1) The document discusses different types of scissor bites (malocclusions where the maxillary teeth are positioned buccal to the mandibular teeth), including definitions, classifications, causes, and treatment options. 2) Scissor bites can be caused by factors like microglossia, abnormal tooth germ position, and skeletal Class II issues. Treatment depends on a patient's age and severity of the scissor bite, ranging from removable appliances to orthodontic devices to orthognathic surgery. 3) The document presents several case studies as examples. One case discusses using a bonded constriction quad-helix appliance to reduce the maxillary arch width in a growing patient with a bilateral scissor

1. SCISSOR, TELESCOPE, BRODIE – BITE
WHAT IS IT AND HOW TO MANAGE??
Prof. Dr. Maher Fouda
Yasmine M. Hammad

2. Definition
 It’s a malocclusion where the maxillary posterior teeth occludes completely buccal
to the mandibular posterior teeth.
Scissor Normal Cross

3. When one tooth or several teeth are positioned more buccally or lingually in
relation to the opposing teeth, the malocclusion is called “Crossbite”. The more
severe form of crossbite is “Scissors-bite” in which in habitual occlusion the
mandibular dentition is contained in the maxillary arch. Scissors-bite may develop
from a maxillary buccal or mandibular lingual crossbite. When scissors-bite on
multiple molars is a result of transverse skeletal discrepancy, the malocclusion is
termed “Brodie bite.” Scissors-bite may appear as unilateral or bilateral.
Treatment of a Bilateral Scissors-Bite in an Adolescent With Fixed Appliances Ahmad Sodaga et al. Iran J Ortho. In
Press; online 2016 May 30.

4. Treatment of a Bilateral Scissors-Bite in an Adolescent With Fixed Appliances Ahmad Sodaga et al. Iran J Ortho. In
Press; online 2016 May 30.
A, An illustration of scissors bite at the distal aspect
(black line normal occlusion).;Intrusion and palatal
tipping are necessary for correction of scissors bite,
B, after intrusion and palatal tipping of the maxillary
molar to allow the mandibular molar to move without
resistance, the mandibular molar can easily be
uprighted;
C, the maxillary molar descended for settling after
correction of the mandibular molar into the proper
position;
D, an illustration of the post-treatment appearance

5. CLASSIFICATION
Scissor bite
Acc. To number
of teeth involved
Single tooth
Segmental
Acc. To side
involved
Unilateral
Bilateral

6. Severe forms of scissor bite or Brodie syndrome is rare
orthodontic malocclusion that occurs with a frequency of 0.01%
in general population. Several methods have been described to
obtain a correction from a dental, skeletal and soft tissue points
of view.
In the literature various approaches were described: from jaws
osteotomies, surgery first approach, to the use of orthopedic-
functional devices and extractions along with the fixed
multibrackets orthodontics combined with miniscrews for the
skeletal anchorage.
Fantasia E, D'Emidio M, Padalino G, Rodi G. Comparison of Orthodontic Techniques used for treating patients with severe form
of scissor bite: a systematic review. WebmedCentral ORTHODONTICS 2016

7. CONTENT
Case
reports
Young
(growing)
Removable
app.
Fixed app.
Adults and
Adolescents
(non-growing)
Orthodontic
(Non- surgical)
Surgical
Maxilla Mandible

8. Treatment options of Brodie-bite in children
4 case reports.
1. - Bilateral Brodie Bite in Early Mixed Dentition Using Bonded
Constriction Quad-helix Appliance.
2. - Occlusal gujdance for unilateral scissors bite in primary
dentition.
3. - Scissor bite in a young patient treated with an orthodontic-
orthopedic device.
4. - Treatment and retention of a mandibular arch
telescoped within the maxillary arch

9.  Brodie bite, adversely affects chewing and muscle functions, but also impairs normal
growth and development of the mandible.
 This syndrome is rare occuring in 1-2% of the mixed dentition population. As it does
not affect the aesthetics, parents are not aware of its presence amounting to the few
case reports of this condition in the literature.
 Like posterior crossbite (transverse discrepancy) it does not self corrected.
 Problems of Brodie Bite:
1. Affect chewing function
2. Muscle function
3. Impairs normal growth and development of the mandible.
 This makes the early correction of this condition rather essential.
 Possible causes of Brodie bite include: microglossia, hypoglossia, neurological and
muscular mechanisms causing oral habits, skeletal Class II factors, and abnormal
tooth germ position or eruption direction.
A Case report Bilateral Brodie Bite in Early Mixed Dentition Using Bonded
Constriction Quad-helix Appliance..
Nojima K. et al Bull Tokyo Dent Coll 2011 52: 39 - 46

10.  A boy aged 9 yrs and 2 months with symmetric frontal facial features and convex
profile.
 Intraorally patient had:
1. +5mm overbite
2. +8 overjet
3. Spacing in maxillary anterior
4. Bilateral Brodie bite.
(excessive upper width, narrow lower arch width)
5. Class II molar relationship

11.  Full permanent dentition noted in the Panoramic x-ray.
 Cephalometric analysis indicated slight mandibular retrognathism. The case
was diagnosed with bilateral Brodie bite with mandibular retrusion

12. Treatment Objective
 To reduce the upper arch width, expand the lower arch to establish stabilized molar
occlusion relation and achieve Class I molar relation along with appropriate overbite and
overjet until eruption of permanent dentition is completed.
 Reducing the maxillary arch width by covering the occlusal surfaces of the upper D, E and
6 on both sides with resin to raise the bite and activate the constriction of quad-helix
appliance.
 A bi-helix appliance was fitted to the mandibular first molars to expand the mandibular
arch.
 A 5 month follow-up showed improvement,
a cervical headgear was then fitted to
correct the Class II molar relation.
Patient was observed until the eruption
of permanent dentition was completed.
Treatment Plan and progress

13.  After 2 years and 6 months, a Class I
molar relation was achieved although
spacing in both the maxillary and
mandibular dentition remained.

14.  Cephalometric superimposition before
and after treatment showed that in the
skeletal pattern, anterior growth of the
maxilla had been controlled, while the
mandible had grown markedly in the
anterio-inferior direction with no
clockwise rotation. Major skeletal
improvement was achieved in the ANB
angle from 4 degrees to 1.5 degrees.
 No antero-posterior or vertical
movement occurred in either the
maxillary anterior teeth and molars
had shifted slightly in a mesial
direction, with almost no vertical
change.

