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4. INTRODUCTION;
Open bite mal occlusion has long held
fascination in orthodontics.
It is difficult to treat and relapse
tendencies are strong.
- Young H. Kim AO 1987
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5. DEFINITIONS;
Normal bite: It is defined as vertical
overlap of the incisors. The lower incisal edges
in relation to the lingual surface of the upper
incisors present at or above the cingulam
(normally there is 1-2 mm overbite)
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16. Depend on position;
Intra arch
The tooth itself is
malpositioned within arch
creating open bite
- infraversion / inclination abnormally without
root.
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17. Inter arch;
-No vertical overlap
-abnormality in
upper/lower or both
- Ant/post segment
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20. ETIOLOGY OF OPEN BITE;
WHY OPEN BITE ?
- EPIGENETIC FACTORS
- ENVIRONMENTAL FACTORS
- HABITS
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21. Pre – disposing factors;
maxilla
Skeletal
Mandible
Dental
Excess eruption of posteriors
Decreased eruption of anteriors
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22. Various factors influencing open bite;
a) Disturbances in embryonic development;
1) Muscle dysfunction
2) Hemi mandibular hypertrophy
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23. 1) Muscle dysfunction;
Kiliaridis s, mejersjo c
- Etiology;
- Ejo 1989
- defect in the uterus.
- Pathology
- affect the particular muscle
Bone formation in the origin of
muscle
Loss of musculature
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30. b) Genetic influence;
- A strong influence of inheritence on
facial features is obvious at a glance.
- mal occlusion produced by inherited
characteristic in 2 ways;
What it has to do with open bite ?
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31. Long face pattern;
King L, Harris EF, Tolley EA
- AJO 1993
Long face syndrome;
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32. Ackerman, Isacson, Shapiro
- AJO 1970
Genetic inheritence
Skeletal influence
Dental influence
Open bite
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33. c) Environmental influence;
The open bite can be produced by
1) equilibrium forces
2) Functional forces
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34. 1) Equilibrium forces;
It states that object subject to unequal
forces will be accelerated and there by
move to different space.
Proffit WR; AO 1978
Hence the equilibrium has to be
maintained.
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36. a) Juvenile equilibrium;
The teeth that are in function
parallels the rate of vertical
growth of mandibular ramus
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37. The rate of eruption is controlled by forces
opposing direction, not those promoting it.
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38. 2) Functional forces;
Biting force and eruption
Downward growth
of mandible
Open bite
Masticatory muscle gains strength at puberty.
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39. HABITS
Definition;
It is the tendency towards an act of repeated
performance relatively fixed or consistent
and ease to perform by an individual.
We are just beginning to realize how common and
varied the vicious habits of lip and tongue, and
how power full and persist to overcome
- Angle.
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40. Earliest writings;
- causes of irregularities through habits that
pushes teeth forward.
- Lefoulon 1839
- balance of force to retain teeth in position.
- Desirabode 1843
- “lateral pressure theory”
- Bridgeman 1859
- “Sim Wallace theory”
- Bennett
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42. Thumb sucking;
Definition;
It is defined as the placement of thumb
or one/more fingers in varying depths
into the mouth.
Klein AJO 1979
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43. Physiological condition;
-It is considered normal till 3 – 4 yrs.
- It is an non nutritive sucking habit
- Recent studies indicate that thumb
sucking is practised even during the intra –
uterine life.
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46. Theories;
1) Freudan theory;
1- 3 years – oral and anal phase.
2) Oral drive theory of sears and wise;
1950
Prolonged habit leads to thumbsucking.
3) Benjamins theory;
Thumbsucking develops in infants due
to the rooting reflex/placing reflex.
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47. 4) Psychological aspects;
Children develop this habit as a feeling of
insecurity, when they are deprived of love,
care and affection.
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48. Phases of thumbsucking;
Phase – 1;
- First three years of life.
- sub clinically significant.
Phase - 2;
- 3 – 6 yrs of life.
- clinically significant.
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49. Phase - 3;
- beyond 5 – yrs.
- intractable sucking.
- Its an alert to an dentist.
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50. DIAGNOSIS;
- Check for childs emotional status.
- feeding habits
- Intra – oral examination;
- incissors
- open bite
- Clean nails
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51. TREATMENT;
1) Psychological approach;
Beta hypothesis theory by Dunlop
Consious purposeful repeatation.
2) Mechanical aids;
Basically reminders
3) Chemical approach;
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52. TONGUE THRUSTING
DEFINITION;
It is defined as the forward movement of
the tongue tip between the teeth to meet
the lower lip in deglutition and in sounds
of speech so that the tongue becomes
interdental.
Tulley AJO 1969
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53. Classification;
According to moyers;
Simple
complex
- To establish lip seal
- Anterior open bite
- Contraction of
circum – oral muscles.
- abnormal mentalis
- diffuse open bite.
- poor occlusion.
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55. According to James s. Braner and holt
Type 1 - Non deforming tongue thrust.
