional activity. DrRavikanthLakkakula 6
  7. 7. CLASSIFICATION 1 . Skeletal Open Bite. class I class II class III 2. dental openbite. anterior openbite posterior openbite DrRavikanthLakkakula 7
  8. 8. Skeletel Openbite Dental Openbite It is a result of increased downward and backward inclination of the mandible. The mandibular angle is increased. It is a result of underdevelopment anteriorly of the maxillary and mandibular alveolar processes. DIEEFRENCE BETWEEN SKELETAL AND DENTAL OPENBITE DrRavikanthLakkakula 8
  9. 9. Skeletel anterior openbite Dental anterior openbite It is related to excessive vertical growth of dentoalveolar complex, especially in posterior molar region. It has occlusal contacts only at molar level, with both occlusal planes diverging anteriorly. It is primarly due to reduced incisor dentoalvelor vertical height. It has occlusal contacts in premolar and molar region, with Occlusal plane diverge from the first premolar forward. DrRavikanthLakkakula 9
  10. 10. 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. DrRavikanthLakkakula 10
  11. 11. In vertical growth patterns the dentoalveolar symptoms include a protrusion in the upper anterior teeth with lingual inclination of the lower incisors and over eruption of posterior teeth and steeper than normal mandibular plane angle. DrRavikanthLakkakula 11
  12. 12. In horizontal growth patterns, tongue posture and thrust may cause proclination of both upper and lower incisors. DrRavikanthLakkakula 12
  13. 13. Dr Ravikanth Lakkakula 13
  14. 14. Dental openbite is a openbite without facial is associated with some or following characteristics , 1.Normal craniofacial pattern. 2.Proclined incisors. 3.Under Erupted anterior teeth. 4.Normal or slightly excessive molar height. 5.Mesial inclination of posterior dentition. 6.failure of eruption of teeth with unknown etiology. 7.Divergent of upper and lower occlusal planes. 8.No gummy smile. 9.No vertical maxillary excess. 10. Habits like thumb ,finger suking and tongue thrusting. 11.Without remarkable cephalometric findings. 12.There may be spacing between anteriors. 13. Speech defects can be found with lisping of voice.There may be associated upper respiratory infections . Lisping associated with Anterior openbite and spacings is called Interdental Stigmatism. DrRavikanthLakkakula 14
  15. 15. VARIOUS FORMS OF ANTERIOR OPENBITE 1. An overjet combined with an open bite of less than 1mm can be designated as pseudo-open bite problems. 2. A “ simple open bite ” exists in cases in which more than 1 mm of space may be observed between the incisors, but the posterior teeth are in occlusion. 3. A “ complex open bite ” designates those cases in which the open bite extends from the premolars or deciduous molars on one side to the corresponding teeth on the other side. DrRavikanthLakkakula 15
  16. 16. 4. The “ compound or infantile ” open bite is completely open, including the molars. 5. The “ iatrogenic ” open bite is the consequence of orthodontic therapy, which produces atypical configurations because of appliance manipulation or adaptive neuromuscular response. In mixed dentition period , various therapeutic measures may causes an Open bite : 1. An open activator with a high construction bite causes a tongue thrust habit and resultant anterior openbite. During intrusion of posterior teeth a posterior openbite also may be created , especially in the deciduous dentition. DrRavikanthLakkakula 16
  17. 17. 2. In expansion treatment the buccal segments can be tipped excessively buccally , with elongation of the lingual cusps. This creates prematurity and effectively opens the bite. 3. In distalisation of maxillary first molars with extraoral force the molars are often tipped down and back , elongating the mesial cusps. This creates a molar fulcrum that open the bite and is of particular concern in downward and backward growing faces that already have excessive anterior face heights. DrRavikanthLakkakula 17
  18. 18. POSTERIOR OPENBITE It is a condition characterized by lack of contact between the posteriors when the teeth are in occlusion. It is mostly occurs in the segment of posterior teeth. Causes of posterior openbite : 1.Mechanical interference with eruption either before or after the tooth emerge the alveolar bone. 2.Failure of eruptive mechanism of tooth so that excepted amount of tooth eruption does not occur. DrRavikanthLakkakula 18
  19. 19. Mechanical interference with eruption may be caused by ankylosis of the tooth to the alveolarbone, which can occur spontaneously or as a result of trauma, or by obstacles in the path of the erupting tooth. Examples of such obstructions prior to emergence are supernumerary teeth and non resorbing deciduous tooth roots or alveolar bone. After the tooth emerges from the bone, pressure form soft tissues interposed between the teeth (cheek, tongue, finger) can be obstacles to eruption . Ankylosed teeth are usually in infra occlussion and are said to be submerged. The most commonly submerged tooth is retained lower deciduous second molar. DrRavikanthLakkakula 19
  20. 20. The second possible cause of eruption failure is a disturbance of the eruption mechanism itself. These patients have no other recognizable disorder, and no mechanical interferences with eruption seem to exist. The condition may be the cause of posterior open-bite which does not respond to orthodontic treatment. Treatment The primary aim of treatment should be to remove the cause. Lateral tongue spikes are a valuable aid in control of lateral tongue thrust.Once the habit is intercepted, a spontaneous improvement often follows. The posteriors can be forcefully extruded. In cases of posterior open bite due to infra occlusion of ankylosed teeth, it is best treated by crowns on posteriors to restore normal occlusal level. DrRavikanthLakkakula 20
  21. 21. SKELETAL OPEN BITE POSITIONAL DEVIATIONS According to Sassouni 1. The four bony planes of the face are steep to each other, bringing the center 0 close to the profile. DrRavikanthLakkakula 21
  22. 22. 2. The anterior arc, therefore follows the convexity of the profile. DrRavikanthLakkakula 22
  23. 23. 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. DrRavikanthLakkakula 23
  24. 24. 4. The cranial base angle and the gonial angle are obtuse. DrRavikanthLakkakula 24
  25. 25. DIMENSIONAL DEVIATIONS 1.The total posterior facial height (S-Go) tends to be half the size of the anterior total facial height (N- Me). DrRavikanthLakkakula 25
  26. 26. 2.The lower anterior facial height exceeds the upper anterior facial height. DrRavikanthLakkakula 26
  27. 27. 3.The facial breadths tend to be narrow, giving a long, ovoid appearance in the frontal view. DrRavikanthLakkakula 27
  28. 28. 5. The ramus is short with an antegonial notch at its lower border. 6. The mandibular symphysis is narrow antero posteriorly and long vertically. 7. Maxillary base : Upward tipping of the forward end of the maxillary base and Downward tipping of the posterior end of the maxillary base.(anticlockwise) DrRavikanthLakkakula 28