15. Scissor bite in a young patient treated with an orthodontic-orthopedic
device. A case report.
Favero v., Et al. European journal of paediatric dentistry 2013 vol. 14/2
 An 8-year-old girl in mixed dentition presented with right complete scissor bite,
including the first permanent molar. Class I occlusion on both sides, an increased
overjet and a decreased overbite. The midline lines were not coincident. On the right
side, a scissor bite on all the lateral posterior teeth was remarkable. The palate was very
large and overexpanded , with presence of diastema between the incisors. The lower
arch showed a contraction on the right side with lingual torque of the teeth and due to
the torque the arch form was symmetric. The oral movements were not perfect, while
opening and protruding the mandible an initial left movement was remarkable. The
patient neither referred pain, nor functional limitations.

16. 2 3
4 5

19. 7 86

20. Occlusal gujdance for uniiateral scissors bite in primary
dentition: A case report
Sachiko Hayashi-Sakai, et al. PEDIATRIC DEAXTAL JOURNAL 2007 17(2).• 160-166.
 A 5 year and 5-month-old Japanese boy was brought to the Pediatric Dental clinic with
the complaint of an eating disorder. His mother noticed that his eating time was longer
that that of his faternal twin brother.
 Clinical examination showed normal age-appropriate development of his face and
dentition except for the severe scissor bite in the left molar region, which allowed no
occlusal contact between the opposite teeth. Terminal planes: on the unaffected side
were of the distal step type. ??What does that mean? The patient's fraternal twin
brother had normal occlusion.

21.  Frontal cephalogram was obtained and the width of
the inter-cervical line of the primary 2nd molars on
maxilla and mandible were measured to be
compared with that of normal Japanese children
standards.
 It was found that the maxillary width
was remarkably larger beyond normal.
 Study models were also
examined and both arch length
and width between the primary C
and E were obtained.. This also
indicated an above than normal
reading for the upper arch.
 Other measures were within normal
range, Overbite was 2.8mm and overjet was 2mm.

22. Treatment Plan
 For occlusal guidance, the authors designed a removable type appliance for reducing
the maxillary dental arch width. To provide a constrictive effect, a conventional
expansion screw was modified to give reverse rotation .
 Technique: the master maxillary cast was sectioned in half and trimmed so that the
desired mxillary width was obtained, the halves were glued together then the appliance
with expansion screw was fabricated on that cast. Here, the appliance was transferred
to the original maxillary cast and activated to fit it.
 It was expected that by covering the
occlusal surfaces the maxillary left
primary first and second molars would
move toward the palatal side smoothly.

23.  In order to raise the occlusal vertical
dimension and to anchor the unaffected
teeth at the same time, the appliance
covered the occlusal surfaces between the
right primary lateral incisor and the second
molar. The authors directed the patient's
mother to ensure that the boy use this
appliance all day long except at meals and
when brushing his teeth and exercising, and
to give the screw a one-quarter reverse turn
(0.1mm) each week. During follow up the
period of the screw turn was gradually
shortened from once a week to every 4
days.

25. Evaluation of treatment.
When the patient finished using the retainer at the age of 6 years and
10 months , a frontal cephalogram and study models were taken and
examined again to evaluate the treatment. Measurements of the same
inspection items were made as described earlier in methods and
compared to their pretreatment values. The most significant change
was recognized in the arch width of the inter-buccal
groove of the maxillary primary second molars. Overbite
and overjet remained unchanged.

26. Treatment and retention of a mandibular arch telescoped within
the maxillary arch: case report
Milton E. Gellin, DDS PEDIATRIC DENTISTRY: MAY/JUNE, 1991 ~ VOLUME 13, NUMBER 3
 At 6 years, 4 months old, a male Caucasian was examined with the chief complaint of
"difficulty in eating." The patient was unable to establish centric occlusion because the
right mandibular posterior teeth were telescoped within the maxillary arch. Skeletal
midlines were correct, but the mandibular dental midline deviated to the left of the
maxillary midline (Fig 1). With the midlines approximately aligned, posterior occlusion
was minimal (Fig 2). The maxillary arch width was greater than one standard deviation
from the mean of 41.85mm, whereas the mandibular arch was significantly deficient by
more than two standard deviations from the mean of 40.2 mm. The mandibular
posterior teeth had severe lingual inclination.

27. Treatment objective
Was to expand the mandibular arch bilaterally, so that the posterior teeth
would have an acceptable interdigitation. After expansion, the mandibular arch
would be retained with a lingual arch until the late mixed dentition; then the patient
would be placed on periodic recalls to evaluate the stability of expansion in the
permanent dentition.
When the patient was 7 years, 9 months old, the mandibular permanent
incisors were erupted fully. A lingual arch was selected to accomplish the
expansion, along with a maxillary bite plane to disengage the posterior occlusion.
The lingual arch was expanded to one half of the buccolingual width of the
first permanent molars. Three additional activations followed at approximately one
month intervals. When the lingual cusps of the mandibular posterior teeth began to
occlude with the maxillary posterior teeth, the maxillary bite plane was
discontinued. The lingual arch served as a retainer for 15 months.

28.  When the patient was 11 years, 8 months old, the maxillary right first and second
premolars and the maxillary right second molar were noted to be completely buccal to
the mandibular teeth, with mild crowding of the maxillary and mandibular incisors. The
first permanent molars and right permanent canine were in a Class I relationship, but
the left permanent canine was in a Class II relationship( Fig 3). In addition, there were
no nonworking interferences. The patient had a normal range of mandibular
movement with no joint sounds. Treatment time was 18 months.

29. The last observation was made when the patient was 18 years old, with the maxillary
arch out of retention for four years, and the mandibular anterior incisors out of
retention for two years three months (Fig 4). Cephalometric appraisal at 18 years of
age revealed a Class I dentition superimposed on a Class II relationship due to a
posteriorly positioned mandible.

32. CONTENT
Case
reports
Young
(growing)
Removable
app.
Fixed app.
Adults and
Adolescents
(non-growing)
Orthodontic
(Non- surgical)
Surgical
Maxilla Mandible

33. Treatment options of Scissor-bite in Adolescents
3 case reports.
1. Scissor Bite Correction by Bite Plane
2. Crowding, Protrusion and Scissors Bite: Extractions and Extra-
Alveolar Bone Screws
3. Treatment of a Bilateral Scissors-Bite in an Adolescent With
Fixed Appliances

34. Features in scissor bite:
1. Facial profile-The scissor bite has no significant influence on the facial profile.
2. Airway-The scissor bite is not known to reduced airway.
3. Chewing function-The chewing function is bad since the molars make no
contact with each other.
4. Jaw joints-Patients may experience a clicking or pain in the jaw joints since the
jaw is usually forced to function in a deviated position during the chewing
process.
5. Teeth wear-Molar wear is unlikely since the molars do not come in contact with
each other.

