(\ Manual for the Clinical Application of MEAW Technique _ ) Orthodontic Therapy Using Multiloop Edgewise Arch-Wire Editor: Sadao Sato Professor, Kanagawa Dental College (Orthodontics Dept.) Authors: Sadao Sato, Susumu Akimoto, Atsushi Matsumoto, Akiyoshi Shirasu, Junzo YoshidaPreface It has been more than 20 years since the Multiloop Edgewise Arch-Wire (MEAW) we introduced in Japan. It was primarily used to treat open bite conditions but its usage has gone far beyond what it was originally designed for. It is now being used for the treatment of almost all types of malocclusions. In fact, most of the dentists and orthodontists in Japan use MEAW to treat their orthodontic cases. However, textbooks about the use of MEAW for orthodontic treatment have not been available and numerous practitioners have been requesting for it, Indeed there great demand for such a book and I had relayed this request to Dr. Young H. Kim, the author and proponent of MEAW, but unfortunately, due to his hectic schedule he was not able to complete it. Thus; the publication of a book on MEAW did not materialize. Thus, for this reason, this textbook on the use of MEAW in orthodontic treatment wa published with the help of Daiichi Shika Publications, This book does not contain the MEAW Technique and the philosophy of Dr. Y.H. Kim but it contains the basic concept and technique ing MEAW in the treatment of malocclusion Needless to say that the most important aspect in the treatment of malocclusion is the knowledge about it. If one lacks the knowledge about the strategie treatment and problem poini of each malocclusion, the condition will not improve even with the use of MEAW. Dr. Y.H. Kim once said that MEAW is only a (ool for treatment and nothing else. The use of MEAW is only significant once a treatment plan has been established based on the understanding of the malocclusion and its accurate diagno: In this book, the treatment procedures applied with the use of MEAW in various types of malocclusion will be the center of discussion and illustrations as well as pictures were used for easier understanding. Nevertheless, the procedures and methods that are discussed in this book are not the only possible methods. Though treatment methods may vary from the ones discussed here, the ones used on each patient in this book were based on the patients’s condition, Lastly, the publication of this book has been made possible with the encouragement and advice of Mr. Fujiwara of the Daiichi Shika Publications, Inc. and I would like to thank him from the bottom of my heart Sadao Sato Autumn 2001Table of Contents Preface. 1, Structure and Function of MEAW —/ 1. Structure of MEAW... IL. Function of MEAW. IIL, Modification of MEAW. (Sato) 10 Bending Method Used in MEAW /IS (Sato) 1. Basie Structure of MEAW oles IL. Instruments and Materials Needed for MEAW Construction IIL, First Order Bend........cccseceeeseeeee 0 IV. Second Order Bend (Horizontal loop bend)... Bed eat ata tata V. Third Order Bend (Torque bend). 18 VI. Heat Treatment of MEAW......csessssssseseessessseieesensssseeeseanestecesssnsnssnnseal 8 3. Adjustment Methods Used in MEAW 9 (Sato) Adjustment Methods Used in MEAW etstesnvetstnareill) 1. Tip-back activation, : ot adapahate 2. Tip-back deactivation.....ssssesseeeeee casita 20 3. Step up bend 4, Localized tooth intrusion 5, Tip back bend without altering the o 6. Curve of Spee Jusal plane, 4. Patient Evaluatio: d Treatment Plan /23 (Sato) 1. Records used for diagno: IL. Kim’s Method of analys 1 ODI (Overbite Depth Indicator. 2. APDI (Anteroposterior Displasia Indicator). 3 CF (Combination Factor). IIL, Denture frame analysis, IV, Ocelusal plane and denture frame.. 265. Treatment of Class II Malocelusion (High Angle) /29 (Shirasu) 1. General Characteristics of Class III reversed occlusion (High Angle) Il, Morphological Characteristics of Class III reversed occlusion (High Angle)... IIL, General Treatment Objectives for Class III reversed occlusion (High Angle). WV. Tr 1. Patient’s history iment Procedures for Class III reversed occlusion (High Angle), Diagnosis and treatment plan Treatment progress. Treatment results 6. Treatment of Class III Malocclusion (Low Angle) /45 (Shirasu) 1. General Characteristics of Class II] Malocelusion (Low Angle). Il. Morphologie: Characteristics of Class II] Malocelusion (Low Angle). III, General Treatment Objectives for Class Il Malocelusion (Low Angle). IV, Treatment Pro edures for Class III Malocelusion (Low Angle) 1. Patient's history. 2.Di 3.1 4, Treatment results. sis and treatment plan. ment progress, 7. Treatment for Class | Open Bite /61 (Akimoto) 1. General Characteristics afClass f open bite 1. Main causes of open bite 2, Abnormalities related to open bite. of Class I Open Bite. Il, Morphological Characteristics IL, Evaluation of occlusal plane... IV. Treatment objectives for class I open bite... ‘reatment procedures for class I open bite. 1's history yosis and treatment plan, 1 3. Treatment progr 4 ‘Comparison of the pre and post treatment results 46 46 47 47 49 62 62 63 64 64 165 66 66 66 68 708. Treatment for Class I Open Bite /71 (Matsumoto) 1. General Characteristics of Class Il open bite. aoneee IL Morphological Charactetisties of Class Il Open Bite.......... . 2 ILL, ‘Treatment objectives for class II open bite. 3 IV. Treatment procedures for class Il open bite. 173 1. Patient’s history. eee ean 2. Diagnosis and treatment plan... esa AF ae 76 3. Treatment progress. 4, Treatment results 5. Important points and treatment methods used for this patient 9, Treatment of Class II Deepbite /87 (Matsumoto) I. General Characteristics of Class II deep over bite. 88 U1, Morphological Characteristies of Class Il deep overbite..... arian ani OB II, Treatment objectives for class II deep overbite .......... 7 88. IV. Treatment procedures fr class Il deep overbite ... . 89 1. Patient's history........ agatetanarer BE) 2. Diagnosis and treatment plan. el ted 92 3. Treatment progress... 93 4, Treatment results. 3 a 98 5, Treatment methods used and Some Important points to consider in the Treatment of Class Il Deepbite Malocelusion. ......... seve OL 10. Treatment for Mandibular Lateral Deviation /103 (Akimoto) 1. Definition of mandibular lateral deviation............0 : ol 04 |, Main causes of mandibular lateral deviation aera cuits 2. Abnormalities related to mandibular lateral deviation .. arsed U1, Characteristics of mandibular lateral deviation, ee 105 1, Morphological Characteristics of mandibular lateral deviation............+++0.--.105 2. Functional Characteristics of mandibular lateral deviation. ceeeeeee 106 ILL, Treatment objectives for mandibular lateral deviation ...........2+2+ cee OT IV, Treatment procedures for mandibular lateral deviation 109 1. Patient’s history. 7 a sececpeeece OD2. Diagnosis and treatment plan Feast 110 3. Treatment progress... Wt 4, Comparison of the pre and post treatment results 14 11. Treatment for Crowding /115 (Sato) 1. General Characteristics of crowding. me seed 16 II, Morphologieal Characteristies of erowding. 116 IIL, General Treatment Objectives for crowding......cscccesecessss tenes 7 IV. Treatment Procedures for crowding. 17 1. Patient’s history. casncosessl TB 2. Diagnosis and treatment plan.. 120 3. Treatment progress. 120 4, Treatment results.. 127 12, Treatment of Malocelusion with TMJ Dysfunction /129 (Yoshida) L. General Characteristics of malocclusion with TMJ dysfinetion........seecssesesenenee 30 IL, Characteristics of malocclusion with TMJ dysfunction 130 Case I: Closed locked TMI due to manclibufar lateral deviation (right). ces 30 Case 2: Closed locked TMJ due to mandibular lateral deviation (left). 130 Case 3: Closed locked TMJ due to bilateral loss of occlusal support... eu OO IIL General Treatment Objectives for malocclusion with TMJ dysfunction. 134 1. Splint usage... 134 2. Orthodontic occlusal reconstruction. 135 IV. Treatment Procedures for malocclusion with TMJ dysfimetion .......sssseseeeee wenn 136 1. Patient's history. 136 2. Diagnosis and treatment plan... 140 3. Treatment progress. 142 4, Treatment results 14s References. Index.41. Structure and Function of MEAW 9 (Sadao Sato)10 1. Structure and Function of MEAW STRUCTURE OF MEAW Figure 1-1 Basic structure of MEAW Multiloop Edgewise Arch-Wire (MEAW) is an archwire with horizontal loops positioned at the interproximal spaces of each tooth from the distal part of the lateral incisors up to the posterior teeth (figure 1.1), is usually made up of 0.016” x 0.022” The archwi rectangular wire. The length and the loop size of the archwire are dependent upon the type of the patient's case but basically, its structure is as shown in figure 1.2. The reasons for bending the horizontal loops in the archwire are as follows: 1. Decrease the load / deflection rate, providing a low but continuous orthodontic force on the teeth. 2. The horizontal loop allows an easier control of movement for each tooth. 