  29. 29. 8. There is a lack of chin mental protuberance development. 9.According to the Sheldonian somatotyping, the open-bite type rates high in ecto-morphs. 10.The palatal vault is high and narrow and anteriorly tipped-up palatal plane and divergent occlusal planes. 11.Nasal apparatus are narrow. 12.The temporal fossa is small, suggestive of weak musculature. 13.The cranium is sometimes dolichocephalic. 14.Distal condylar inclination. DrRavikanthLakkakula 29
  30. 30. 15. Proportionally large teeth characterize the dentition. 16. Crowding and bi-dental protrusion are often present. 17. The mouth is wide. The broad lips, short vertically relative to their skeletal support, are kept apart at rest, leading to mouth breathing. 18. When the lips are forcibly closed, the mentalis muscle is displaced upward. This further increases the “chinless” appearance of these persons.(weak perioral musculature.) 19. Large interlabial gap and gummy smile present. DrRavikanthLakkakula 30
  31. 31. SKELETAL CLASS II OPEN BITE 1. This combination is primarily an open-bite type, positionally and dimensionally. 2. The major variant is in the antero-posterior dimensions of the jaws. The palate may be longer, and the mandible shorter. 3. The differential evaluation of these two possibilities is important, as the prognosis and the treatment approach may be different. 4. In this respect, it points out that a given dental Class II malocclusion may be present in opposite facial types. DrRavikanthLakkakula 31
  32. 32. 5. 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. 6. 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. DrRavikanthLakkakula 32
  33. 33. SKELETAL CLASS III OPEN BITE This combination consists primarily of an open-bite with a palatal deficiency or a large mandible. Among the facial deformities, these have probably the worst prognosis in terms of dentofacial orthopedics. DrRavikanthLakkakula 33
  34. 34. If correction of this open-bite is attempted by rotating the mandible in a closing direction, the protrusion of the chin is increased. On the other hand, the reduction of the mandibular protrusion is attempted by rotating the mandible downward and backward, the open-bite is increased. Even surgical correction of the mandible is of limited benefit here, as the teeth interfere in the closing of the lower face height. DrRavikanthLakkakula 34
  35. 35. ETIOLOGY A) Epigenetic factors. 1. Posture, morphology and size of the tongue. 2. Skeletal growth patterns of the maxilla and the mandible. 3. The vertical relationship of the jaw bases. B ) Environmental factors 1. Abnormal function . 1. Thumb or Digit sucking habit. 2. Tongue thrusting habit. 2. Improper respiration. 1. Mouth breathing. C ) Genetics. D) Other factors - Trauma (to condyle) - Idiopathic condylar resorption. - Jevenile rheumatoid arthritis. DrRavikanthLakkakula 35
  36. 36. Open bite develops as result of the interaction of many etiologic factors. 1. In young children, digit habits and pacifiers are the most common etiologic agents. 2. 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. DrRavikanthLakkakula 36
  37. 37. 3. 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. DrRavikanthLakkakula 37
  38. 38. SKELETAL FACTORS IN THE DEVELOPMENT OF AN OPEN BITE TYPE: The combination of 1. Excessive development of the upper mid-face heights. (cranial base to molars) 2. A lack of development of posterior facial heights (S- Go) results in the downward and backward rotation of the mandible. DrRavikanthLakkakula 38
  39. 39. 2. The posterior half of the palate is tipped downward, carrying the molars further downward. This gives rise to a large palato mandibular plane angle. 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. DrRavikanthLakkakula 39
  40. 40. 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. DrRavikanthLakkakula 40
  41. 41. SUCKING HABIT Sucking the right thumb involving the nose. The patient presses the thumb onto the palate on both the front section of the maxilla and the upper anterior teeth.the finger also rest on the lower inncisors as a fulcrum. Intra oral symptoms Sucking or pressing the thumb against the maxilla promotes the development of a class 2 malocclusion. If the finger rest on the mandible ,the lower teeth are often moved forwards resulting in an edge to edge bite or crossbite. Apposition of sucking finger on the maxilla DrRavikanthLakkakula 41
  42. 42. APPOSITION OF SUCKING ON THE MANDIBLE The Ring finger and little finger are pressed onto the lingual side of the mandibular alveolar process and the lower anterior teeth ; the index and middle fingers rest on the cheek. This type of suckling habit tilts the upper and lower teeth toward the labial. The change in position of the upper teeth is mostly mechanical and that of the lower teeth a secondary effect of the forward downward tongue posture. DrRavikanthLakkakula 42
  43. 43. TONGUE POSTURE 1.Tongue posture and function should be primary considerations in Open-bite problems. According to Proffit “ if a patient has a forward thrusting posture of the tongue, the duration of this pressure even if very light could affect tooth position vertically or horizontally”. 2. Differentiation between primary causal and secondary adaptive or compensatory tongue dysfunction is essential. According to Proffit “A tongue thrust swallow is a useful physiologic adaptation if you have an open bite, which is why an individual with an open bite also has a tongue thrust swallow” (i.e.Secondary adaptive tongue dysfunction) DrRavikanthLakkakula 43
  44. 44. ACCORDING TO BAHR AND HOLT, FOUR VARIETIES OF TONGUE THRUST MAY BE DIFFERENTIATED 1. Tongue thrust causing anterior deformation:- i.e anterior open bite, sometimes coupled with bilateral narrowing of the arch and a posterior crossbite. Moyers (1964) terms this a simple open bite. 2. Tongue thrust without deformation :- Despite the abnormal function, no deformations ensues. DrRavikanthLakkakula 44
  45. 45. 3. Tongue thrust causing buccal segment deformation with a posterior open bite is often seen clinically. Lateral tongue thrust activity also can be responsible for a functional deep bite, a variation of the posterior open bite. Some Class II, division 2 malocclusion fit this category. Invagination of the cheek into the interocclusal space also may be a factor in this dysfunction. 4. Combined tongue thrust:- causing both an anterior and a posterior open bite, is another common dysfunction. This is called a complex open bite by Moyers and is more difficult to treat. DrRavikanthLakkakula 45
  46. 46. ACCORDING TO RAKOSI, FOUR VARIETIES OF OPEN BITE DUE TO TONGUE POSTURE MAY BE DIFFERENTIATED: 1.Anterior Open Bite Occlusal Openbite in a deciduous dentition, caused by a tongue dysfunction as a residum of a sucking habit. Habitual position : The tongue positioned forward during functioning, thus impeding the vertical development of the dento alveolar structures around the upper and lower anterior teeth. DrRavikanthLakkakula 46