35. Scissor Bite Correction by Bite Plane
Amit Prakash et al Indian J Dent Adv 2013; 5(4): 1425-1427
A female patient, 16 years and 3 months of age, consulted
with a chief complaint of improper occlusion and irregular teeth.
She had a convex profile and a symmetric frontal view. She gives
history of surgical treatment for the cleft lip (Figure1). On clinical
examination, both canine and molar relationships were Class I on
both sides, but a scissors-bite of the posterior arch on the right side
was observed. Overbite was 6.5 mm and overjet was1.1 mm. The
dental midline was deviated to right by 3 mm. On cast analysis, the
arch-length discrepancy was 2.2 mm in the maxilla and 8.3 mm in
the mandible.

36. Treatment objectives
 The patient was given the diagnosis of Angle Class I malocclusion, with a skeletal
Class I jaw base relationship, lip protrusion, moderate anterior teeth crowding, and
a scissors-bite of the right side.
 Were to correct incisor crowding, obtain a good facial profile, achieve acceptable
occlusion with a good functional Class I occlusion, and eliminate the scissors-bite.
Bite plane was used for the correction of scissor bite. (Figure2).

37.  After achieving acceptable occlusion, fixed appliance treatment with 0.022 MBT
prescriptions were done for achieving the treatment objectives(Figure 3).

38.  Post treatment results were good and stable
As a result, complete treatment of a scissors-bite in the
present case was achieved in 5 months.(Figure 4)..

39. BEFORE AFTER

40. Treatment of a Bilateral Scissors-Bite in an Adolescent
With Fixed Appliances
Ahmad Sodaga et al. Iran J Ortho. In Press; online 2016 May 30.
The patient was a 13-year-old boy, his
chief complaints were crooked teeth and
difficulty in chewing. In temporo-mandibular
joint examination, there was subluxation and
clicking on closing. He had a skeletal class II
relationship with retruded upper incisors,
deviated chin to the right, mandibular deficiency
and deep bite.
Posterior crossbite from the left first
premolar to the right first molar was observed.
Maxillary and mandibular dental midlines were
deviated to right. The transverse cant of the
occlusal plane was minor. There was severe
space deficiency in both arches and the right
mandibular canine was impacted.

41. In the lateral cephalometry analysis (Table 1),
mandibular deficiency was noticed. The major
problems were summarized as chin deviation, bilateral
scissors-bite, class II division 2, deep bite, midline
deviation, severe space deficiency and impacted lower
right canine. The patient had a slight centric relation-
centric occlusion shift.
Variables Pre ttt Post ttt
ANB +7 +4
FMA 27 29
U1 to FH 109 115
U1 to SN 98 106
IMPA 94 113
Inter-incisal angle 130 100

42. Treatment Objectives
 Treatment objectives were correcting dental crowding, traction of impacted canine to
the arch, create normal overjet and overbite relationships with good functional
occlusion, and eliminate scissors-bite. We planned to constrict maxillary arch with
transpalatal arch and expand the mandibular arch with an active lingual arch, with aid
of criss-cross elastics.
Treatment Alternatives
 According to patient chief complaint, correction of scissors-bite was the first priority.
However, in our view, correction of dental and skeletal class II relation was another
major issue. Because of deep bite and reduced overjet, there was no option for
growth modification at the first step. Therefore, we started the treatment with fixed
appliance at the upper arch. Moreover, right mandibular canine was unerupted. As
the lower dental arch was crowded and severely constricted, for traction of impacted
tooth we could not extract any teeth. Therefore, we decide to expand the arch
orthodontically and postpone growth modification; because it usually increases IMPA
too.

43. Treatment Progress
 Metal brackets (0.022-in slot, MBT prescription) were used for this
treatment. Upper arch was banded and bonded first. For initial
aligning and leveling 0.014 and 0.016-in nickel titanium arch wires were
used. After aligning and leveling of upper arch, palatal miniscrew was
inserted between upper right first and second premolars, for intrusion
and lingual tipping of the first molar. After two weeks and before
loading, the miniscrew failed. Because of patient discomfort, we did
not try miniscrew insertion for the next time. 0.018-in stainless steel
archwire was used for leveling. We started wire constriction from this
archwire, followed by 19 × 25-in nickel titanium and 19 × 25-in
stainless steel. A transpalatal arch was fabricated from 1.0 mm
stainless steel to help arch constriction.

44.  It was placed 3mm away from palatal mucosa in order to help
in intrusion of molars. It had slightly constricted and inserted
in the lingual sheaths of the molar bands. A lingual arch with
expansion arms was made for lower arch. It was expanded
and then inserted once-a-month.
 After creation of proper overjet, lower arch was bonded.

45. Treatment Results
 The final records show that scissors-bite was
completely resolved, overjet and overbite were
appropriate and the impacted tooth was in its
proper position. We reached a good functional
occlusion and patient’s chewing function was
improved. Canine relationship and dental
midline were not ideal at the end of treatment.
We suggested extraction of one premolar, but
the patient and his parents refused. At the end
of treatment, patient was referred to a
periodontist for lower arch inflammation and
gingival hyperplasia.

46.  As like the other non-extraction therapies in mandibular
deficiency cases, IMPA increased. We suggested the
parents to perform advancement genioplasty procedure at
18-year-old to enhance his profile. By this means,
Holdaway ratio would greatly improve.

47. BEFORE AFTER
This patient had class II division 2 malocclusion, with bilateral scissors-bite and unerupted tooth. With constricted
transpalatal arch and modified active lingual arch followed by repeated arch coordinations, we reached good
alignment and functional occlusion. This procedure rescued the patient from future orthognathic surgery.

48. Crowding, Protrusion and Scissors Bite: Extractions and Extra-
Alveolar Bone Screws
Hui-Hwa Chen, Chris Chang et al. Int J Orthod Implantol;39:54-70)
A 16-year-3-month girl presented with concern about
decreased masticatory function due to lingual tipping of her
posterior teeth, lip protrusion, and a small maxillary midline
diastema with a black triangle. The facial profile (convexity) was
good, but there was a bimaxillary protrusion with a particularly
prominent lower lip. Moreover, there was no evidence of
contributing oral habits or temporomandibular dysfunction.