3. Makes the alignment and intrusion of the supraerupted tooth as well as the torque adjustment easy. 4. With the aid of elastics, it can reconstruct the occlusal plane. ( Figure 1-2 Structure of the ideal arch Fig 1-3 shows the horizontal loop and its parts. Their functions will be discussed later.4. Structure and Function of MEAW 11 1, Horizontal loop: the major part of the archwire; it relieves the vertical force and regulates the vertical movement of the tooth, Horizontal loop 2. Breaker: it regulates the horizontal ‘movement of the tooth and simultaneously moves each tooth and detailing may be done as well. ‘Horizontal part of archwire 3. Loop base: it regulates the tip back bends Fig. 13. and torque control. 4, Horizontal part of the archwire: This part is inserted into the bracket slot where the wire force is transmitted to the teeth. To create an ideal arch with the horizontal loop, the ideal archwire length is 2.5-3x the length of the usual archwire, This would decrease the orthodontic force by 1/5 and at the same time continuously applies an orthodontic force to the teeth. This allows tertiary regulation in the wire promoting an ideal tooth ‘movement of the entire dentition, I. | MEAW Function MEAW as shown in figure 1-4 consists of a tip back bend, The tip back bend varies from one patient to another depending on the treatment approach to the occlusal plane. But usually the tip back bend on each tooth is 2° — 3° and 15° - 20° for the entire dentition, The application of this archwire intra- orally and the use of elasties in the anterior teeth will improve the entire dentition, aan Fig, 1-4. Tip back bend121, ‘Structure and Function of MEAW Fig. 1-524 Various types of elastic application The following are the variations in the elastic position (Fig 1-5 a-f) The synergi ayvayne Vertical elastics (a) Short class II elastics (b) Short class III elastics (c) Triangular elastics (d) Box form elastics (e) Check elastics (f) effect of MEAW and elastics provide the following: Alignment of the dentition Control tipping of the ocelusal plane Control vertical dimension Establish good intercuspation Control the tooth axis especially those with mesial tipping4. Structure and Funetion of MEAW 13 Ill. Modifications of MEAW MEAW is such a versatile wire and can be used in different types of malocclusion. The following are the different modifications of MEAW, each one applicable to a specific type of malocclusion. 1. The different types of adjustments (fig 1.6a-e) a, No adjustment Tip back bend Tip back bend (for no occlusal plane changes) Continuous step bend Partial step bend sees During the treatment period, adjustment of the horizontal loop to a certain degree is possible when needed, (fig 1.7a-d). sssqqq __ S996q 7 S98995_ + S9Sesao— 2 Sqqns— Fig. 1.6 Types of bend adjustments Fig. 1.7 MEAW loop adjustments14° 1, Stucture and Function of MEAW Fig. 1-8 MOAW Fig. 1-9 SOM Modified Offset Arch Wire (MOAW) (Fig 1-8) MEAW with offset in the premolar region is used in patients where vertical control and correction of the molars are needed, ‘This is the first step of treatment for patients with class III high angle, crowding, or open bite conditions. 3. Sectional Modified Offset MEAW (SMOM) (Fig 1-9) When sectional MEAW is attached to the premolar and molar teeth, vertical control can be applied to the said teeth, while with the application of an offset MEAW, there is anteroposterior control to the anterior teeth, This can_ be used for TMD cases with retruded mandibular position to obtain occlusal support and anterior guidance for the mandible.2, Bending Method Used in MEAW 15 (Sadao Sato)16 2. Bending Method Used in MEAW |. The Basic Structure of MEAW MEAW consists of horizontal loops with an arch form similar to the ideal arch used in the final phase of edgewise treatment (fig 2-1). Therefore, the anatomical morphology of the dentition (i.e. the labial and buceal surfaces of teeth) is incorporated in the / MEAW. 1. First Order Bend: bend in the horizontal I Lateral inset \ Canine offset direction of the dentition, it includes the Molar ofset lateral inset, canine offset (eminence) and molar offset. 2. Second Order Bend: the bend following the first order bend. Horizontal loop is incorporated in this step. | 3. Third Order Bend: passive and active | torque to control the tooth angulations. a. Passive torque: Torque incorporated \ into the archwire to prevent any changes to the angulations of the teeth, The purpose of the torque is to Ke conform the shape of the wire to the labial and buccal surfaces of the teeth, Fig.24 b. Active torque: the wire is twisted/bent to change the tooth angulations. Il. Instruments Needed in MEAW construction 0.016 x 0.022 inch rectangular wire (stainles 1 steel or Blue Elgiloy wire) 2. Arch turret (arch former) 3. Pliers a. Kim pliers b. Tweed pliers c. Nance2. Bending Method Used in MEAW 17 lll. First Order Bend Get the midline of the wire and with the use of an arch turret (arch former) create a mild curve in the anterior teeth. Then create an inset between the central and lateral incisors by marking the part to be bent and using a ‘Tweed plier, bend the wire inwards mesially and outwards distally bilaterally Determine the degree of inset at this stage. IV. Second Order Bend (horizontal loop) The procedure in creating a horizontal loop, which is the basic element in MEAW, is shown in fig 2-2a. The plier to be used in this procedure is the Kim plier. The horizontal loop of the upper and lower wire is around 18-20 degrees. Afier placing the first order bends and horizontal loops in the archwire, it is important to have symmetry of the right and the left side of the archwire. 2 ee Fig. 2.28 MEAW bend Fig. 2.2 MEAW bend Fig 2.2¢ MEAW bend18 2. Bending Method Used in MEAW. Vv. Third Order Bend (torque bend) When MEAW is bent and the torque for the entire dentition has been planned, use an arch former to get the shape of the dentition and use the torque slot to twist the wire. However, there are cases where torque adjustment is needed during the orthodontic treatment procedures. In this regard, the principle behind the torque bend has to be understood. There are basically 3 elements for torque bend. Dental curve (First order bend) Straighten the curve of the first order Fig 2.9 bend Twist of wire 1 2. To do a labial crown torque in the anterior part of the MEAW, make a slight curve in the anterior region of the archwire as shown in fig 2-3. Twist inward the wire starting from the distal of the first loop. The degree of the torque adjustment at this stage is dependent on the curve strength. Then tightly clamp the legs of the first horizontal loop located at the distal surface of the lateral incisors and bend to vertically straighten the first loop that has tipped distally, Vi. Heat Treatment for MEAW To activate the wire, it is subjected to a 5-10 minute heat treatment at 500°C, with the use of an clectropolishing treatment, before the MEAW is inserted into the patient’s mouth, In the absence of a furnace, an alcohol lamp Heat the wire until the color changes to golden brown. Make s that the color is even. can be used.3, Adjustment Methods Used in MEAW 19) (Sadao Sato)20 3, Adustment Methods Usod in MEAW MEAW Adjustment Various types of bends like the tip back and step bend can be utilized in the treatment depending on the patient’s case. These types of bends may initiate cither activation for the progression of the treatment or could be adjusted for deactivation purposes. The basic adjustment techniques are discussed below. 1. Tip-back activation In order to incorporate tip back bends into the archwire, adjust the horizontal loop of the MEAW from a right angle to an acute angle (fig 3.1). Use the plier to bend and the other hand to hold the loop. 2. Tip-back deactivation Deactivation is done by weakening the tip-back bend when the alignment of the entire dentition has been completed. Tip back deactivation starts from where the tip back bends were placed. _ ages Fig. 3.1 MEAW adjustment, Tip-back bond3, Adjustment Methods Used in MEAW 21 a, Se Step-down age Step-up Fig. 3.2 MEAW adjustment, Step-bend Fig. 3. MEAW adjustment, Step bend Step-down bend To selectively extrude a tooth, MEAW is adjusted through a step bend. To do this, expand the horizontal loop using the plier and bend the anterior portion of the horizontal loop to lower the loop base. ‘To make a step bend during the treatment, insert the plier into the horizontal loop and create a new permanent shape (fig 3-2). In case the degree of step is insufficient, do the adjustment as shown in fig 3-3.22 9, Adjustment Mothods Usod in MEAW 9998s Fig. 3.4 Tipback bend Fig. 3.5 Curve of Spee 4. Selective tooth intrusion A step up bend can be done for selective tooth intrusion. A step down bend is adjusted to its opposite direction to form a step up bend. 5, _ Tip-back bend without changing the occlusal plane When aligning the tooth axis without