  47. 47. 2.. Lateral Openbite Occlusal In this type of open bite the occlusion on both sides is supported only anteriorly and by the first permanent molars. Habitual Position The tongue thrusts between the teeth laterally. The tongue dysfunction occurs in conjunction with a disturbance in the physiologic growth processed around the first and second deciduous molars. DrRavikanthLakkakula 47
  48. 48. 3.Complex open bite: Occlusal Severe vertical malocclusion. The teeth occlude only on the second molars. Habitual Position : Tongue-thrusting occurs during function. DrRavikanthLakkakula 48
  49. 49. 4.Tongue dysfunction and malocclusion: In mandibular prognathism, the downward forward displacement of the tongue often causes an anterior tongue-thrust habit. DrRavikanthLakkakula 49
  50. 50. Visceral swallowing (infantile swallowing ) has time linked etiology for tongue thrust. It is physiologically normal until the child 4 years of age. After this time , the visceral swallowing act is considered an orofacial dysfunction, should this type of deglutition , with tongue thrust and contraction of the facial musculature, persist in older children and adults, it may be among others a result of a long term sucking habit associated with an open bite. DrRavikanthLakkakula 50
  51. 51. MOUTH BREATHING 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 thereby altering the oro - facial equilibrium leading to malocclusion. Chronically disturbed nasal respiration represents a dysfunction of the orofacial musculature; it can restrict development if the dentition and hinders the orthodontic treatment. The extra oral appearance of these patients is often conspicuous. And is termed “adenoid facies” DrRavikanthLakkakula 51
  52. 52. Classification of mouth breathers , 1. Obstructive Complete or partial obstruction of the nasal passage. 2. Habitual Unconsciously performed act whereby breathing occurs despite removal of obstruction. 3. Anatomic Lip morphology does not permit complete closure of the mouth. DrRavikanthLakkakula 52
  53. 53. OCCLUSAL AND DENTAL FINDINGS IN CASE OF ORONASAL RESPIRATION 1. Upper jaw is constricted. 2. Mandibular arch is well formed 3. bilateral cross-bite. 4. high palate and narrow upper arch. 5. Long and narrow face. 6. Narrow nose and nasal passage. 7. Short and flaccid upper lip. 8. Contracted maxillary arch. 9. Flaring of incisors. 10. Anterior marginal gingivitis. DrRavikanthLakkakula 53
  54. 54. GENETICS The genetic component of an open bite is related primarly to the patients inheriting growth potential. Studies have shown that traits such as anterior facial heights are to a high degree ,inherited. Obtaining thorough family history will help the clinician predict a patients growth potential. DrRavikanthLakkakula 54
  55. 55. THE ASSOCIATION BETWEEN ANTERIOR OPEN-BITE AND AMELOGENESIS 1. Amelogenesis imperfecta were investigated clinically, and with cephalometric radiography in order to determine the prevalence and nature of the anterior open-bite. 2. It is suggested that the frequent association of anterior open-bite and amelogenesis imperfecta is caused by a genetically determined anomaly of craniofacial development, rather than by local factors influencing alveolar growth. DrRavikanthLakkakula 55
  56. 56. This anomaly characterized by an anterior infra occlusion or anterior open-bite. Issel believe that the co-existence of the two conditions may be attributed to a pleiotropic action of the amelogenesis imperfecta genes, influencing the growth of the craniofacial skeleton. Witkop and his co-workers, postulated that rough and sensitive teeth lead to abnormal tongue activity which, displaces the anterior teeth to produce a open-bite, Locally interfere with the growth of the alveolar processes, and could alter the morphology of the craniofacial complex DrRavikanthLakkakula 56
  57. 57. OPEN BITE DUE TO RICKETS Enamel hypoplasia of the upper and lower anterior teeth as well as of the first molars results from a vitamin D deficiency which occurred at the age of about 1 year of age. The skeletal and dento alveolar open bite is aggravated by the adaptive tongue dysfunction. DrRavikanthLakkakula 57
  58. 58. MANAGEMENT Management is based on etiology and localization of malocclusion 1. Management in dento-alveolar open bite Habit control and elimination of abnormal perioral muscle function 2. Management in skeletal open bite 1. During active growth phase. Redirection of growth. 2. After active growth phase. Extraction and orthodontics or orthognathic surgery DrRavikanthLakkakula 58
  59. 59. The timing of treatment and determination of growth pattern are crucial. Based on type of dentition , the management can be divided into 1. Management in deciduous dentition. 2. Management in mixed dentition. 3.Management in permanent dentition. DrRavikanthLakkakula 59
  60. 60. TREATMENT IN 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. Autonomous improvement can be expected only , if the deforming muscle activity is terminated and the open bite is not complicated by crowding or cross bite of the upper arch. DrRavikanthLakkakula 60
  61. 61. 4. Treatment with screening appliances is indicated in such open- bite cases. 5. A skeletal open bite is seldom observed in the deciduous dentition. Habit control is of only secondary consideration in these cases, retarding the increasing severity of the dysplasia. 6. Extra oral orthopaedic appliances such as chin cups can be used effectively to redirect the growth. DrRavikanthLakkakula 61
  62. 62. SCREENING APPLIANCES 1. Screening appliances intercept and eliminate all abnormal peri-oral 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. DrRavikanthLakkakula 62
  63. 63. Management of mixed dentition 1. Dento-alveolar 1. Early mixed dentition. - Screening appliances and habit breaking appliances. 2. Late mixed dentition - Multi-attachment fixed appliances. - Extended retention phase. - Swallowing and lip exercises. 2. Skeletal Management depends on severity of malocclusion and possibility of a Dento -Alvelolar compensation. DrRavikanthLakkakula 63
  64. 64. The inclination of the maxillary base plays a vital role in the management. If the jaw bases are divergent, the prognosis is poor. If the maxillary base is tipped downward and forward, functional appliance therapy may be successful. If the jaw bases are divergent, fixed appliance therapy is indicated In severe cases, orthognathic surgery with impaction of buccal segments is performed. If the lip sealing ability is disturbed, surgical resection of the mentalis muscle is performed to reduce the ‘golf ball’ chin effect. Schili insists on surgery after eruption of lower canines to enhance stability. DrRavikanthLakkakula 64
  65. 65. 3.Combined dento-alveolar and skeletal - Elimination of abnormal perioral function Screening and habit breaking appliances, serial extraction, activators, etc. - Improvement of the skeletal relationship Fixed appliances or orthognathic surgery (severe) DrRavikanthLakkakula 65
  66. 66. MANAGEMENT IN PERMANENT DENTITION Treatment approaches can be divided into 1.Habit control , lip seal and swallowing exercises. 2. Growth modification to control vertical growth and posterior dento alveolar development.(early permenent dentition period.) 3.Orthodontic camouflage(only orthodontics) 4.Orthognathic surgery (combined orthodontic and surgery) DrRavikanthLakkakula 66