49. Skeletal:
 • Class I ( SNA 90 °, SNB 88 °, ANB 2° )
 • Low mandibular plane angle ( SN-MP 30°, FMA 23° )
 • Condylar heads symmetric in length and position
Dental:
 • Mandibular dental midline was 2mm to the left of the
facial and maxillary midlines.
 • Small maxillary midline diastema with a black triangle
 • Bilateral Class I canine and molar relationships.
 . Lingual crossbite of the maxillary left lateral incisor
(#10)
 • Buccal crossbite of three molars: one on the right (#2),
and two on the left (#14 &15).

50. Objectives of Treatment
1. Resolve maxillary and mandibular crowding.
2. Correct bilateral buccal crossbites.
3. Achieve an ideal overjet and overbite relationship
 Maintain the maxillary and mandibular skeletal bases in all planes of space
 Maxillary Dentition: Retract incisors, intrude incisors, maintain inter-molar/inter-
canine width
 Mandibular Dentition: Retract incisors and decrease their axial inclination.

51. Treatment Plan
1. Extract all four first premolars to resolve crowding.
2. Reduce bimaxillary protrusion to improve lip profile.
3. Place an extra-alveolar (E-A) OrthoBoneScrew® (Newton’s A,
Hsinchu City, Taiwan) in each buccal shelf of the mandible
(Fig. 11) to serve as anchorage for elastics to correct the
lingually tipped molars (#18, 19 and 31).
4. Intermaxillary elastics to correct the sagittal discrepancy.
5. Detail occlusion with finishing bends and settling elastics.
6. Retention with clear overlay retainers in both arches.

52.  A 022” slot Damon Q® passive self-ligating (PSL) bracket system (Ormco, Glendora, CA) was selected.
 High torque brackets were bonded on the maxillary incisors and the arch was aligned with an .014” CuNiTi
archwire. Bite turbos, constructed with Fuji II® glass ionomer cement, were placed on the occlusal surfaces of
the lower left lateral incisor and canine (#22 & #23) to facilitate correction of the crossbite of the maxillary left
lateral incisor (#10).
Appliances and Treatment Progress

53.  One month later, when the crossbite (#10) was corrected, the anterior bite turbos were removed, and
occlusal bite turbos were bonded on the lower first molar (#30) and the lower left second premolar
(#20).
 Standard torque brackets were then bonded on all mandibular teeth, except the second molars, and an
.014” CuNiTi archwire was placed. At the same appointment, buttons were bonded on the lingual surfaces
of the mandibular left 1st molar (#19), and both lower second molars (#18 & 31). Cross elastics
(Chipmunk 1/8” 3.5oz) were applied to correct the posterior crossbites bilaterally.

54.  In the 4th month of treatment, an OrthoBoneScrew® (OBS) (2x12mm) was inserted in each
mandibular buccal shelf, lateral to the second molars (Fig. 14). Power chains were stretched
between the miniscrews and the lingual buttons on the mandibular second molars.

55. The occlusal height of the bite turbos on teeth #20 and 30 were increased to avoid contact
between the OBSs and the maxillary dentition. The power chains anchored by the OBSs,
began to efficiently up-right the lower second molars in three dimensions .

56. In the 15th month, an .016x.025” SS archwire was placed on the lower arch. L-type elastics
(Bear 1/4” 4.5oz) were applied from the upper canines to the lower second molars, bilaterally.
The paths of the elastics were positioned gingival to the bracket on the lower first molars
In the 17th month, the L-type Class II elastics were continued. Proximal enameloplasty was
performed on the four upper incisors. Torque springs were applied bilaterally on the lateral
incisors to decrease their labial root torque.

57. Maxillary Dentition
 Antero-post: Retraction of incisors and protraction of
the buccal segments. Vertical: Maintained. Inter-
molar/Inter-canine Width: Crowding corrected with
first premolar extraction
After 21 months of active treatment, the appliances were
removed and retainers were delivered for both arches.
Mandibular Dentition
 Antero-post: Retraction of incisors and protraction of the buccal segments.
Vertical: Maintained. Inter-molar / Inter-canine Width: Crowding corrected
with first premolar extraction

58. Retention
 Clear overlays were delivered for both
arches. The patient was instructed to wear
them full time for the first 6 months and
nights only thereafter. Instructions were
provided for the home hygiene and
maintenance of the retainers.

59. Final Evaluation of the Treatment
 T h e p a t i e n t w a s p l e a s e d w i t h t h e r e s u l t , particularly with regard to
masticatory function and facial harmony. Post-treatment intraoral photographs and study
casts show a Class I molar and canine on the right side, with Class II canine and Class I
molar relationships on the left side. The dental and facial midlines were coincident.
 Superimpositions of tracings demonstrate the retraction of the incisors and protraction of
the buccal segments to close the first premolar extraction spaces. The lower lip was
retracted to relieve the lip protrusion and produce the lip balance that the patient
expected. The upper incisor to SN angle was decreased from 115 to 112°, and the lower
incisor to the mandibular plane angle was reduced from 106 to 95°.

61. Case report conclusions :)
Using extra-alveolar bone screws and bite turbos provided optimal
mechanics for correcting a bilateral scissors bite. This innovative method
was consistent with an overall excellent resolution of a challenging,
asymmetric malocclusion. Premolar extractions and space closure were an
efficient solution for resolving the bimaxillary protrusion in a timely manner.
Bimaxillary retraction with bone screws to correct bimaxillary protrusion
would have increased treatment time for the present patient, because they
could not be placed in an optimal location initially.

62. V. I. NOTE!!!

64. CONTENT
Case
reports
Young
(growing)
Removable
app.
Fixed app.
Adolescents
(non-growing)
Orthodontic
(Non- surgical)
Surgical
Maxilla Mandible
Adults

65. Treatment options of Scissor-bite (Surgery)
6 case reports.
1. Mandibular Widening by Distraction Osteogenesis in the Treatment of a
Constricted Mandible and Telescopic Bite.
2. Unilateral Brodie bite treated with distraction Osteogenesis.
3. Treatment of unilateral buccal crossbite with mandibular symphyseal distraction
osteogenesis.
4. Orthognathic treatment for a patient with facial asymmetry associated with
unilateral scissors-bite and a collapsed mandibular arch.
5. Advantages of symphyseal distraction in the treatment of Brodie’s Syndrome.