changing the occlusal plane, step- down bend and tip back bend adjustments can be done as shown in fig 3- 4. Curve of Spee At the last procedure of treatment, an anteroposterior compensatory curve bend is placed to the dentition and the adjustment is shown in fig 3.5.4. Patient Evaluation and Treatment Plan 23, (Sadao Sato)24 4, Pationt Evaluation and Treatment Plan i Records Needed for the Diagnosis Below are the records needed for the case analysis of a patient with malocclusion. Patient's dental history Intra-oral photos Facial profile photos Panoramic radiograph Cephalometric radiograph Diagnostic dental cast (mounted) Record of condylar movement (axiograph) Others: TMJ x-ray, MRI ete. SN AYR The basis for the morphological characteristics of the patient at this stage is not sufficient but can be substantiated by doing a cephalometric analysis. ll. Kim’s Method of Analysis 1. ODI (Overbite Depth Indicator) This is used as an indicator for vertical types of malocclusion which are the open bite and deep overbite conditions. In ODI, the main element for measurement is the AB-MP angle. This angle is a reliable indicator of the vertical dimension of malocclusion. More specifically, there is a strong correlation of the vertical dimension of malocclusion and the lower facial area especially the adaptation of the mandible, Therefore, the angle measurement should be understood as a figure representing the correlation of skeletal adaptation in ocelusal function. Two greatest factors which decreases ODI h angle open bite condition resulting from mandibular hyperdivergence 2. Class III condition resulting from the anterior adaptation of the mandible dimen: Either of these two factors may affect the vertic n of malocclusion. To determine whether a case is a low or high angle is not the only important aspect in diagnosis. What is more significant is to be able to discover the cause of such conditions,4. Patient Evaluation and Treatment Plan. 25 | opiaea \\ APDI: 14243 CF: ODI+APDI l Fig. 4-1 Kins analysis 2. APDI (Anteroposterior Dysplasia Indicator) APDI, as the word implies, is the indicator of the antero-posterior relationship of the upper and lower jaw. This figure, as shown in figure 4-1, is a result of the statistical analysis of Kim where it determines the combination of the facial plane angle, AB-MP angle, and FH-PP angle which is geometrically equivalent to the PP-AB. Therefore PP-AB is apparently the antero-posterior relationship of the upper and lower jaw. This is self-explanatory. 3. CF (Combination Factor) CF is a combination of ODI and APDI. CF represents the tendency of the le to open. A high CF indicates a tendency for low angle but when the CF is low, it shows the tendency for high angle. According to Dr. Kim, this serves as an indicator to determine the need for tooth extraction prior to the orthodontic treatment. Thus, when the CF is low, the need for tooth extraction is higher. mandi26 4. Pationt Evaluation and Treatment Plan Ill. Denture Frame Analysis (Fig 4-2) Denture frame is the occlusal component of the basic facial skeleton which consists of the palatal plane in the basal plane of the maxilla, the AB plane in the anterior limit of the upper and lower jaw, and the mandibular plane (MP), known as the triangular pattern, The balance of this triangular pattern is closely related to the tipping of the occlusal plane and the vertical dimension in the functional plane of the occlusal system, Therefore it is possible to find out the balance of the triangular plane by checking the relationship of the occlusal plane to the patient’s characteristics, Fig. 4-2. Denture tame analysis IV. Occlusal plane and the Denture Frame Ocelusal plane is the most important plane for the function of the masticatory organ. The mandible functionally adapts to this occlusal plane. Therefore, any change in the ocelusal plane will affect the mandibular position as well as the balance of the denture frame, Below are the characteristics of the denture frame. 1, Class II Malocelusion (Fig 4-3 a,b) In a class III skeletal pattern, the occlusal plane is flat. Since the vertical dimension is excessively high, the mandible adapts through an anterior rotation resulting to Class III High Angle, However, when the vertical dimension is low with an anteriorly over-rotated mandible, the possible result would be a closed bite condition resulting to a Class III Low Angle. It is therefore important to understand clearly each patient’s characteristies in creating a treatment plan. 2. Open bite (Fig 4-4 a,b) Open bite is divided into two major types, the Class IIT and Class [I open4A. Patient Evaluation and Treatment Plan 27 Fig. 43a Class Il High Ange Fig, 4a Class Il Open Bite Fig. 4-4b Class lI Open Bite bite conditions. The basic treatment method for each type varies. Therefore, it is very important to distinguish one from the other. Class III open bite is characterized by lingual tipping of the anterior teeth due to a flat occlusal plane while Class IT open bite displays a posterior rotation of the mandible related to a steep occlusal plane,28 4. Pationt Evaluation and Trestment Plan Fig. 4-5a Class Il High Angle 3. Class Il Malocclusion (Fig 4-5a, b) The common type of class Il malocclusion is usually characterized by a steep occlusal plane. This type of Class II problem, therefore, resulted from the failure of the mandible to adapt anteriorly. However, in patients with sufficient ‘occlusal support due to the excellent vertical growth of the mandibular ramus, the maxilla rotates anteriorly allowing occlusal adaptation, The occlusal plane, in this case, is flat. 4, Lateral Displacement of the Mandi (Fig. 4-6) In patients manifesting a lateral displace- ment of the mandible, the occlusal plane on both sides usually differs. The mandible is displaced to the side where a steep occlusal plane is evident. In addition, there is also a functional disorder of the TMJ usually on the displaced side. It is important to consider these factors in establishing a treatment plan. Fig. 4-5b Class Il Low Angle Fig. 4-6, Latralcisplacoment of tho mandible5, Troaiment of Class Il Malocclusion (High Angle) 29 (Akiyoshi Shirasu)30 5. Treatment of Class il Malocclusion (High Angle) | General Characteristics of Class III Malocclusion (High Angle) Class III Hyperdivergent Malocclusion is the skeletal reversed occlusion that is associated with an open bite condition. This is the type of malocclusion where heredity constitute the strongest etiologic factor and is considered to be one of the most difficult orthodontic cases to treat. Generally, the morphological characteristics of this malocclusion are poor antero-posterior growth of the maxilla and excessive growth of the mandible, The usual treatment for this type of malocclusion is through the use of a maxillary protraction device, chin cap appliance and surgery. When this patient is examined carefully, the maxillary ocelusal plane is flat. This resulted from molar crowding (posterior discrepancy) related to the insufficient eruption space caused by the insufficient antero-posterior diameter due to an increased vertical growth of the maxilla. Consequently, it caused the supraeruption of the molars resulting to an open bite condition bringing about ahigh vertical dimension. This phenomenon could cause some molar interference and will give rise to the anterior rotation and displacement of the mandible resulting to a skeletal reversed occlusion. Malocclusion cannot be simply considered as an abnormal skeletal growth alone but rather a functional abnormality as well Il. Morphological Characteristics of Class III Malocclusion (High Angle) The morphological characteristies of Class Ill malocclusion are: excessive vertical dimension, flat occlusal plane, and reversed Curve of Spee in the lower molars due to posterior discrepancy, a short antero-posterior diameter of the maxilla, mandibular anterior displacement, weak bone tissues and an obtuse FH-MP angle. The eruptive force of the tooth is intense and the tooth crown length is long. Moreover, labial tipping of the maxillary teeth, lingual tipping of the mandibular teeth, poor antero-posterior growth of the neurocranial base, narrow cranial angle (especially the occipital bone angle) are symptoms of the disharmony of the entire craniofacial skeleton5. Treatment of Class Il Malocclusion (High Angle) 34 Ill. General Treatment Objectives for Class III Malocclusion (High Angle) The treatment objective for Class III reversed occlusion (High Angle) includes the attainment of a dynamic harmony of the craniofacial skeleton by restoring a functional mandibular movement and a harmonious skeletal framework. This can be done through an approach that focuses on the occlusal system. This requires an understanding of the dynamic mechanism of the entire craniofacial skeleton and the morphological characteristics of malocclusion, There are two treatment objectives for this type of