  67. 67. HABIT BREAKING APPLIANCES 1. spur appliance. 2. Blue grass appliance 3. Crib appliance. 4. Quad helix. 5. Oral screen. DrRavikanthLakkakula 67
  68. 68. SPUR APPIANCE The spur appliance is constructed from 0.045-inch stainless Steel wire to which eight short, sharpened 0.026-inch spurs, 3 mm in length, are soldered to the anterior part. The spurs are positioned 3 mm away from the cingulae of the maxillary incisors and are directed at an angle (downward & backward) to encourage correct tongue posture, with the tip of the tongue behind the maxillary central incisor papilla. The spur appliance is soldered to maxillary molar bands and cemented. DrRavikanthLakkakula 68
  69. 69. The anterior open bite usually takes 6 to 8 months to close after appliance cementation, but may take longer in some patients. The maxillary lingual arch with spurs is a more versatile appliance for modifying anterior tongue rest posture for the following reasons: 1. It allows expansion or reduction in inter molar width. 2. It inhibits molar eruption. 3. Spurs can be placed anywhere along the arch (which allows correction of both anterior and posterior open bites). 4. It permits headgear wear by welding buccal tubes on the molar bands to which the lingual arch is soldered. 5. It can arrest finger habits. 6. It is inexpensive. 7. It is easy to construct in the office DrRavikanthLakkakula 69
  71. 71. BLUE GRASS APPLIANCE Haskell was introduced, to conjunction with a program of positive reinforcement in managing thumb sucking in children 7-13 years of age. It consist of a modify six sided roller machined from teflon (Beveled on 3 sides, 5/8 inch in length , ¼ inch in diameter) to permit purchase of tongue. This is slipped over 0.045 stainless steel wire soldered to maxillary first permanent or deciduous second molar orthodontic bands. This appliance is placed for three to six months. DrRavikanthLakkakula 71
  72. 72. The patient believes they have acquired a new “ toy ” with which to play with their tongue, as instructions have given him to roll the roller , instead of sucking the digit. Long-term familiarity with the roller reduced the oral gratification and depending upon appliance use. Thus, digit sucking was eliminated and the dependency upon a positive reinforcement was slowly removed. DrRavikanthLakkakula 72
  73. 73. CRIB APPLIANCE It may be a fixed or removable appliance. The removable appliance is made of acrylic, like a fence. The cribs are long vertical cribs, made in the anterior palatal aspect, resting lingually to the upper anterior, long aspect, resting lingually to the upper anteriors ,long enough, not to interfere with the mandibular movements. It is made up of 020 inch ss wire , lies 3-4mm from the incision, having a length of 6-12mm. The cribs act as 1) To break the suction and force of the digit on the anterior segment. 2) To remind the patient of his habit. 3) To make the habit a non-pleasurable one. DrRavikanthLakkakula 73
  74. 74. QUAD HELIX WITH CRIBS APPIANCE The quad helix is fixed appliance used to expand the constricted maxillary arch. The palatal cribs is designed to interrupt a digit sucking habit by interfering with finger placement as sucking satisfaction. This can also be used as retainer following maxillary expansion with quad helix. A heavy lingual archwire (0.038 inch) is bent to fit passively in the palate and is soldered to the molar bands. Additional wire is soldered into base wire to from crib as mechanical obstruction for the digit. DrRavikanthLakkakula 74
  75. 75. ORAL SCREEN Introduced by Newell . Most effective way to reestablish nasal breathing is to prevent air from entering the oral cavity. Oral screen should be constructed with acrylic material compatible with the oral tissues. Reduction in the anterior open bite is obtained after treatment for 3-6 months. It acts in a number of ways. 1. Prevents the habit. 2. Corrects the open-bite. 3. Exercises the hypo tonic lip and the mentalis muscle. DrRavikanthLakkakula 75
  76. 76. THERMOPLASTIC THUMB POST A thumb device is usually made of nontoxic plastic and is worn over the child's thumb. It is held in place with straps that go around the wrist. A thumb device prevents a child from being able to suck thumb and is worn all day. It is removed after the child has gone 24 hours without trying to suck a thumb. The device is put back if the child starts to suck his or her thumb again. Thumb devices need to be fitted by a health professional. DrRavikanthLakkakula 76
  77. 77. MYOFUNCTIONAL AND ORTHOPAEDIC THERAPY (GROWTH MODIFICATION METHODS) The openbites can be intercepted by growth modulation. The aim is to achieve counter clockwise mandibular rotation and clock wise rotation of maxilla for closure of an open bite, in order to control the increase in anterior face height and achieve improved occlusal outcomes and a balanced profile.Treatment approach is directed at vertical control of facial growth and / or ‘real’ or relative intrusion of the posterior teeth. 1.High pull head gear. 2.Vertical chincup. 2. Frankel 4 Regulator. 3. Bionator. 4 . Activator. 5. Posterior bite blocks. 7. Active vertical corrector. DrRavikanthLakkakula 77
  78. 78. 8. Vertical holding appliance. 9. Spring loaded bite block. 10. Rapid molar intruder appliance. 11. Tandem appliance. 11. Elastic activator. DrRavikanthLakkakula 78
  79. 79. HIGH PULL HEAD GEAR (KUHN, 1976) The occipital headgear consists of a long outer bow which fits over the occiput of the head. The force generated by a high pull (occipital) has both distalising and intrusive forces since the force is exerted above the occlusal plane. Such forces are used in conditions where vertical control of the molars is important. The maxillary posterior segment can be intruded by an occipital headgear which rotates the maxilla in clock wise direction thereby closing the open bite . DrRavikanthLakkakula 79
  80. 80. VERTICAL PULL CHIN CUP Patients exhibiting a downward and backward rotation of the Mandible with increased vertical growth, benefit from therapy using a vertical pull head gear with chin cup if treated during the mixed dentition period. Vertical chin cup inhibits the vertical growth in the mandibular posterior dentoalveolar region. It decreases mandibular plane angle and helps in closure of gonial angle indicating anterior rotation of mandible. DrRavikanthLakkakula 80
  81. 81. FRANKEL ǀѴ REGULATOR((FRÄNKEL, 1980) It is used as Exercise device for an early interference with functional deviation in the presence of Openbite and bimaxillary protrusion in deciduous and early mixed dentition. It is indicated in cases where the incompetence of an anterior oral seal is associated with a poor behaviour of the lip musculature. Therapeutic effect with Frankel 4 can only be expected when the child is co-operative in lip exercises and mode of action of the labial pads are context with that of the buccal pads. DrRavikanthLakkakula 81