66.  To correct the Brodie –bite malocclusion, many treatment options were
proposed. They include dental extractions, interproximal reduction and
orthodontic compensation. The last option could damage the periodontium,
particularly if there is a vestibuloversion of the lower anterior teeth, because it
forces the teeth out of their alveolar bone.
Advantages of symphyseal distraction in the treatment
of Brodie’s Syndrome
Christine SAUVE, Thomas WOJCIK, Joe FERRI, J Dentofacial Anom Orthod 2013;16:405

67.  To treat the increased maxillary width,
some authors have suggested palatal
constriction, such as a segmental
Lefort I osteotomy. This more delicate
technique only allows for constriction
of about five to six millimeters by
resecting the bone between the
segment. This approach risks damage
to the palatal mucosa and creation of
an oral-antral communication

68. Other options are possible. For example, osteotomy to enlarge the mandible, as a
treatment for a constricted mandible, is described. This include surgical separation at the
mandibular symphyseal midline. Fragments are then positioned by rotational and
translational movements at locations and are stabilized with the help of plates and
screws. Also a bone graft is necessary in order to fill the gap defect that is created at the
osteotomy site. This technique has however been abandoned in light of the increased
number of gingival dehiscences, of periodontal problems and of relapses.
Since all these options present a number of disadvantages,
such as instability or esthetic compromise, symphyseal
distraction is an alternative treatment to consider in the
correction of Brodie’s Syndrome.

69. SYMPHYSEAL DISTRACTION
This distraction technique is utilized in order to increase the transverse
dimension of the symphysis. It presents a certain advantage when the dentoalveolar
or skeletal anomaly cannot be corrected by traditional orthodontic therapies. These
transverse deficits are found in an underdeveloped symphysis, in cases of significant
lower incisor overlapping, in syndromic malocclusions such as Pierre Robin,
Franceschetti and of course, Brodie’s Syndrome.
Osseous distraction is a procedure that allows the creation of new bone
between two osseous segments that are gradually separated by traction. which is
achieved progressively by daily activations of the distraction device. The
mineralization of the callus is initiated after the third week following the end of
activations (consolidation period).

70. Timing ??
 Mandibular symphysis fuses around the first year of life, the
procedure of symphyseal distraction can be performed on a
patient during the growth phase, as soon as the incisors and
the permanent mandibular canines erupt, and on adults.
 Before planning this type of surgery, a complete oral and
dental examination is mandatory A panoramic x-ray makes
it possible to assess the position of the dental roots. If
significant dental crowding is also present, cone-beam is an
invaluable tool for optimal visualization

71.  A few days after surgery, the distraction device can be activated. The latency period
certainly allows for the creation of an osseous callus, but also the healing of the
mucosa. One or several activations can be prescribed, without however exceeding
three millimeters a day. An excessively fast pace of activation lowers the quality of
the callus whereas a too slow rate of activation can lead to a premature osseous
consolidation and therefore, an insufficient expansion

72. However, in the course of distraction, the adjacent teeth migrate during
callotasis if they are not orthodontically retained. This phenomenon called
‘‘walking-teeth phenomenon’’ is due to the elastic traction of the transseptal fibers
of the periodontal ligament. Once the activations are stopped, a period of
consolidation is necessary.
Some authors recommend maintaining this phase for two months before
beginning orthodontic movements.

75. In Conclusion
 Even if Brodie’s Syndrome is not a common malocclusion, it is
important to know all the available therapeutic options to improve
patient’s occlusion, function and esthetics.. Symphyseal distraction
has proven to be a highly recommended treatment solution given its
many advantages, particularly concerning osseous growth and
periodontal preservation

76. Severe Unilateral scissor-bite and bimaxillary protrusion treated by
horseshoe Le Fort I osteotomy combined with mid-alveolar osteotomy.
Shimazaki k. et al, Angle Orthodontist, Vol 84, No 2, 2014
a female aged 26 years,
months, came complaining
chiefly of dysmasesis caused by
the right-sided scissor bite, an
‘‘unsettling’’ feeling around the
area of the right molars and
protrusion of the lips. The
patient had been aware of her
right-sided scissor bite
since the age of 18, but she had
not sought treatment prior to
this point.

77. Lefort 1 Osteotomy
During this part of the surgery, the upper jaw is
removed and repositioned in order to correct a
“maxillary deformity”

78. Frontal photographs showed a symmetrical mandible
and chin, difficulty in lip closure, and a gummy smile.
The patient had a convex profile. Intraoral examination
revealed that the overjet was +3.0 mm and that the
overbite was +4.0 mm, with a leftward midline
discrepancy of 2.0 mm
(measured as a 2.0- mm
deviation of the lower right
central incisor to the left).
Mandibular right premolars and
molars were lingually inclined,
and the scissor bite in question
was noted

79. Cephalometric analysis indicated a slight
skeletal Class II tendency with SNA of
85.0u, SNB of 80.0u, and ANB of 5.0u.
Labial inclination of the maxillary anterior
teeth (U1 to FH) was 117.7u.
The upper and lower lips were placed
anterior to the E-line by 2.5 mm and 4.5
mm, respectively .

80. A postero-anterior cephalometric radiograph
showed an inclination of the maxilla and the
mandible in the frontal dimension.
The cephalometric tracing showed that the
maxillary occlusal plane inclination was 4.0u,
and the menton was deviated 2.0 mm to the
right.
Tracing of the pretreatment postero-anterior
cephalometric radiograph. Lo indicates right
latero-orbitale; Lo’, left latero-orbitale;
and Me, lowest point on the midline curve of the
symphysis.

81. Treatment objectives
The patient refused tooth extraction; therefore, to correct labial inclination of the maxillary
anterior teeth, the maxilla required transposition upward and backward and clockwise
rotation. Furthermore, to eliminate the occlusal cant due to the overerupted right maxillary
premolars and molars and the lingual tipping of the right mandibular premolars and molars
the right maxillary dental arch needed to be moved superiorly and medially. For these
corrections, two-jaw surgery involving an HLFO combined with mid-alveolar osteotomy and
BSSRO was planned.