case whieh are: 1, To eliminate posterior discrepancy 2. To stcepen the occlusal plane (tipping the occlusal plane and decreasing the vertical dimension in the molar area) IV. Treatment Procedure for Class Ill Malocclusion (High Angle) (Fig. 5-1) Elimination of posterior discrepancy is initially needed. In order to attain this, the mandibular 3 molars, and the maxillary 2"4 (or 3" molars) are extracted. ‘The treatment procedures are as follows: 1. Step 1. Leveling. Attach the brackets and tubes to the entire dentition, and start leveling using an 0.014-inch roundwire. (Fig 5-La) 2. Step 2. Elimination of Interference. Attach the MEAW appliance to the upper and lower teeth, use a tip back bend activation from the premolar to the molar areas. Elimination of the interference in the molar area can be done through alignment and intrusion. (Fig 5-1b) 3. Step 3. Establish mandibular position. Strengthen the tip back bend in the molar area, remove the tip back bend in the premolar area and use a step up bend instead to erupt the teeth, This will establish a stable mandibular position. (Fig 5-1) 4, Step 4. Occlusal Plane Reconstruction, Remove the tip back bend in the entire MEAW appliance and use a step up bend in the molar area of the lower jaw to steepen occlusal plane. Step down bend can be added to the anterior teeth of the upper jaw for occlusal reconstruction. (Fig 5-1d) Step 5. Obtain a physiologic occlusion. Do a tooth axis control (torque control), adjust the occlusal guidance and obtain a good intercuspation. (fig 5-le)on (High Angle) 325. Treatment of Class Ill Malocclusi Fig 5 ilystration of the Treatment Procedure for Class Ill Malocclusion (High Angle)5. Treatment of Class Il Malocciusion (High Angle) 33 Fig. 52 Facial profile (pre-treatment) Fig. 5.3 Inta-oral picturos showing the ecclusal condition pre-treatment) 1. Patient History Chief Complaint: lower jaw protrusion Age: 12y 9mos Sex: Female Facial profile: face is oblong, mild protrusion of the chin. (Fig 5-2) Intra-oral photos: The occlusal relationship of the canine and molars is Angle’s class III with an overjet of — 1.4 mm, and an overbite of 0.2 mm, (fig 5-3) Cephalometric radiogram: SNA 77.1°, SNB 77.6°, ANB — 0.5°, showing, a protrusion of the mandible. FH-MP is 38.1°, PP-MP is 40.9° showing a tendency for High Angle. Antero-posterior dimension of the maxilla A’-P” is 46.2 mm, UOP (P) 81.1°, displaying a flat occlusal plane.34 5, Treatment of Class ill Malocclusion (High Angle) Fig. 84 Panoramic x-ray (pre-treatment) According to Kim’s analysis, an ODI of 49.0°, APDI 87.3°, CF 136.3° is indicative ofa class III high angle condition with a low CF value. This will require tooth extraction (fig 5-17a, b, chart 5-1 pre-treatment). Panoramic x-ray: Absence of upper 3" molars, and presence of only the left mandibular 3" molar (fig 5-4). 2, Diagnosis and Treatment This patient was diagnosed to have a skeletal class III High Angle condition due to an FH-MP of 38.1°, which is obtuse, and a PP-MP of 40.9°. The antero- posterior diameter of the maxilla A’P” is short, 46.2 mm, It was observed that the upper 3" molars are not present and only the lower left 3" molar is present. This considered to be a case of a strot In this type of case, the usual or traditional treatment of choice for the skeletal problem is through the use of a chin eap appliance for the inhibition of mandibular growth, and the facemask to stimulate maxillary growth, However, a significant keletal factor treatment effect cannot be expected from these types of appliance in terms of improving the disharmony of the entire craniofacial skeleton. The treatment obj obtain a dynamic harmony of the craniofa ives after the extraction of the lower 3" molar were to 1 skeleton, restore the dynamic mandibular movement through stabilizing the disharmonized craniofacial skeleton and the active approach to improve the occlusal system through the use of the upper and lower MEAW.5. Treatment of Class ill Malocclusion (High Angle) 35, 3. Progress of Treatment Step 1: Leveling Standard edgewise brackets and tubes were attached to the upper and lower teeth. Leveling was started with the use of a 0.014-inch super elastic wire. Step 2: Elimination of occlusal interference ‘A month later, MEAW was applied to both the upper and lower dentition in order to climinate the molar interference. Alignment and intrusion was started through a progressive tip back bend of 5° from the premolar teeth to molar area using a vertical clastic and a short class III elastic (3/16 inch, 6 oz) in the anterior teeth (fig 5-6). Fig. 5.6 1" month: Stage of interference elimination with MEAW36 5. Treatment of Class Il Malocctusion (High Angle) Fig. 5-7 2" month: Elimination of interference stage Two months later, an additional 5° tip back bend in the molar area was done and alignment and intrusion were continued, Moreover, a step down and a step up bend was done in the upper and lower premolar areas respectively, where infraversion of the said teeth are apparent. The increase of the vertical dimension in this area was started, Mandibular position was distalized due to the decrease of vertical dimension in the molar area (fig 5-7). Step 3: Establishing mandibular posi On the 3“ month, after the interference has been eliminated through alignment and intrusion in the molar area, mandibular position was distally guided through the decrease of vertical dimension in the molar area. The anterior teeth overlap has primarily deepened. To erupt the infra-erupted premolars, a step down bend in the lower anterior and canine teeth was done. The tip back bend in the molar area and the rest was adjusted, A vertical elastic was used in the anterior teeth (fig 5-8). On the 5" month, a step up bend was done in the anterior and canine area of the upper dentition to obtain an appropriate vertical dimension and to physiologically guide the mandible to a stable position. The anterior teeth overlap was improved by obtaining a physiologic vertical dimension. ‘The tip back bend was removed in the upper molar area. A vertical elastic was used in the anterior teeth (fig 5-9),5. Treatment of Clas Il Malocclusion (High Angle) 37 Fig. 5-8 3"4month: Stage whore mandibular postion was established Fig. 5-8 5” month: Stage where mandibular positon was estabished38 5. Treatment of Class I Malocclusion (High Angle) Fig. 5-10: 6" month: Stage of occlusal plane reconstruction Fig. 6:11: 7" month: Stage of occlusal plane racanstruction5, Treatment of Class Il Malocclusion (High Angle) 39 Step 4: Occlusal plane reconstruction On the 6" month, the tip back bend in the lower molar area was removed and the MEAW was flattened because the molar interference has been eliminated, vertical dimension in the premolar area was improved, a physiologically stable mandibular position was obtained, The step up bends in the anterior teeth, canine and premolar areas of the maxilla were also removed. A short class III clastic and a short class I elastic was used in the right and left side respectively, to improve the midline (fig 5-10). Seven months since the start of treatment, a step down bend was placed in the upper canine and anterior area to initiate the steepening of the maxillary occlusal plane. A Mulligan appliance was used to expand the maxillary dental arch. In addition to that, the Curve of Spee was placed to aetively erupt the lower molars, To maintain a stable mandibular occlusion, the step up bend was removed in the lower dentition except on the anterior area, A better intereuspation was achieved due to the removal of the step up bend. Vertical elastic and a short class II elastic was used in the right and left side respectively (fig. 5-11). tep 5: On the 10" month, the reverse bend in the lower molar area was replaced with a step down bend. The improvement of ocelusal guidance and intereuspation was done through torque control and detailing, A good occlusal relationship was then attained. A vertical el ed in the anterior area (fig 5-12). was, Fig, 5-12 10" month: Attainment ofa physiologic occlusion stage40 5. Treatment of Class Il Malocctusion (High Anglo) Fig. 5-13 11" month: Attainment of a physiologic occlusion stage Fig. 514 19" month: Start of retention During the 11" month, the step up bend in the lower molar area was removed and the intermaxillary elastic was discontinued (fig. 5-13). Step 6: Retention A stable occlusion was obtained on the 13" month of the treatment period. The entire appliance was removed and a tooth positioner was used to start the retention (fig. 5-14).5. Treatment of Class Ill Matoccusion (High Angle) 44 Fig. 5-15 Facial profile (post-othodontic treatment) Fig. 5-16 Inra-oral pictures showing the occlusal condition (postorthodntic treatment) 4, Treatment Results An approach to the occlusal system and improvement of the disharmony of the entire maxillofacial skeleton was done even if this case has a strong skeletal factor. The facial profile