Type 2 – Deforming anterior tongue thrust.
Type 3 – Deforming lateral tongue thrust
Type 4 – Deforming ant; & lat; tongue thrust
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56. Etiology ;
According to fletcher;
1) Genetic factors;
Neuromuscular variations in oro
facial region.
2) Learned behaviour;
Prolonged action & gum tenderness.
3) maturational;
Age – swallow pattern.
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57. 4) Mechanical restrictions;
- macroglossia.
- arch constricted.
5) Neurological disturbances;
- motor disability
6) Psychogenic factor;
- discontinuation of other habits.
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58. DIAGNOSIS;
- Size of the tongue
- posture of the tongue
- Structure of the tongue
- Function of the tongue
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59. 1) Size of the tongue;
Variations in tongue size ,
Reaches its adult size by the age
of 8 years.
Why asses the variations ?
True macroglossia
Pseudo macroglossia
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60. Macroglossia;
The whole oral cavity is filled with the
tongue mass, presence of indentations
on the periphery.
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63. Etiological factors;
- habitual posturing of the tongue.
- hypertropied tonsils and adenoid tissue.
- arch deficiency in all dimensions.
- severe mandibular deficiency.
- cyts/tumors that displaces the tongue
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65. MACROGLOSSIA;
Signs and symptoms.
- Open bite (ant/post)
- Diastema (mx/md)
- Accentuated curve of spee in maxillary arch
- Reverse curve of spee in mandibular arch.
- difficulty in swallowing
- mandibular prognathism.
- Larry M. WOLFORD, AJO 1996
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66. Cephalometric & Radiographic assessment.
- over angulation of upper and lower anteriors.
- Dispropotionately excessive mandibular
growth.
- increased gonial angle.
- increased occlusal and mandibular plane
angle.
- David A. AJO 1996.
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68. Criteria for evaluation;
- The greatest possible area of tongue should
be above reference line.
- The base line is independent of skeletal
structures.
- The tongue should not change with
position of the mandible.
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71. 2) Posture of tongue;
The posture is evaluated for various open
bite tendencies.
It can be flat/arched, protracted/retracted,
narrow/long.
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74. STRUCTURE OF TONGUE;
In infancy the extrinsic suspensory
muscles attach the tongue to various
osseous structures largely resposible for
gross movements in horrizontal plane.
- It has the property of elasticity &
contractility ----- tongue thrust.
Acts through all / none law.
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81. Do tongue thrust cause open bite ?
Pressure on teeth by swallow - 1 secs
Individual swallow – 800/dy - & few in sleep.
Total 1000/dy
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82. Treatment;
Defect in posture;
- habit breaking appliance.
- muscle exercise through elastics.
Defect in size;
- Glossectomy..
- surgical correction.
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85. SEQUENCE OF PROCEDURES;
STAGE I :
GLOSSECTOMY
ORTHOGNATHIC
SURGERY
- Psychological approach.
- No IMF
- No air way obstruction.
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87. STAGE 3 :
COMBINED
- Both the procedures combined together at a
same surgical stage.
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88. MOUTH BREATHING;
Definition;
It is defined as the the pattern of
breathing totally / partially through oral
cavity due to anatomical / functional
variations.
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90. ETIOLOGY;
Mouth breathing primarily has effect on
- posture of jaws.
- Position of tongue
- posture of head.
Altered equilibrium
Growth
Tooth position
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91. Mouth breathing
Mandible lowered
LFH
Tilted head
lowered tongue
Change of 5 degree
cranio vertebral angle
Mandible rotated
Open bite
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Obstruction relieved
94. Physiological variations;
All humans are some mouth breathers.
Average breathing air flow ------ 20 – 25/L/mnt
Partial mouth breathing --------- 40 – 45 L/mnt
Transitional stage ----------- 80 Mintz S, Shepard RJ.
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95. Pathological variations;
It becomes a habit when the breathing
persists even when the obstruction is
removed.
Opposing principles;
Total nasal obstruction
Increased LFH
Battgel J
BJO - 1996
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100. How much obstruction has to occur for effect on
growth ?
- It depends on location of the obstruction.
Anterior
Middle portion
posterior
- nasal function
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101. Methods in assessing the nasal obstruction.
- Cross sectional area.
- Peak nasal air flow
- Nasal resistance.
- Respiratory mode (oral/nasal air flow ratio)
-AJO 1998
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102. Rhinomanometric studies;
Study of air flow with flow meters, and
pressure gauges.
Cleft lip and palate patients increase tendency of
mouth breathing ?
- AJO 1998
Posterior nasal obstruction by
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104. Hyoid bone position;
- AJO 1984.
In 1981 Bibby and Preston.
Hyoid bone is not fixed to a space by any
bony articulations.
Hyoid bone is determined by muscles and
ligaments attached to structures above and
below it.
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105. - It is influenced by the tongue posture and
mandibular position.
it signifies
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106. TREATMENT;
- Removal of the cause.