  82. 82. FR – 4 has two buccal shields , two lower lip pads , a palatal bow , an upper labial wire and four occlusal rests made of 20 guage stainless steel wire. The main purpose of the acrylic components is to interfere with abberent functions of the cheek and lip musculature. Another important aim is to establish a structural and functional balance between the various muscle group of the Circum oral capsule. DrRavikanthLakkakula 82
  83. 83. The lower lip pads should restrict an hyperactive mentalis muscle and train the lip musculature for establishing a proper anterior seal. The labial bow may be used to correct proclination of maxillary incisors. Occlusal rests should individually be adapted to the anatomy of the Occlusal surfaces of the maxillary buccal teeth and are to stabilize the appliance vertically. Palatal bow placed behind the last molar allowing the appliance to shift in a dorsal direction. Any notching inter proximally has to be avoided to make sure that a dorsal shifting of the appliance is not impeded by lodging of occusal rests interdentally. DrRavikanthLakkakula 83
  84. 84. Buccal shields should extend deep into the sulci, particularly in the apical region of the maxillary first premolar and the maxillary tuberosity. The thickness of the acrylic shields should not exceed 2.5 mm. Labial pads : It have rhomboid shape which best fits the labial surface of the lower frontal alveolar process. The upper edges of the lip pads should have a distance of at least 5mm from the gingival margin which is important for preventing stripping of the labial gingiva. Distal edge of the pads should not overlap the labial protuberance of the canine root which would render speaking difficult and irritate the mucosa of the lower lip. Main purpose of lip pads is to prevent a hyper active mentalis muscle from raising the lower lip. DrRavikanthLakkakula 84
  85. 85. Working principle of FR – 4 The working principle is established forward rotation with the posterior edge of the buccal shield as the rotational centre. Anterior the mandible is raised by the force vector of anterior vertical muscle that are strengthen by lip exercise. 1. Aimed at correcting the poor lip valve mechanism. 2. Marked activity of temporalis and masseter when lips are closed 3.According to Frankel tongue thrust is compensatory. Proper lip seal function of anterior valve depends on postural equilibrium between muscles located circularly and those located radially around the mouth. DrRavikanthLakkakula 85
  86. 86. LIP AND SWALLOWING EXERCISES Lip exercises (Eg: holding a paper or cardboard between lips, button holding method ) can improve the lip seal. These exercises are repeat several times a day. Children’s in school are asked to hold the lips together while in class , they can practice at home with small piece of paper. swallowing exercises (i.e, swallowing without tongue thrusting, putting the tip of the tongue behind the upper or lower incisors ) may reinforce the establishment of a mature deglutitional and functional pattern for the tongue during both treatment and retention. DrRavikanthLakkakula 86
  87. 87. BIONATOR(PEARSON, 1978) The open bite appliance is used to inhibit the abnormal posture and function of the tongue. 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. To inhibit the tongue movements the acrylic portion of the lower lingual part extends into the upper incisor region as lingual shield, closing the anterior space without touching the upper teeth. DrRavikanthLakkakula 87
  88. 88. The labial bow wire runs approximately between the incisal edges of the upper and lower incisors. The labial part of the bow is placed at the height of correct lip closure , thus stimulating the lips to achieve a component seal and relationship. The vertical strain on the lips tends to encourage the extrusive movement of the incisors after eliminating the tongue pressures. DrRavikanthLakkakula 88
  89. 89. ACTIVATOR The activator is not indicate for treatment of skeletal open bite. It may be used treatment of open bite tongue thrust and finger sucking habit. The activator is constructed so that eruption of posterior teeth prevented, where as elongation of anterior teeth encouraged. The incisor area is ground away for extrusion and the molar area ground away for extrusion. Besides the correcting vertical development, activator act as a habit appliance by intercepting tongue – lip contact. DrRavikanthLakkakula 89
  90. 90. POSTERIOR BITE BLOCK Posterior bite blocks impede posterior teeth eruption and their design has been continuously modified. They can be made of wire or plastic to fit between the maxillary and Mandibular teeth, or they can be spring-loaded or fitted with magnets. The blocks are usually set at a slightly elevated position vertically, so that, in theory, the stretched muscles place an intrusive force on the posterior teeth, which in turn helps control eruption and permits an upward and forward autorotation of the Mandible. DrRavikanthLakkakula 90
  91. 91. ACTIVE VERTICAL CORRECTOR The active vertical corrector , designed by Dellinger, has a two occusal bite block with cobalt – samarium Magnets, in repulsion produces 600 – 700 grams of force per magnet. Acrylic shields prevent lateral jaw deviations and the corrector can be used together with head gear or vertical chin cup. DrRavikanthLakkakula 91
  92. 92. In each arch, two circular (1.5 ×10 mm) neodymium- Iron- boron magnets (high energy Magnetics) were inserted in repelling mode in the first molar region. The appliance itself consisted of a posterior maxillary and mandibular occlusal bite block. The right and left bite blocks were connected by a 1.0-mm steel bar ; both bite blocks were retained by two Adams clasps in each quadrant. To prevent the development of a cross bite due to shearing forces, buccal shields that extended occlusally were added to the mandibular bite block. DrRavikanthLakkakula 92
  93. 93. One magnet per distal quadrant was used, with the exception is if all the permanent teeth erupted, where two magnets were used. In Bite-block group, the appliance had the same thickness as the two components of the magnet splints. The appliance was removable except for one case where bite- blocks were fixed with glass-ionomer cement because the patient was concerned that he might forget to use the Appliance. DrRavikanthLakkakula 93
  94. 94. The repelling magnets transfers the continuous forces to the posterior teeth, varying in magnitude according to the distance between the magnets ; the closer the magnets, the higher the force, while the bite-block appliance transferred intermittent forces to the teeth only when it was in contact with them. Correction of open bites was achieved by the intrusion of the posterior teeth in both arches by Reciprocal forces; this resulted in a reduction in Anterior facial height, which allowed the mandible to rotate in upward and forward directions after 4–7 months of treatment. DrRavikanthLakkakula 94
  95. 95. VERTICAL HOLDING APPLIANCE (WILSON) The vertical holding appliance (VHA) is a modified transpalatal arch that has an acrylic pad. The VHA uses tongue pressure to reduce the vertical dentoalveolar Development of maxillary permanent first molars. Some researchers have concluded that the VHA is useful in restricting and helping reduce the percentage of lower anterior facial height in growing patients. DrRavikanthLakkakula 95