has changed to mesocephalic type and the mandibular protrusion was improved (fig 5-15). Intra-oral findings were Angle’s class | canine and molar relationship, overjet of 3.5 mm, overbite of 1.0 mm, showing a significant improvement (fig. 5-16). The lateral cephalometric radiogram showed an improvement in the mandibular protrusion with an SNA of 79.0°, SNB 76.6° and ANB of 2.4° (fig 5-17, d, chart 5-1 post treatment). UOP (P) of 71.1° shows the tipping of the occlusal plane, functional movement of the mandible was restored and. dynamic harmony of the craniofacial skeleton was attained425, ‘Treatment of Clas Il Malocclusion (High Angle)6. Trealment of Clase Ill Malocelusion (High Angle) 43, Chart 1 Cephalometic Analysis [Bers are Anan Won | PeoD | oat yeast FH-MP 259° | 38.1 374 372 PP-MP zae | 409 422 | 418 OP-MP io2 | 267. | 2a 255 | OP-MPIPP-MP 54.0% | 653 626 609 | UOP (A) es | 7s | rs 724 | UOP (P) 1s me rt 72.0 | FACIAL Angle 49° 878 | 873 | 875 SNA Angle aa | Tad 790 | 79.7 SNB Angle 79 | 76 | 766 76 | ANB Angle 34° “05 24 34 | UI-FH (degree) qi? | 1081 | 1100 © 115.3 Overjet (mm) asmm | -14| 35 | 40 | Overbite (mm) 25mm | 02 1.0 25 ‘AB-MP As 518 56.7 669 | AP 50.0mm | 46.2 49.3 503 ry 230mm | 26.1 26.5 257 | A-B1A-P 46.0% | 565 538 Bit UI-AB (degree) 31.77 18.0 | 24.1 29.4 UAB (mm) 9.5mm, 50 T | 390 L1-AB (degree) 25.8" 215 | 164 20.1 L1-AB (mm) 6.2mm 64] 43 53 Intermolar 174.0° = 176.7 | 1708 | 17.8 FH-PP 1a 28 | -49 46 win a aie ER op! 518 523 APD! 81.1 81.3 COMBINATION FACTOR 1530° | 136.3 | 1329 133.7 There are no significant changes in the intra-oral findings (fig 5-18) and lateral cephalometric radiogram (fig 17 e, chart 5-1 2 years post-tx) 2 years post retention. As shown in the occlusal photos and panoramic x-ray, the upper molar has erupted normally obtaining a stable occlusion (figs. 5-18 and 5-19).44 5. Treatment of Cass Il! Malocctusion (High Angle) i N Fig. 5-18 11" month: rra-oral pictures showing the occlusal conton 2 years postzetenton Fig. 5-19 Panoramic x-ay showing the occlusal condition 2 years post retention16, Treatment of Class ll Malocclusion (Low Angle) 45 Malecciusion (Low Angle) Rn (Akiyoshi Shirasu)46 6 Treatment of Class Ill Malacclusion (Low Angle) I General Characteristics of Class III Malocclusion (Low Angle) Class II] malocclusion (low angle) also known as functional reversed occlusion, shows an insufficient vertical growth in the maxilla, insufficient vertical dimension in the posterior area and a steepening of the occlusal plane in the upper molar area. ‘Therefore, there is a disharmony in the relationship between the vertical dimension and the vertical growth of the mandibular condyle. Normally, the antero-posterior growth of the maxilla is not the problem. The deep overbite reversed occlusion is due to the excessive anterior rotation of the mandible related to the insufficiency of the vertical dimension. This problem is generally or traditionally corrected through the use of a FKO appliance, which is a functional orthodontic appliance, a chin cap appliance for growth control, and alveolar movement for occlusal reconstruction. How- ever these appliances deliver an enormous load to the patient and lengthen the treatment period. The main problem of these cases is the disharmony of the verti which ought to be addressed and improved. | dimension ll. Morphological Characteristics of Class III Malocclusion (Low Angle) In class II malocclusion (Low Angle), the vertical growth of the mandibular condyle comparatively longer antero-posterior di s very active due to an insufficient vertical growth of the maxilla, meter of the maxillary basal bone than high angle cases, mild posterior discrepancy, tipping of the occlusal plane in the upper molar are int Curve of Spee, and insufficient vertical dimension, showing a deep anterior overbite and a reversed occlusion due to the excessive anterior rotation of the mandible. Below are the morphological characteristics: 1. Thick bone tissue, weak eruptive force of the teeth, and clinically short tooth crown length 2. Excellent growth of the mandibular condyle, but low vertical dimension.6. Treatment of Class ill Malocclusion (Low Angle) 47 lll. The General Treatment Objectives for Class III Malocclusion (Low Angle) The usual treatment approach in this type of malocclusion is correction of the negative overjet through the movement of the dento-alycolar bone with the use of a finger spring, lingual arch appliance, and FKO appliance. However, these are not the appropriate treatment methods for this type of malocclusion. ‘The treatment objective for this case should be the inhibition ofan excessive functional mandibular rotation by increasing the vertical dimension and maxillary height. If the occlusal support is secured with the increase of intermaxillar distance, the growth of the sphenoid and ethmoid bones are stimulated through the maxillary and temporal bones due to mastication and various functions of the oral cavity. This secondarily restores the harmony of the craniofacial skeleton. Below are the treatment objectives for this case: 1. Increase maxillary height 2. Increase vertical dimension (flatten the occlusal plane which is steep in the upper molar area) 3. Inhibit excessive functional anterior rotation of the mandible IV. Treatment Procedure for Class III Malocclusion (Low Angle) (fig 6-1) To flatten the occlusal plane, the lower 3 molars, and either the upper 2" or the 3"! molars can be extracted. The upper 2"! and lower 3" molars were extracted in the case presented below and the following were the treatment procedures: 1. Step 1. Leveling. Attach the brackets to the entire dentition (tubes on the terminal molars) and start leveling using a 0.014-inch roundwire. (fig. 6-1 a) 2. Step 2. Elimination of Interference. Place the MEAW on both the lower and upper dentition and put a tip back bend in the molar area to eliminate molar interference, through alignment and intru Make a step bend in the premolar area to improve the vertical dime and raise the bite. (fig 6-1b) Step 3. Establishing mandibular position. Strengthen the tip back bend in the molar area, In addition, strengthen the step bends in the premolar area in order to obtain the appropriate vertical dimension. Establish a physiologically stable mandibular position through bite- raising and the eruption of the premolar teeth. (fig 6-1¢) 4. Step 4. Occlusal Plane Reconstruction. Afier the improvement of the physiologic vertical dimension and the attainment of a stable mandibular position, the tip back bend in the MEAW is entirely removed. A step down bend is then done to flatten the occlusal48 6, Trealment of Clase Ill Malocctusion (Low Angle) Fig. 6-1 Illustration of the treatment procedures for Class Ill reversed occlusion (Low Anglo} a. Leveling stage ». Elimination of interference stago ¢. Establish mandibular position stage 4. Reconstruction of occlusal plane stage ©, Altainment of a physiologic occlusion stage plane in the upper molar area, which erupts the molar teeth, and reconstruction of the occlusal plane is being done. (fig 6-Id) 5. Step 5. Attainment of Physiologic Ocelusion. Do tooth axis control (torque control), regulate the occlusal guidance and attain a good intercuspation. (fig 6-le)6, Treatment of Class I! Malocclsion (Low Angle) 49 Fig. 6-2 Facial profile (pre-treatment) Fig. 6-3 intra-oral pictures showing the occlusal condition (pre-treatment) 1. Patient's History Chief Complaint: Protrusion of the mandible Age: 14 Sex: Female Facial profile: Face is small, and shows protrusion of the lower jaw (lig. 6-2) Intra-oral findings: teeth is Angle C! 6-3) the o lusal relationship of the canine and molar IIL, overjet is 2.5mm and overbite is 6.0mm, (fig.50 6. Treatment of Class ll Malocclusion (Low Angle} Fig. 64 Panoramic xray (pre-treatment) Facial cephalometric radiogram: SNA 81.7°, SNB 82.2°, ANB -0.5°, indicative of a mandibular protrusion. FH-MP is 22.1°, PP-MP is 21.9°, a low angle tendency. The antero-posterior diameter of the maxilla A’-P? is 46.8mm, UOP is 61.9° showing a steepening of the occlusal plane. Based on Kim’s analysis, ODI is 63.8°, APDI 94.4°, CF 158.2°, displaying an Angle’s class III condition (fig 6-17a, b, chart 6-1 pre-treatment). Panoramic x-ray: upper and lower 34 molars are present (fig 6-4). 