82. Presurgical orthodontic treatment
was planned to gain
approximately 3.0 mm of space
between the maxillary central
incisors to protect their roots from
damage during the mid-alveolar
osteotomy

83.  Also, before orthodontic brackets could be applied to the right
mandibular molars involved in the scissor bite, the occlusal surfaces of
these molars needed to be built up with composite resin to raise the bite.
 This treatment plan was designed to deliver a faster resolution of the
scissor bite by orthognathic surgery. The procedures, risks, advantages,
disadvantages, and costs were explained to the patient, and she was able
to give full informed consent prior to the
start of treatment.

84. The treatment alternative was orthodontic treatment
only. The critical procedures for scissor bite
correction
are intrusion and palatal or buccal tipping of the
involved teeth when they are both extruded and tilted.
After the scissor bite is corrected, additional premolar
extractions are needed to resolve bimaxillary
protrusion.
However, the orthodontic procedure was deemed
to be severe, and the patient was informed that the
treatment would be complicated and prolonged if
orthodontic procedures alone were used. The patient
was given the option (together with the advantages
and disadvantages) of having orthognathic surgery
combined with orthodontic treatment as an
alternative.
The patient chose to accept this option .
Treatment Alternatives

85. Presurgery orthodontic treatments involved occlusal surface buildup with composite resin to
raise the bite, followed by attachment of preadjusted edgewise appliances, wires placed in both
arches for leveling, alignment, and space creation between the maxillary central incisors.
After 3 months both archwires were replaced with 0.016 x 0.022–inch stainless-steel archwires
with crimp-on surgical hooks in preparation for orthognathic surgery. Two-jaw surgery took
place under anesthesia. Presurgical photographs are shown
Treatment Progress

86. Before surgery, a maxillary splint was constructed on articulated models mounted in centric
relation for positioning of the left-side dento-alveolar segment. In addition, we used these
models to determine the optimal positioning of a continuous archwire and resin plate to be
placed in the right dento-alveolar segment of maxilla, such that it was positioned as parallel
to the Frankfurt horizontal plane as possible.

87. These appliances were used to assist in fixing the left and right dento-alveolar
segments during the operation. The thickness of the resin plate was 1.2 mm.

88. After Le Fort I osteotomy
and down-fracture,
horseshoe osteotomy was
performed from the
superior surface of the
maxilla. The dento
alveolar segment was then
halved between the
maxillary central incisors
using a surgical saw .

89. The left dento-alveolar segment
was then moved into its
predicted position using the
maxillary splint to position it 4.0
mm posterior and 1.5 mm
superior at the left first molar
and 6.0 mm posterior and 4.0
mm superior at the maxillary
incisors, before fixing it with
titanium plates.

90. The left dento-alveolar segment. The right
dento-alveolar
segment was moved into its predicted
position using the resin plate and continuous
archwire to
align it 6.0 mm posterior, 8.0 mm superior,
and 4.0 mm medial at the right first molar
before fixing it, again with
titanium plates .

91. Before After

92. Unilateral Brodie bite treated with distraction osteogenesis
John W. King, and James C. Wallace, Am J Orthod Dentofacial Orthop 2004;125:500-9
 A girl, aged 11 years 10 months, Although the patient had the sickle cell anemia
trait, she was in excellent physical and dental health. Pretreatment facial
photographs showed a convex profile, mildly protrusive lips, and facial symmetry
with competent lips.

93.  The maxillary dental midline was 1.0 mm to the left of the facial midline; the mandibular
dental midline was 1.6 mm to the left of the facial midline. The patient had a Class I
malocclusion, 3 mm of overjet, a 75% overbite, and a mild curve of Spee.

94.  The panoramic radiograph showed a complete
permanent dentition, with erupting second
molars and impacted third molars.
 Although the patient’s profile was convex and
her lips were full, the lateral cephalometric
radiograph indicated that the maxillary and
mandibular incisors were in upright positions
in their respective apical bases and that there
was a moderate skeletal Class II discrepancy
with an ANB angle of 7°. With a Frankfort-
mandibular plane angle (FMA) of 36.5°, the
patient demonstrated a hyperdivergent
skeletal pattern. Despite evidence of a
significant airway deficiency and enlarged
adenoids, there was no clinical evidence of
mouth breathing.

95. Treatment objectives
 The main objective in treating this malocclusion was to correct
the left-side posterior buccal crossbite and establish occlusal
interdigitation. Because the patient’s smile was attractive and
the maxillary width was normal, we would attempt to maintain
this width. The overbite and overjet would be reduced to an
ideal relationship. Interdental spacing—the patient’s chief
complaint—would be eliminated. Although the maxillary and
mandibular incisors were in acceptable positions, some
uprighting would be needed to eliminate the arch length
excess.

96. Treatment Alternatives
 The 1st treatment option: was to use intermaxillary crossbite elastics to tip the mandibular left
posterior teeth labially and the maxillary left posterior teeth lingually. But because the
diagnosis indicated the crossbite was primarily a skeletal problem, long-term stability was a
concern. Also, lingual tipping of the maxillary left posterior teeth might alter the pleasing
pretreatment smile.
 The 2nd option: was to place a Hyrax expander in an “open” position, to produce palatal
constriction and narrow the maxilla bilaterally. This technique would correct the left buccal
crossbite but might also create a right posterior crossbite. Also, there was some concern about
changing the preexisting broad smile.
 The 3rd option: involved closing the mandibular interdental spacing and maintaining the
mandibular intercanine and intermolar widths. A maxillary segmental osteotomy could be used
to correct the crossbite.
 The 4th option : involved maintaining the maxillary width and closing the interdental spaces.
The left posterior buccal crossbite would be corrected through mandibular widening by
midsymphyseal distraction osteogenesis. Because the buccal crossbite was a true unilateral
problem, the widening would have to be primarily on the left side while the right occlusion was
maintained.

97.  The patient and her mother selected the fourth option, which
targeted the primary orthodontic problem (the mandibular
transverse deficiency). If the right posterior occlusion could be
maintained, this treatment option would provide the best
combination of occlusal function, optimal esthetics, and long-
term stability.

98. Treatment progress
 Preadjusted fixed appliance was placed in the maxillary arch for leveling and alignment.
Three months later, a biteplate was constructed, and the mandibular appliances were
placed. The orthodontic brackets were angulated to allow root divergence between the
mandibular central incisors. A “figure 8” ligature wire was placed on each side of the
osteotomy site, connecting the central incisor, the lateral incisor, and the canine to
prevent “walking teeth” during the distraction period.
 During the predistraction phase of orthodontics. A .016 x .022-in stainless-steel arch
wire was placed before the osteotomy. The archwire was cut at the osteotomy site at the
initiation of distraction. This provided segmental anchorage during the distraction
phase.