  96. 96. The VHA was fabricated with banded maxillary permanent first molars connected with a 0.040 - inch chrome cobalt wire with a dime-size acrylic button at the sagittal and vertical level of the gingival margin of the molar bands. Four helices were incorporated into the wire configuration for flexibility. The appliance was cemented in place. DrRavikanthLakkakula 96
  97. 97. SPRING-LOADED BITE BLOCK The construction bite was taken by hinging the mandible open 3 to 4 mm beyond the rest position in centric relation. This resulted in 6.0 to 8.0 mm of vertical opening in the second premolar region. The spring-loaded bite block has helical springs made of 0.9 mm stainless steel wire that are placed both lingually and buccally between the first premolar region and the last molar region. DrRavikanthLakkakula 97
  98. 98. The lower end of the buccal spring was soldered to an Adam’s clasp (0.8 mm, stainless steel), whereas its occlusal end was completely embedded into the occlusal bite block . The lingual spring was inserted with both ends in the acrylic resin of the occlusal bite block and mandibular plate. Two, a 0.9-mm stainless steel hook was placed buccally into the occlusal bite block in the molar region to measure the amount of activation with a Dontrix gauge . During each appointment (every 4 weeks), the springs were activated to apply an intrusive force of 450 grams. DrRavikanthLakkakula 98
  99. 99. Patients are instructed to use the appliance for an Average of 14 hr Daily for 6 months. Intrusive forces are generated by masticatory muscles (anterior temporalis , posterior temporalis and masseter) leads to intrusion of posterior teeth , there by autorotating the mandible , leads to reducing the open bite. DrRavikanthLakkakula 99
  100. 100. Early growth modification of midfacial deficiency with expansion and facemask therapy has been the standard treatment for Class III malocclusions. A disadvantage of this approach is that it alters both the anteroposterior and vertical planes; the desired downward and forward movement of the maxilla is often accompanied by downward and backward clockwise rotation of the mandible. Although such mandibular rotation is desirable in deep-bite cases with Hypodivergent growth patterns, it is inappropriate for Patients with anterior open bites and hyperdivergent Growth patterns. TANDEM APPLIANCE DrRavikanthLakkakula 100
  101. 101. The vertical dimension can be managed in hyperdivergent- growth patients by utilizing appliances with interocclusal acrylic, such as a bonded expander, bite blocks and tandem appliance. Dr. Klempner (2011) is the inventor of this appliance. Tandem Appliance comprises three separate components, one fixed and two removable. The upper section is a fixed Hyrax, Haas, Quad Helix, or Max-2000 expander with buccal arms soldered for attachment of protraction Elastics. DrRavikanthLakkakula 101
  102. 102. The lower section is similar to a removable retainer, with posterior occlusal coverage and buccal headgear tubes embedded in the lower first-molar regions . An .045" headgear face bow, with the outer bows bent out For elastics attachment, is inserted into the lower tubes. DrRavikanthLakkakula 102
  103. 103. Posterior finger clasps are placed mesial and distal to the second deciduous molars, with C-clasps on the lower deciduous canines for mechanical retention. The bonding small composite buttons to the labial surfaces of the lower canines to engage the C - clasps and thus ensure stability of the appliance during traction. In the deciduous dentition, where adequate retention may be a particular concern, a lower midline expansion screw can be added, with instructions given to the parents to activate the screw one quarter turn as needed between visits. DrRavikanthLakkakula 103
  104. 104. At the beginning of treatment, patients are instructed to wear the appliance with light, 8 oz elastics from the outer face bow to the buccal arms of the upper expander. Subsequently, heavy orthopaedic traction with 14 oz elastics effectively delivers the protraction force to the maxilla. The posterior acrylic coverage of the lower appliance prevents maxillary extrusion during protraction, resulting in closure of the mandibular plane angle and the anterior open bite by Mandibular autorotation. DrRavikanthLakkakula 104
  105. 105. RAPID MOLAR INTRUDER APPLIANCE Drs. Aldo Carano and William C. Machata (2007) introduced. The RMI is a noncompliance appliance that can deliver continuous intrusion forces to the maxillary and mandibular molars. Besides the high patient acceptance and hygienic advantages, the appliance is easy to use with fixed appliances. The greatest advantage of starting treatment in the Permanent dentition is to combine the RMI with fixed Appliances so that both maxillary and mandibular Arches will be aligned simultaneously. DrRavikanthLakkakula 105
  106. 106. The RMI uses flexible spring modules to deliver intrusion forces to the maxillary and mandibular first molars. The appliance consists of one spring module and two ball connectors per side. The terminal ends of the flexible spring modules are designed to attach the ball connectors, which will insert into Headgear or lip bumper tubes welded on molar bands. DrRavikanthLakkakula 106
  107. 107. The Rapid Molar Intruder is available in two different sizes and force levels: Size M for mixed dentition cases - 800 gms of intrusive force. Size A for adult cases - 1000 gms of intrusive force. The straight terminal ends attach to upper Headgear tubes, and the angulated terminal ends attach to lower lip bumper tubes. The ball pin connectors were inserted mesially into both maxillary and mandibular molar tubes. DrRavikanthLakkakula 107
  108. 108. Mechanism of the appliance When the patient tends to close jaws, the intrusion force created by the flexion of the elastic spring modules is transferred to the maxillary and mandibular first molars, which will produce an upward and forward mandibular rotation . Because the force is applied buccal to the center of resistance of the molar teeth, buccal tipping of the molar crowns will be inevitable. To prevent this side effect, a transpalatal arch in the maxillary arch and a lingual arch in the mandibular arch should also be utilized. DrRavikanthLakkakula 108
  109. 109. The lingual and palatal arches were then soldered to the molar bands. For those patients with fully erupted second molars in the RMI plus fixed appliance group, a 1-mm stainless steel wire occlusal rest was added that extended from the transpalatal and lingual arches to the occlusal surface of the second molar to avoid elongation of these teeth. After molar intrusion is completed, leave the soldered palatal and lingual arch in place for retention. DrRavikanthLakkakula 109