2. Diagnosis and Treatment Plan This patient was diagnosed to have a class III reversed occlusion (low angle) with the following characteristics: anterior rotation of the mandible, insufficient vertical dimension and steepening of the posterior occlusal plane as evident in the FH-MP of 22.1°, and UOP (P) of 61.9, The main treatment objective was to improve the anterior teeth overlap through dental movement, However, the more important goal in treating this ppaticnt is to inhibit the excessive functional rotation of the mandible by inereasing the vertical dimension and maxillary height, consequently restoring the craniofacial harmony by achieving a physiologic intermaxillary distance. Therefore, as part of the treatment plan, alignment is done on the lower molar area, where mesial tipping is evident, and extraction of the lower 3"! molars is done for bite raising in the premolar area. Extract both the upper 2 molars to facilitate the correction of the maxillary occlusal plane.6, Treatment of Class Il Malocclusion (Low Angie) 51 3. Progress of Treatment Step 1: Leveling The molar tubes and standard edgewise brackets were attached to the upper and lower dentition. Leveling was started with the use of an 0.014-inch super elastic wire (fig 6-5). Step 2: Elimination of occlusal interference MEAW was placed a month after the onset of treatment, and alignment and intrusion in the molar area was started by using a tip back bend of 25° to eliminate molar interference. In addition, a step down and step up bend was done in the premolar area to improve the vertical dimension, A vertical elastic and a short class III elastic (3/16 ineh, 6 02) was used in the anterior teeth (fig Fig. 66 1* month of treatment: Elimination of interference stage and MEAW illustration52 6, Treatment of Ciace Ill Malocctusion (Low Angle) Fig, 6-7 2"! month: Stage of eliminating inlorterenco 6-6). On the 2"! month of treatment, alignment and intrusion was continued with an inerease of 5° on the tip back bend of the molar area, Vertical dimension was also improved by increasing it through strengthening of the step up bend in the lower and step down bend in the upper premolar areas. This initiated the opening of the mandible and its movement to a distal position. A short class III clastic and a class III component box type elastic were used for premolar teeth eruption (fig 6-7). Step 3: Establishing mandibular position On the 3 month, a step up bend was created in the anterior and canines to obtain an appropriate increase of the vertical dimension in the premolar area, increasing the opening of the mandible thus establishing a stable mandibular position. The tip back bend in the molar area was removed because the interference has been eliminated through alignment and intrusion. Improvement of the anterior teeth overlap was done by opening the bite in the molar and anterior area. A. vertical component box type elastic was used to obtain a mandibular position and to erupt the premolars (fig 6-8). On the 4!" month, the appropriate vertical dimension was obtained and a stable mandibular position was achieved. Furthermore, anterior negative overjet was improved. The step up bend between the molar and premolar teeth was removed and the occlusion was allowed to stabilize. A class III elastic and a vertical component box type elastic was used on the right and left side respectively to stabilize the occlusion in the premolar area and obtain the proper mandibular position (fig 6-9).6. Treaiment of Class Il Maloccusion (Low Angle) 53 Fig. 6-9 4" month: Stage in establishing the mandibular position54 6. Treatment of Class Il Malocclusion (Low Angle) Fig. 6-10 6" month; Occlusal plane reconstruction stage Fig. 6-11 6” month: Occlusal plane reconstruction stage6. Treatment of Class Il Malocctusion (Low Angle) 55 Step 4: Reconstruction of occlusal plane On the 5"" month, the step bend between the upper canine and premolar teeth as well as the bend between the lower molar and premolar teeth were removed to flatten the occlusal plane in the upper and lower molar areas. Anterior overbite has deepened securing a stable occlusion, A vertical component box type elastic was used (fig 6-10). On the 6" month, the step up bend in the maxilla was entirely removed and a reverse bend was used in the molar area to flatten the occlusal plane. The step up bend in the lower dentition except the anterior area was removed to flatten the occlusal plane. Removal of the step up bend allowed a closer occlusal relationship in the anterior area. A vertical elastic was used in the anterior area (fig 6-11) Step 5: Att: On the 7" month, the step up bend in the lower anterior area was maintained but the reverse bend in the upper molar area was removed. Axis control was done to obtain a good intercuspation and to adjust the occlusal guidance, rendering a closer occlusion, The intermaxillary elastic was discontinued (fig 6-11), inment of a physiologic occlusion On the 8" month, the step up bend was entirely removed (fig 6-13). Fig, 6-12 7" month: Stage of attaining a physiologic occlusion56 6, Treatment of Class il Malocclusion (Low Angle) Sano _——— Fig. 6-13 6 month: Stage of attaining a physiologic occlusion| Fig. 6-14 9!" month: Start of retention Step 6: Retention On the 9"" month of the treatment period, the brackets were entirely removed because a stable occlusion has been achieved and retention was started with the use of a tooth positioner (fig 6-14).6. Trealment of Ciass I Malocctusion (Low Angle) 57 2% Fig. 6-15 Facial role (postocthodontic treatment) Fig. 6-16 intra-oral pictures showing the occlusal concition (post orthodontic reatmen!) reatment results After 9-months of treatment aimed at inhibiting the excessive functional mandibular movement and actively increasing the maxillary length and vertical dimension, the facial profile has changed to a mesocephalic type, and the mandibular protrusion has improved (fig 6-15). Intra-oral findings showed an Angle’s class I canine and molar relationship, overjet was 3.5 mm, and overbite was 1.1mm showing an improvement (fig 6-16). The lateral cephalometric radiograph showed an ANB of 1.0° with an SNA of 81.1° and SNB 80.1° showing an improvement in the mandibular protrusion, FF-MP was 24.2°, and PP-MP became 23.7°. UOP (P) was 85.4°, evident of a flat occlusal plane58 6. Treatment of Class ill Malocclusion (Low Angle) pre and posttreatment 6. Pestireatment xray 8. Kay aftr a 2-year retention6. Treatment of Class Il Malocelusion (Low Angle) 59 Chart 6-1 Cephalometric Analysis Deniure Frame Analysis. Norm Pre-TX _ Post-TX [2 years Post-1X FH-MP. 25.9" 22.1 | 242 23.8 PP-MP- 24.6" 24.9 | 237 24.8 OP-MP 13.2° 98 16.8 175 OP-MP/PP-MP_ 54.0% | 44.8 | 71.0 70.6 UOP (A) mo | 76.3 | 814 80.4 oP (P) 75" 61.9 | 854 84.0 FACIAL Angle ao | 92.0 | 910) 912 SNA Angle 83.3" 84.7 | 61.4 80.5 ‘SNB Angle 78.9" 82.2 80.1 793 ANB Angle 34° 05 1.0 12 U1-FH (degree) wit | 1187 122.8 123.0 | Overjet (mm) 25mm |. 25 | 35 Overbite (mm) 2.5mm 6.0 14 AB-MP- 713° 636 | 655 50.0mm | 46.8 | 47.1 23.0mm | 25.4 | 24.4 INP 46.0% | 542 518 UT-AB (degree) 317 | 244 | 926 U1-AB (mm) 9.5mm 24 48 | L-AB (degree) 25.4" 243 | 107 | L1-AB (mm) 6.2mm Be} 45 Intermolar 174.0" | 1766 | 17.2 FH-PP 13° of 05 “Kim Anaysis Norm Pre-TX | Post-Tx a APDI 81.0° pl 72.0° 638 © 66.0 64.5 | 156.8 154.4 94.4 90.9 89.6 | COMBINATION FACTOR 153.0° | 158.2 (fig 6-17c, b chart 6-1 post treatment). ‘There were no significant changes in the intra-oral findings and the cephalometric radiograph even after the 2-year retention period (fig 6-1 Te, chart 6-1, 2 years treatment). The intra-oral x-rays even showed the normal eruption of the maxillary 3" molars (fig 6-19) and a stable occlusion.60 6. Treatment of Class il Malocclusion (Low Angle) Fig. 6-18 Inra-oral photos showing the occlusal condition afer 2-years of rtention Fig. 619 Panoramic x-ray showing the occlusal condition after 2-years of retention7. Treatment of Class | Open Bite 61 (Susumu Akimoto)62. 7. Treatment of Class | Open Bite 1 General Characteristics of Class | Open Bite Class I open bite has a normal antero-posterior occlusal relationship. Ocelusion is just not possible because of the vertical gap in the upper and lower anterior teeth, best described as a negative overbite (fig 7-1). ‘An open bite condition during the permanent dentition period is one of the most difficult malocclusions to treat. However, this can be easily managed upon consideration of the factors mentioned below. 1, Main causes for open bite condition There are various factors that could lead to an open bite condition. The ‘most common causes are as follows: 1. Bad habits: thumbsucking, tongue biting, lip biting, abnormal swallowing ete. Respiratory: tonsillar enlargement, enlargement of the adenoid, oral respiration, allergic rhinitis ete (fig. 7-2) 3. Posterior discrepancy: insufficient eruptive space for the molars (fig.7-3), This could lead to their supraeruption. 