99.  Before the mid symphyseal osteotomy, a full-coverage maxillary splint was constructed
on an articulator that was mounted in centric relation. The splint was modified by
creating a deep intercuspation on the mandibular right side and a flat plane occlusion
on the left. This stabilized the occlusion on the right side and allowed for transverse
widening on the left.

100.  Before surgery, crimp-on surgical hooks were placed in both arches between the
brackets on the patient’s right side. A hybrid distractor (bone-borne and tooth-
borne) was constructed before the mid-symphyseal osteotomy.
 The mid-symphyseal osteotomy was then performed. After the 7-days latency
period, she returned to our office, and we initiated distraction by making 0.5-mm
turns twice per day, 1 in the morning and 1 at night. During the distraction period,
the patient was instructed to wear the maxillary splint and right-side intermaxillary
elastics full time, except for eating and brushing. Distraction was stopped when
the canines were in an ideal transverse relationship and the buccal crossbite was
corrected.

101. The total distraction, measured by the distraction screw expansion,
was 6.0 mm. A denture tooth was placed in the distraction site on
an anterior segmental archwire.

102.  Periapical radiographs were taken every 4 weeks during the consolidation
period to monitor the osteogenesis (Fig 13). During the10-week consolidation
period, no tooth movement was attempted.

103. Treatment results
 The Brodie bite was
successfully corrected, and
the excellent right posterior
occlusion was maintained. At
the end of treatment, the shift
from centric relation to centric
occlusion was less than
0.5mm; this was
verified through bilateral
manipulation. During the
mandibular distraction
osteogenesis, significant
widening occurred, from 6.04
mm at the intercanine position
to 2.59 mm at the intermolar
position.

104. Thus, there was nearly parallel
distraction of the skeletal and dental
components, as measured on the dental
casts and the antero-posterior
cephalometric radiograph. Mandibular
symphyseal distraction with the hybrid
distractor produced a greater transverse
increase in the anterior part of the arch
than in the posterior. During the post
distraction phase of orthodontic
treatment, the mandibular interdental
arch dimensions were reduced to near
predistraction amounts.

105. Life is all about sharing ;)

106. CONTENT
Case
reports
Young
(growing)
Removable
app.
Fixed app.
Adolescents
(non-growing)
Orthodontic
(Non- surgical)
Surgical
Maxilla Mandible
Adults

107. Simple and Efficient Technique for Correction of Unilateral Scissor
Bite Using Straight Wire
Gajanan Dolas et al. Journal of Clinical and Diagnostic Research, 2016
A 14 year old boy reported with the chief
complaint of irregularly placed upper and lower
front teeth. The patient found it difficult to
masticate on right side because of scissor bite
malocclusion of molars and premolars. The
patient had a straight profile with competent lips.
On intra-oral examination the canine and molar
relation was Class I on both sides and scissor bite
of molars and premolars on right side.

108. Treatment plan and progress
 A 0.022” × 0.028” MBT slot prescription
was used. Mandibular first molar was
banded and mandibular left first and
second premolar brackets were bonded.
 • A 0.020 S.S. A. J. Wilcock wire
(premium plus) out of the spool, made
minimal adjustments and placed in
mandibular arch.

109. Treatment plan and progress
 The wire without making arch form was
placed such that its one side was engaged
on left sided molar tube, and the other side
was engaged on the molar tube on scissor
bite side.
An acrylic bite block was placed on left side;
to reinforce the anchorage from molars and
premolars on one side to relieve the scissor
bite on other side. It was based on the
concept of using light continuous force.

110.  After about six weeks time good
amount of correction was seen in
lower arch and the lower molar
had been relieved of scissor bite.
About 5mm expansion was seen in
lower arch.

111. Nonsurgical correction of a severe anterior deep overbite accompanied by a
gummy smile and posterior scissor bite using a miniscrew-assisted straight-
wire technique in an adult high-angle case.
Xue-Dong Wang et al. Korean J Orthod 2016;46(4):253-265]
 A 26-year-old Chinese woman presented with a chief complaint of crooked teeth and a
protrusive mouth. The patient stated that her facial profile was similar to that of her aunt.
Along with profile convexity, an increased lower facial height was noted. An acute nasal–
labial angle, an incompetent lip, strain in the circumoral musculature on lip closure, and a
gummy smile were also observed.

112.  Angle Class II molar relationship with a severe anterior deep
bite and moderate crowding of the mandibular teeth. The
mandibular midline was shifted to the patient’s right by 1 mm.
A scissor bite was also observed between the maxillary and
mandibular left second molars. The mandibular right second
premolar was receiving root canal treatment. The maxillary
incisors showed old crown restorations with gingival
inflammation.

113. • Panoramic radiographs showed post and cores, but no signs or symptoms of
temporomandibular disorders.
 Lateral cephalometric analysis revealed skeletal Class II
malocclusion with a retrognathic mandible (A-point−
nasion−B point [ANB], 10.6o) and a high mandibular plane
angle (sella-nasion plane to mandibular plane angle
[MP/SN], 53.2o). The maxillary incisors were lingually
inclined and angled between the crowns and roots
because of the presence of post–core restorations.

114. Treatment objectives
 The principal treatment objectives including the following: tooth alignment,
achievement of an optimal overjet and overbite. establishment of Class I canine
and molar relationships, and correction of the gummy smile and facial profile.
 Different treatment options were presented to the patient involving leForte I
osteotomy, geneoplasty as well as fixed appliance ith extraction ot with
miniscrew. The patient chose the last (miniscrew) option.
Treatment alternatives

115.  Under local anesthesia, the maxillary right and left first premolars, mandibular right and left
second premolars, and the maxillary and mandibular right third molars were extracted. A
pre-adjusted edgewise appliance with 0.022-inch slots was bonded on both arches.
 Alignment and leveling with sequential nickel-titanium archwires were achieved in 6 months
miniscrews diameter, 1.5 mm; length, 8 mm were inserted into the buccal and palatal
alveolar bone in the maxillary posterior region on both side.