  110. 110. ELASTIC ACTIVATOR (KINETOR) It is a modified activator ,is similar to activator,difference is posterior bite blocks are replaced by rubber tubes. The rigid intermaxillary part of the lateral occlusal zones is replaced by elastic rubber tubes which is Pushed on a wire loop with a diameter of 8 mm and thickness of 1.5mm. It is advisable to use highly resilient wire to avoid breakage during mastication. The rubber tubes are exchanged every 2–3 months for maintaining continuous tension in the neuromuscular system . DrRavikanthLakkakula 110
  111. 111. Mechanism of action Through tight fitting of the rubber tubes to the posterior teeth in rest position they exert an intrusive vertical force when swallowing or chewing. By stimulating orthopaedic gymnastics (chewing gum effect) counterclockwise rotation of the mandible was accomplished by a decrease of the gonial angle. DrRavikanthLakkakula 111
  112. 112. The design of the activator incorporates labial bows for control of the upper and lower anterior teeth. Facets cut in the acrylic help directing the eruption of the anterior teeth. The upper and lower front teeth should be at least 2 mm away from the acrylic when the patient has the appliance in the mouth and bites on it with the maximum force. The anteroposterior position is controlled with posterior clasps pressing against the mesial surface of the first molars.If there is a history of tongue hyperactivity a crib is Incorporated for behaviour modification by interfering with An anterior tongue position. DrRavikanthLakkakula 112
  113. 113. FIXED APPLIANCES MAEW technique. Extrusion arch technique. Preadjusted edgewise technique. Lingual technique. Invisaligners. Implants. Surgical orthodontics DrRavikanthLakkakula 113
  114. 114. MULTILOOP ARCHWIRE EDGEWISE TECHNIQUE Kim(1987) introduced multiloop archwire edwise technique to correct openbite malocclusion. It uses a combination of multiloops in boot shape on .016 × .022 inch ss wire in .018 edgewise slot and short heavy anterior 3/16 inch, 6 ounze elastic. The vertical loop segment serves as a break between the teeth, lowers the load/deflection rate and provides horizontal control. The horizontal loop further reduces the load/ deflection rate and provides vertical control. DrRavikanthLakkakula 114
  115. 115. There are five loops on either side vertical loop components are centered at interproximal areas and the horizontal loop components are directed mesially. Before the placement of MAEW teeth must be well aligned. The treatment changes with this technique mimimally effect the skeletal pattern ,mainly in the dento alveolar region by increasing upper and lower anterior dento alveolar heights. Recently so called modified MAEW or upper accuntuated and lower reverse curve Niti archwires combined with intermaxillary elastics was introduced by Enacar et al. DrRavikanthLakkakula 115
  116. 116. Kim suggested to wear anterior elastics at the first loop of upper and lower arches to intrude the posterior teeth. In case of upper midline shift or canine relation ship problem need to be corrected , direction of wearing elastics modified to attach between first and second loops, which depends upon type of malocclusion. In this case anterior elastics were worn at the first loop as kim suggested. The lower dental midline improved from the original by closing lower anterior spacing, but finally it shifted to the right by 0.5mm,which indicates that use modified anterior elastics as mentioned. DrRavikanthLakkakula 116
  117. 117. Made of .016 x .022 SS or .017 X .025 TMA with 900 offset bend at the molars. The extrusion arch is a one couple system that applies a single extrusive force to the anterior teeth and crown mesial/root distal moment and intrusive force to the posterior segment. When the anterior end of the extrusion arch wire is brought up and tied to the incisors, a second-order couple is produced at the molar which tends to rotate the molar crown mesial/root distal with a center of rotation located exactly at the center of resistance. EXTRUSION ARCH MECHANICS DrRavikanthLakkakula 117
  118. 118. The equilibrium is achieved because the anterior end of the wire wants to extrude the incisors and the wire in the molar tube tends to intrude the molar. Both these forces are equal and opposite and define another couple tending to rotate the whole system clockwise in an amount equal and opposite to the tendency of the couple at the molar bracket to rotate the system counter clockwise . DrRavikanthLakkakula 118
  119. 119. When the extrusion arch wire is seen from the frontal plane, it is clear that the intrusive force at the molar tube is acting buccal to the Center of resistance.This result in a tendency to intrude the molar and rotate it around the center of resistance in a crown facial/root lingual direction. This side effect can be minimized by stabilizing the molars with the help of a passive transpalatal arch. An alternative is the use of stiff 0.019x0.025 SS wire in the brackets of the anchor unit . Use of vertical elastics can counter the tip forward moment on the buccal segment. This will stabilize the buccal segment and minimize the adverse effect on the molars. DrRavikanthLakkakula 119
  120. 120. Action at the Incisors When a group of teeth is to be extruded, a segment of heavy arch wire (0.019x0.025 SS) may be used in the brackets of the anterior teeth, to consolidate them . The extrusion arch can be tied either to a segment of wire in the incisor brackets, a continuous arch wire in all of the brackets, or placed directly into the brackets of the incisors. If the extrusion arch is tied to a segment of wire in the anterior brackets, the segment of wire moves the teeth attached as a unit. This will move readily, but will move the incisor brackets to different heights than the rest of the teeth in the arch. DrRavikanthLakkakula 120
  121. 121. If the extrusion arch is tied to a continuous wire, the bracket heights are better maintained with respect to each other. Point of Application of Force If the extrusion arch is tied at the central incisors as single point contact, it is probably acting anterior to the center of resistance . Such a force, in addition to extruding the incisors, will act anterior to the center of resistance of the anterior segment. DrRavikanthLakkakula 121
  122. 122. PREADJUSTED EDGEWISE TECHNIQUE During bracket placement in open bite cases , upper and lower anterior brackets are placed 0.5 mm more gingivally than normal. It is helps to closure of bite. If second molars are need to banded for improving position or torque control later in the treatment, it is benificial to leave curve of spee in posterior aspect of lower arch and to step the archwire upto the second molars of the upper arch. This will minimize extrusion of first molars and premolars. DrRavikanthLakkakula 122
  123. 123. If class ǀǀ or class ǀǀǀ elastics are required , they should be attached to the posteriorly to the premolars rather than molars.These short elastics minimize the extrusive effect on the back of the arches. If upper and lower arch crowding is present and or protrusion , upper and lower premolar extraction considered. DrRavikanthLakkakula 123