4, Others: Incorrect dental treatment (restorative material is too high), large tongue, heredity etc j ——— a 7K Fig. 7-1 Cophalometr acing ofa paint 97-2 Cophaometicrdiogram showing the or ‘an open bite condition oft tissue defect (T: enlargement of ‘A: adenoid enlargement. E: allergic rinis) tonsils,7. Treatment of Class | Open Bite 63 2.7.3 in posterior ciscropancy, occlusal interference in the moa area asi ogcurs cot ho squeezing afetin tho Lot jen the Inleference develops, the mandible antonorly rotates associated with its anterior ransvorsion, making the aseuian ‘o.adapt oi. In worst cases, the mandible rotates posterior, resulting to an open bite condition, ‘The greatest difference between the traditional method of treatment using the multi-bracket system and the treatment approach being introduced in this book is that premolar extraction is hardly done, Though the mechanism of the multi-bracket system is quite related to the mechanism of MEAW, the difference lies in the diagnosis. With the traditional mechanics of premolar extraction, the molar can be moved mesially to use the extracted space. This in turn results to the decrease in the vertical dimension which is useful in improving the negative overbite in the anterior teeth, However, this is considered a symptomatic approach to treatment. The most important aspect in all types of orthodontic treatment is to identify the cause and eliminate it. Thus providing an extremely simple kind of treatment possible. In this case, one of the most important aspects to consider is the close relationship of the open bite and the presence of the 3“ molars. In this light, posterior discrepancy is the cause of the open bite condition. 2. Abnormalities due to Open Bite 1, Facial asymmetry 2. Functional abnormalities: mastication, swallowii tongue, lips ete, 3. Psychological abnormalit ig, pronunciation,64 7. Treatmentof Class | Open Bite Il. The Morphological Characteristics of Class | Open Bite The morphological characteristics of this condition are, small ODI, a steepening of mandibular plane, obtuse mandibular angle, excessive anterior facial height, excessive low posterior facial height, flat occlusal plane, upward tipping of the lower occlusal plane, upward tilting of the palatal plane ete. Il. Evaluation of the Occlusal Plane The examination of ocelusal plane is important especially during the treatment of an open bite condition. Normally, the occlusal planes of the upper and lower dentitions coincide However, in this case, the occlusal plane for each of the dentition has to be evaluated (fig 7-4). 1, Normal occlusal plane The incisal edge of the upper central incisors should be 3-4mm below the lip line (when the mouth is closed) while the incisal edge of the lower central incisors should be within the same level of the lip line. Once the line connecting the midpoint of the upper and lower central incisal edge and tip of the mesial cusp of the molar, also known as the occlusal plane, is extended, this will almost pass through the center height of the mandibular ramus. Fig. 7-4 Generally, «commen occlusal plane i established for both te upp and ewer deni, Vowever, in paens wih open be conditions, the oocusi panel stabeshed ‘i Separately. 2. Maxillary occlusal plane This is evaluated by connecting the line between the upper Is molar and the incisal edge of the upper central incisors. 3. Mandibular occlusal plane This is evaluated by connecting the line between the lower La molar and the incisal edge of the lower incisors. 4, Occlusal plane evaluation the patient Both the upper and lower occlusal plane is examined in each patient based on the standard normal occlusal plane. MEAW is only applied to the area where occlusal plane needs to be corrected. In case where the occlusal plane has to be corrected in both the upper and lower jaw, MEAW is then applied to both arches. both the upper and lower dentition of7. Treatment of Class 1 Open Bite 65 IV. Treatment Objectives for Class | Open Bite Malocclusion 1. Leveling The first step in treatment is leveling, In patients with tooth crowding, refer to the leveling method used in Chapter 11. In patients without tooth crowding, proceed to leveling. 2. MEAW application Apply MEAW to the part where occlusal plane has to be corrected as per previous examination. Adjustments of the MEAW can be done for activation in combination with the use of a vertical elastic (3/16 in., 6 02) in the anterior teeth, In the part where occlusal plane correction is not necded, a plain archwire can be applied. A Kobayashi hook or a consolidation arch can be applied to the area adjacent to the canine (fig 7-5). Normally, a negative overbite can be improved in 2-3 months. As the overlap in the incisors becomes normal, the posterior teeth start to disocelude or open up. Once the overbite is normal, adjustments in the MEAW can be done to establish an occlusal support. The use of the vertical elastic can be continued during the improvement of posterior teeth disocclusion. 3. Completion In the final stage of treatment, ideal archwire is utilized. However, MEAW can be continuously used as an ideal arch. Fig. 75 In this illustration, a MEAW for the maxila, a consolidation arch for the mandible, and a vertical elastic were used to Correct tne maxitary occtisal plane. Atip back bend was done to the MEAW in ihe pper Gantiion for activation,66 7. Treatment of Glass ! Open Bie 4. Precautions The use of a vertical elastic to improve the negative overbite is indispensable. In case the negative overbite does not show any improvement despite treatment or the open bite condition worsens, this is solely due to the problem with the manner the vertical elastic was used, Determine the patient's compliance in terms of the usage of the vertical elastic, and determine appropriately as to why this has happened. V. Treatment Procedures for Class | Open Bite In an open bite condition during the permanent dentition period, elimination of posterior discrepancy is important. Normally, the maxillary and mandibular 3" molars are extracted but the upper 2"! molars can be extracted in young patients. In case the patient practices some bad habits, a myofunctional therapy (MPT) can also be done. Desired results will not be attained when these factors are not considered during the treatment period. Once these factors are disregarded, this could become the cause of relapse even if treatment was successful 1, Patient's history ‘Age: 25y 8 mos. old Sex: Female Chief complaints: Incorrect bite, pronunciation is not normal Patient’s history / Present symptoms: had tonsillectomy at age 24y I Lmos. old, Has chronic fever and tonsillitis. Facial profile: Face is oval-shaped, profile is straight (fig 7-6). Intraoral findings: overjet = 4mm, overbite =~3mm, a case of Angle class I open bite (fig7-7). Panoramic x-ray: All 3" molars have erupted, with complete set of teeth (fig 7-8). Cephalometric radiogram: Infraversion of the upper and lower central incisors (fig 7-9). the right and left TMJ respectively. Based on Kim’s analysis, ODI was 71°, which is almost the average value for the Japanese population, With this data, treatment is considered to be comparatively simple. 2, Diagnosis and Treatment Plan To eliminate the cause and prevent relapse, all the 3" molars were extracted. MEAW was then applied to both the upper and lower dentition simultaneously to control the maxillo-mandibular occlusal planes.7. Treatment of Class | Open Bite 67 Fig. 7-8 Pre-treatment Panoramic x-ray68 7, Treatment of Class | Open Bite Fig. 7-9 Prestrealment cephalometric tracing 3. Progress of Treatment Since the degree of tooth crowding in this patient was mild, MEAW was used at the start of treatment. MEAW was adjusted for alignment and intrusion of the molars of the upper and lower arches. Vertical elastie was used in the anterior teeth (fig 7-10). 3 months later, the negative overbite was improved. It was also observed that there was a mild disocclusion on the 2"! molars (fig 7-11) On the 6" month, a positive overbite was observed. The adjustment made in the MEAW (ic. tip back bends) was discontinued to attain an occlusal support because the gap between the molars has increased (fig 7-12). A stable occlusion was observed on the 8" month. Only the wire was removed. Two months later, bracket debonding was done (fig 7-13). At 10.4 month, after debonding, it was noted that there was a slight decrease in the overbite, However, the occlusal condition remained to be relatively normal (lig 7-14). The active treatment period was 8.6 months,7. Treatment of Class Open Bite 69 Fig. 7-11 Inra-oral photos 3 months from the start of veatment 5 Bey a Fig. 7-12 Iniro-ora photos 6.5 months from the start of treatment |e 1 ‘ea ‘a edt | Y oy Fig. 7-13 Inra-cral photos 2.2 months post treatment Fig. 7-14 inra-oral photos 10.4 months posttreatment70 7. Treatment of Class | Open Bite Chart 7-1 Cephalometric Analyses pre-and posttreatment Pre sO | FH-OP (Lower) | 17 9 | Ramusinclination | 89 90 | | 2. Superimposition at | the palatal plane 3. Superimposition at MP Fig. 7-15 Superimposition of tho pro and post cephalometric tracings 4. Comparison of the pre and post treatment values (chart 7-1, fig 7-15) As shown in the chart, the ODI_ improved to 75° from 71° and the MP closed by 1°. The occlusal plane in both the upper and lower dentition has remarkably changed. There was a 4° and 8° change in the upper and lower dentition respectively Based on the superimposed tracings, lingual tipping in the upper anterior teeth as well as the labial tipping in the lower anterior teeth