116.  An elastic tieback with a single power-chain unit was tied
from the maxillary left palatal miniscrew to the maxillary
left second molar for correction of the scissor bite
between the maxillary and mandibular left second molars
and for avoiding mesial movement of the maxillary left
first molar

117.  The force used to correct the scissor bite was 50 gN, and the bite was
corrected after two appointments. The bilateral maxillary molars were
intruded using elastic chains extending from the miniscrews to the
buccal tubes, with a force of approximately 50 gN on each side.

118.  A classic sliding mechanism with a 0.019 . 0.025- inch stainless steel archwire
was used for space closure in both arches. All the tiebacks were placed on the
miniscrews to avoid mesial movement of the molars.
 Another 2 miniscrews (diameter, 1.5 mm; length, 7 mm) were inserted into the
maxillary anterior alveolar bone on both sides for incisor intrusion, with a force
of approximately 50 gN per side.

119.  Long-distance elastics were
not used for space closure
and retraction to avoid molar
extrusion. A helical spring was
used to reserve space for
maxillary incisor crown or
veneer placement at 19
months after bonding, in the
finishing and detailing stage,
when an obvious improvement
in her gummy smile was
observed. A short vertical
elastic was used to increase
intercuspation and co-
ordinate the maxillary and
mandibular midlines.

120.  The overall duration of active orthodontic treatment was 25
months.

121.  The gummy smile is
dramatically
improved. The
post-treatment
intraoral
photographs show
Class I molar and
canine relationships
with normalized
overjet and overbite
Facial and intraoral photographs obtained after final restorations. The posttreatment
facial photographs show the facial esthetics has been obviously improved with the
chin deficiency corrected and the lower facial height decreased.

122. Post-treatment cephalogram,
cephalometrict racing, and
panoramic radiograph. The
post-treatment cephalogram
shows. Decreased
mandibularplane angle and
A-point−nasion−B point
angle. The post-treatment
panoramic radiograph shows
acceptable root parallelism
and no obvious apical root
resorption

125. Bilateral posterior telescopic crossbite correction through the use of
Goshgarian palatal bar and bite turbos.
Carolina Aguilar González, Oropeza Sosa. Revista Mexicana de Ortodoncia April-June 2016, Vol. 4,(2) : 109-116
 A male patient, 25 of age was presented with mild upper and lower moderate dental
crowding as well as a telescopic crossbite of the second molars. The patient said he
was constantly biting his cheek.
 Extraoral photograph analysis revealed a mild dolichofacial patient with an oval-shaped
face, straight profile and gibbous nose; thin, competent lips, positive smile and a facial
midline that did not coincide with the dental midline.

126.  Upon intraoral clinical
examination it was noted:
that the upper dental
midline was deviated to
the right and the lower, to
the left; a mild upper
dental crowding and
moderate lower dental
crowding, labially inclined
upper second molars,
lingually positioned lower
second molars, bilateral
molar class III and canine
class I; 2 mm overbite and
1.5 mm overjet and curve
of Spee of 3.5 mm on
both sides.

127. Panoramic x-ray revealed that the condyles and mandibular ramus were
asymmetrical absence of radicular parallelism, mild loss of the alveolar
crests and a crown-root ratio of 1:2
Cephalometric data revealed a skeletal class I
with a soft dolichofacial growth direction,
upper incisor protrusion and normally inclined
incisors

128. Treatment plan
 Two treatment options were suggested to the patient. One of them involved
using 0.022” x 0.025” Roth GAC In-Ovation®R self-ligating appliances and 2
mini-implants, either with or without corticotomies.
 The second treatment option was 0.022” Roth GAC In-Ovation®R appliances
and for the correction of the upper second molars, a 0.036” TMA removable
palatal bar.
 The patient did not accept the mini-implants or the corticotomies, so the
second option was chosen.

129. Self-ligating 0.022” Roth fixed
appliances were placed with
bands in the upper and lower first
molars. After three months of
leveling 0.022 Roth tubes were placed
in the lower second
molars and bands with lingual boxes
in the upper second molars
for placing the 0.036” TMA palatal
bar.
Glass ionomer bite turbos were
placed in the palatal cusps of the fi
rst molars in order to open the
bite and allow the second molars to
move. Transverse measurement of
these molars was taken and it was
61.5 mm.

130. Next step in treatment was the
alternate activation on each side of
the palatal bar and after eight
months of activation we managed
to bring the second molars into
their basal arch obtaining a 54 mm
transverse distance.
At the same time, the archwire
sequence indicated by Roth
philosophy was followed in both
arches until the final stage of
treatment was completed with
0.019” x 0.025” stainless steel
archwires. The use of ¼ inch and
3.5 oz class III elastics was
instructed for a better intermaxillary
relationship

131. Retention

132.  The maxillary left second molar was in scissor
bite with its antagonists. A Self tapping mini
screw of 7 mm in length (Dentos) was inserted
with direct method under local anesthesia. A
registration point was marked within the safe
zone area of the palate and the mini screw was
placed with the provided screwdriver.
Scissor bite correction of Maxillary 2nd Molar using Palatal Mini
screw Implant
Neetu Dabla, et al. Indian Journal of Orthodontics and Dentofacial Research, October-December, 2015;1(1):32-34

133.  MBT 0.022" appliance was bonded and a fixed posterior bite plane
with a Trans palatal arch was placed and a lingual button bonded with
respect to maxillary left 2nd molar.

134.  A short elastomeric chain
was attached from the head
of palatal mini-implant to the
lingual button bonded on the
2nd molar band.
Appointments were
scheduled every 21 days
and the elastomeric chain
was changed for adequate
force to be delivered.

135.  The correction of scissor bite was achieved within a span of three and a
half months.

136. There isn’t a standard approach !!
Each form of clinical case requires a proper evaluation considering the age of
patient, the features of pathology as the presence of other complications.
The ortho-surgical correction remains the golden standard in severe
dentofacial deformities because of its more applicability, lower risks of failure and
rapidity, as it doesn’t need patient compliance.
However not all the patients accept to undergo surgery, so pure orthodontic
approach is need. So the combination of fixed orthodontics with skeletal anchorage
has proven the best effective and stable to 5 years from therapy.
Moreover in young patient with mild form of malocclusion when it was
intercepted early, a functional therapy should be attempted.
Fantasia E, D'Emidio M, Padalino G, Rodi G. Comparison of Orthodontic Techniques used for treating patients with severe form of scissor bite:
a systematic review. WebmedCentral ORTHODONTICS 2016