- Interception of the habit.
- Rapid maxillary expansion.
- orthodontic + surgery
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107. Nasal obstruction;
- AJO 1998
- vertically repositioning of maxilla
predictably reduce the nasal resistance.
Not nasal air flow
Breathing mode is behavioral determined than
structurally determination
The highest correlation between these
parameters are 0.24 %---- 0.74%
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109. No change in breathing pattern;
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110. Rapid maxillary expansion;
For maxillary deficiency
Increase nasal air flow
Reduction in nasal resistance was frequently
measured.
Rhinometric studies;
No change in breathing mode.
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111. DIAGNOSIS;
Early detection of symptoms is
recommended, so that treatment can be
provided in time whatever the cause may
be.
- Subtenly, AO 1954
- Ricketts, AO 1968
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112. How to decide for open bite ?
It is the ability to recognize vertical growth
in routine treatment mechanics.
Commonly clinicians evaluate
Mandibular plane for open bite.
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113. DIAGNOSIS;
- SKELETAL OPEN BITE
- DENTAL OPEN BITE.
- ANTERIOR OPEN BITE.
- POSTERIOR OPEN BITE.
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115. Posterior open bite;
- Failure of posterior tooth to erupt fully
in occlusion producing lateral open bite.
Mechanical interference.
Disturbance of eruption
mechanism.
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116. GROWTH PATTERN ;
Its purpose was to assess skeletal factors
associated with development of vertical
facial disproportions.
Horrizontal facial planes tends to be
steeper and more divergent with lower
facial height.
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118. 1) Mandibular plane;
Favoured --- Nanda.
Not favoured --- Skiller/Bjork.
2) Gonial angle; Enlow - Angle.
3) Palatal plane;
Posterior dips
4) Occlusal plane;
Bjork –no
change
Steeper
5) Cranial base;
Larger cranial base and corresponding positional
deviations of mandible associated with open
bite.
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119. CEPHALOMETRIC EVALUATION;
There are six specific cephalometric
angular measurements for identifying the
vertical dysplasia.
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120. 1) SN --- (ANS – PNS);
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121. 2) SN --- MANDIBULAR PLANE;
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126. LINEAR PARAMETERS;
GROUP 1;
PFH/AFH ----- Sum of angle
-Jarabak
GROUP 2;
UFH/LFH
Average --- 0.810
Open bite ---0.686
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127. OBJECTIVE OF OPEN BITE;
1) Creating sufficient overlap with molar relation;
Incisal overlap
0.5 --- 4.0 mm
Average – 2.8mm
- Kim 1974
- AO 1998
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129. The dentition is placed in proper three
dimensional perspective to ensure stability.
- Antero – posterior aspect.
- Vertical aspect.
- Transverse aspect.
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132. Eliminate Blocks:
In order to eliminate blocks the molar
are distally tipped.
Extraction ( 1/2/3) molar
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Non extraction
133. TREATMENT;
It depends on etiology and location
- Dento alveolar open bite.
- skeletal open bite.
TIMING OF TREATMENT;
Not too early not too late
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134. TREATMENT DURING PRIMARY
DENTITION;
Dental open bite;
- Habits ---- after 3 yrs.
Screening therapy.
Skeletal open bite;
- Habit control secondary.
- Growth modification not indicated
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135. TREATMENT ON EARLY MIXED
DENTITION;
Dento alveolar open bite;
- Screening therapy
- Behavior modification.
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136. Screening appliances;
Vestibular screen ------------ digit sucking
Vestibular screen ------ Its modifications.
Tongue crib ------ tongue thrust.
Posterior tongue crib -------- lateral tongue thrust
Activator ----------- Tongue thrust and finger
sucking ( work as a interceptor).
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137. BEHAVIOR MODIFICATION;
COUNSELLING;
A straight forward discussion with the
child during eruption of permanent
incisors.
REWARD;
For not engaging in the habit.
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140. OPEN BITE IN LATE MIXED DENTITION;
Skeletal parameters;
- Major diagnostic criteria is either,
maxilla
or both
Palatal plane
mandible
Ramus
“ KEY “
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153. Mandibular surgery;
Surgery in the ramal part is done only to the
secondary aspect to the maxillary osteotomy
for the auto rotation of the mandible.
Advancement genioplasty
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154. GENIOPLASTY;
Long face pts has excess
eruption of lower anterior
which is flared and unstable
Poor chin balance
Bony cut is given upward and forward angulated
to advance it.
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155. PRE – SURGICAL ORTHODONTICS;
allignment
levelling
Antero posterior incisor position
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156. LEVELLING;
MAY OR MAY NOT BE DONE;
- Depend on facial type.
Stabilizing arch wire;
18 slot ------- 17 x 25
22 slot ------ 21 x 25
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157. POST SURGICAL ORTHODONTICS;
Until stabilizing arch wire is removed
the teeth are held in tight position.
- four weeks
Light vertical elastics
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