  124. 124. If the lower arch does not require extraction for lower incisor retroclination and the molars are more than the 3-4 mm class ǀǀ , extraction of only upper bicuspids can be considered, this will allow for the retraction and retroclination of the upper incisors. If the lower arch does not require extraction for incisor retroclination and the molars are less than the 3mm class ǀǀ extraction of upper premolars are considered. It is most difficult to move upper molars forward 4-7 mm and keep their roots in uprigth position.This is required for proper class ǀǀ molar occlusion, upper second molar extraction considered in such cases, if good third molars are present. This allows for easy distalisation of first molars without opening of mandibular plane. DrRavikanthLakkakula 124
  125. 125. LINGUAL TECHNIQUE The tongue spurs effect 7 th Generation brackets are very thick in the bucco - lingual dimension (in-out), and are the main reason for patients discomfort, tongue irritation and speech problems. This is one of the most discouraging problems of the lingual system related to long hooks stabbing the tongue like spurs. In open bite patients this disadvantage is used as an advantage . After bonding these big irritating brackets, the patient experiences a sudden intraoral environmental change forcing him to modify his tongue posture due to the spiky brackets to a more backward position which is a normal tongue posture, and enables normal peri-oral seal and functional adaptation to the corrected open bite follows. DrRavikanthLakkakula 125
  126. 126. This may contribute to the stability of the open bite correction as was shown using crib therapy . However the posterior G7 brackets, premolars and molars, have no contribution regarding the tongue crib effect or the bite plate effect and may be replaced with flatter and more comfortable brackets. 7th Generation brackets are highly recommended in the anterior segment (canine to canine) for open cases. DrRavikanthLakkakula 126
  127. 127. INVISALIGNERS Clear Aligners with elastics (3/6 – 4 ounce)represent an easy way to treat open bite patients when a relapse occurs during the retention phase or when a minor extrusive tooth movement is necessary (extrusion of less than 2 to 3 mm) during aligner treatment. The aesthetics is excellent with the aligner since it is hardly visible. This can be a definite psychological advantage to teenagers and adults alike. The Clear Aligner with elastics can be used as an effective alternative in certain open bite cases for those who refuse to wear conventional fixed appliances. DrRavikanthLakkakula 127
  128. 128. In order to fabricate Clear Aligners to correct an open bite, impression are taken to create a working cast which is used with a plastic sheet of .030" in thickness (Duran, Scheu-dental, Germany) and a pressure molding machine (Biostar, Scheu-dental, Germany) or a vacuum machine (Dentsply Raintree Essix, Metairie, LA). Clear Aligners made from the set-up model with ideal occlusion are connected to the opposite arch with elastics using buttons attached to the Clear Aligner. Cow-Catch Clear Aligners could be used for finishing and detailing during aligner treatment or for relapse treatment cases. Clear Aligners with Intermaxillary Elastics (Cow-Catch Clear Aligners) DrRavikanthLakkakula 128
  129. 129. When the target tooth achieves its expected extrusion, it touches the surface of the Clear Aligner and no additional extrusion occurs. It has the advantage of being a fail-safe appliance. The main benefit of Cow-Catch Clear Aligners over a tooth positioner is the ability to extrude the teeth more rapidly with elastics . DrRavikanthLakkakula 129
  130. 130. MODIFIED COW-CATCH CLEAR ALIGNER (INTRA MAXILLARY ELASTICS) If the patient cannot open their mouth fully while wearing Cow-Catch Clear Aligners, this can be easily corrected using lingual buttons on the target teeth . A modified Cow-Catch Clear Aligner can be used just as the Cow-Catch Clear Aligner. It is also more convenient and comfortable for the patient because it allows for normal function to continue . Cow catch aligner Modified Cow catch aligne DrRavikanthLakkakula 130
  131. 131. After the anterior open bite treatment is finished, a 0.0175 inch multiflex wire can bonded lingually canine-to-canine as a fixed retainer on the target arch. Furthermore, the new Clear Aligners were delivered as a removable appliance. In order to prevent the intrusive movement of the anterior teeth due to relapse, small projections could be added into the interproximal areas of the target teeth using the Clear Aligner Plier. A potential disadvantage of this type of appliance is that it is highly dependent on patient compliance.17 The aligner should be worn with elastics at least 17 hours per day including sleeping time. DrRavikanthLakkakula 131
  132. 132. IMPLANTS Dr Ravikanth Lakkakula 132
  133. 133. In upper molar intrusion clockwise rotation of upper occlusal plane and lower molar intrusion produces counter clock rotation of occlusal plane and intrusion of upper and lower molar maintain the rotation of occlusal plane. In this way decision between upper and lower molar intrusion depends on initial angle of occlusal plane. In incial intrusion , the decision among the intrusion or extrusion in both arches depends upon incisal and gingival exposure with lips in rest and smiling. DrRavikanthLakkakula 133
  134. 134. VERTICAL ADJUSTABLE CORRECTOR Using a double tube in molars a rectangular intraoral arch wire can be ligated to all brackets. In gingival molar tube vertical adjustable corrector is used as second arch. The anchorage reinforced with three implants . One in midline , another two between first and second molar on each side.VAC is ligated to anterior micro implant to reinforce the anchorage and intrusion is carried out with elastic pull between the intraoral arch and VAC. DrRavikanthLakkakula 134
  135. 135. MINIPLATES  It essentially consists of titanium miniplates, which are stabilised in the maxilla or the mandible using screws.  Different designs of miniplates are available, the 'L' shaped miniplates have been the most commonly used ones, while the 'T' shaped ones have been proposed for usage while intruding anterior teeth . The screws used for fixing the miniplate are usually 2-2.5mm in diameter .  Intrusion of the lower molars was achieved with the application of power chain or closed coil spring. DrRavikanthLakkakula 135
  136. 136. SURGICAL MANAGEMENT DrRavikanthLakkakula 136
  137. 137. 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. 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 DrRavikanthLakkakula 137
  138. 138. 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 orthodontic- surgical approach. Superior repositioning of the maxilla, via total or segmental maxillary osteotomies, is indicated in skeletal open bite patients with excess vertical maxillary growth. DrRavikanthLakkakula 138
  139. 139. 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. DrRavikanthLakkakula 139
  140. 140. Bilateral sagital split osteotomy genioplasty Lefort ǀ osteotomy DrRavikanthLakkakula 140
  141. 141. 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. DrRavikanthLakkakula 141