has slightly increased. Moreover, supraeruption of the upper and lower 1* molar was not observed, instead alignment was apparent.8, Treatment of Class I Open Bite 71 (Atsushi Matsumoto)72 8. Troatment of Cis I! Open Bite Ih General Characteristics of Class Il Open Bite This is classified as the type of malocclusion where the antero-posterior growth of the maxilla is poor and the ability of the mandible for an anterior adaptation is i in the posterior teeth related to their excessive elongation caused by posterior discrepancy. In an open bite condition associated with a mandibular distocclusion, it docs not mean that excessive elongation of the molars is always present. There are instances where the adaptive force is insufficient due to the posterior rotation of the mandible related to the steepening of the occlusal plane in the molar area, sufficient, This can be due to the cuspal and occlusal interference ll. | Morphological Characteristics of Class II Open Bite Excessively high anterior facial height \ 2, Excessively low posterior facial height 3. Steep mandibular plane 4, Obtuse mandibular angle Growth tendency of the mandible is in an inferior direction with posterior rotation 6. Excessive vertical dimension 7. Excessive elongation of the molars (supraversion) 8. Two occlusal planes * Occlusal plane in the upper anterior teeth area is flat * Occlusal plane in the upper posterior area is steep 9, Abnormal curve of Spee (reverse curve) 10, Asymmetrical maxillo-mandibular dental arch width 11. Cuspal interference in the molar area 12, Occlusal interference in the molar area 13. Unstable ocelusal support 14, Absence of anterior guidance8, Treatment of Class Il Open Bite 73, 6. 9. 10. i 12 13, 14 15, 1. lll. Treatment Objectives for Class Il Open Bite Habit modification (i.e. abnormal swallowing and tongue thrusting, ete.) In cases when the tongue is observed to be large, glossectomy can be done. For respiratory-related problems, address the enlargement of the pharynx and tonsils, oral respiration, allergic rhinitis and other otorhinologic related d Eliminate the functional factor and obtain a physiologic condylar and mandibular position. Stimulate an anterior rotation of the mandible (during the growth period, anterior position can be expected through mandibular growth guidance). Eliminate posterior discrepancy (intrusion and extraction of upper and lower molars) to control the vertical dimension within the denture frame. Align every single tooth based on the appropriate curve of Spee. Flatten the ocelusal plane in the molar area, Eliminate discrepancy of the upper and lower dental arch, Retract the upper dental arch to its appropriate position and improve the molar class II relationship. Allow to a certain degree anterior teeth clongati overbite (open bite). Obtain an occlusal support and stabilize occlusion. Obtain an appropriate occlusal and anterior guidance Improve midline discrepancy. Obtain a normal physiologic occlusion. Attain an excellent profile “ases, n to improve the negative . Consider over-correction for slight relapse and choose a stable retention method. V. Treatment Procedures for Class II Open Bite Patient’s History Age: 16 y.o. Sex: Male Chief complaints: Cannot bite well due to an open bite condition in the anterior teeth Facial profile: frontal is oval in shape, lateral is convex in shape, relaxed upper and lower lip during the resting phase (fig 8-1) Intra-oral findings: labial tipping of the upper anterior teeth, overjet of +2mm, overbite of -10mm, Discrepancy in the upper and lower dental arch width was observed. Curve of Spee in the mandible was also observed to be reversed (fig 8-2).74 8, Treatment of Class ll Open Bite Fig. 82. Prestreatment intra-oral photos Fig. 6-3 Pre-treatment Panoramic xray8. Treatment of Class II Open Bite 75 Fig. 8-4 Pre-treatment Cephalometric radiogram Fig. 8-6 Pre-treatment cephalometric tracing Panoramic x-1 y results: The four 3" molars were impacted (fig 8-3). Cephalometric radiogram findings: There was no abnormal antero-posterior position of the maxilla observed in the lateral cephalometric radiog severe hyperdivergence was noted due to the opening of the mandibular angle and excessive mandibular height, The mandible showed a posterior This can be classified into a Dolichocepha type. The maxillary molars were suspected to have supraerupted, Presence of mesial tipping in the upper and lower molars were also observed (fig 8-4). Based on the cephalometric tracings, it was observed that there was steepening of the occlusal plane in the upper posterior area (6-7), and flattening of the occlusal plane in the upper anterior area (1-5) (fig 8-5). The mandible showed a slight dis- placement to the right side as shown in the frontal view cephalometric radiogram (fig 8-6). Fig. 6-6 Pre-treatment P-A Cephalometric x-ray,76 8, Treatment of Clase ll Open Bite Fig. 6-7 lustraton of te teatment plan and the diferent phases of taoth movement for iss I open bite 2. Diagnosis and Treatment Plan In this patient, anterior rotation of the mandible is not possible because of the supracruption of the molars caused by posterior discrepancy. This was classified into a skeletal open bite condition. To improve the open bite condition, elongation of the anterior teeth at a certain degree has to be done and intrusion of the molars is important to correct their supraeruption. In patients with class II open bite, reconstruction of the occlusal plane in the molar area is important. The anterior rotation of the mandible as a result of the occlusal reconstruction is desired. First, eliminate the cuspal interference in the posterior molar area, To stimulate anterior rotation of the mandible, extract molars when needed, Then eliminate interference by alignment and intrusion of the lower 2" molars thus flattening the occlusal plane in the lower molar area, And finally, flatten the occlusal plane in the upper molar area to do the final occlusal reconstruction. Illustration of the treatment plan and tooth movement phase is shown in fig 8-7.8, Treatment of Class il Open Bite 77 Fig. 8-8 intra-oral photos 2 months aftr stat of treatment 3. Progress of Treatment | n of the upper and lower posterior teeth to reconstruct the occlusal plane in the maxillo- mandibular molar area. Distal movement and | Fig 8-8 shows the intra-oral pictures after 2 months of treatment. A MOAW (Modified | Offset Arch-Wire, 0.016 x 0.022 inch, blue elgiloy wire) was installed. To improve class II relationship and crowding, distal movement and intrusion of the upper molar teeth are done. The Fig. 6-9 Adjustment method done in MOAW fr this patient, use of leveling for the anchorage ‘of upper anterior teeth crowding was held back. In order to eliminate excessive flaring in the upper anterior teeth area, a lingual arch was used to reinforce anchorage. On the other hand, alignment was in progress while applying an intrusive force to the lower molar area Fig 8-9 shows the adjustment method done in MOAW with this patient.78 8. Treatment of Class II Open Bite Fig. 8-10 Inira-oral pictures after 4 months of treatment Step 2: Leveling and reconstruction of the occlusal plane in the upper and lower molar area Fig 8-10 shows the intra-oral pictures 4 months following the start of the treatment. Alignment was in progress and intrusion of the lower 1° molar with the use of MOAW. In order to improve the crowding in the upper anterior area, the lingual arch was removed. An 016-inch NiTi wire and open coil was used for leveling. Alignment and intrusion was continued in the lower dentition with the use of MOAW and anterior vertical clastics. Fig 8-11 shows the intra-oral pictures 6 months following the start of treatment. MEAW was applied to simultaneously align the anterior teeth in the upper and lower arches. Buccal tubes were bonded on to the upper 3" molars to allow eruption and at the same time induce their mesial tipping. A plain MEAW (Multiloop Edgewise Arch-Wire: 0.016 x 0.022 inch, blue elgiloy wire) ‘was installed in the upper and lower dentition for simultancous alignment, The open bite condition in the incisor area has improved. The gap in the upper molar was used to climinate crowding, Vertical elastics were used in the anterior teeth, Fig 8-12 shows the intra-oral pictures 9 months since the start of treatment. To improve the class Il relationship, MOAW was applied in the maxilla with the objective of eliminating cuspal interference in the posterior molar area through intrusion and distal movement of the 3"! molar with mesial tipping. Afier which, the upper I molar distally moved again through the upper MOAW. To flatten the mandibular occlusal plane, a slight reverse curve was applied to the MEAW. Vertical elasties were used in the anterior teeth,8, Treatment of Cass il Open Bite 79 Fig, 8-12 intra-oral pictures ater 9 months of treatment Step 3: Attainment of a physiologic condylar and mandibular position Fig 8-13. Intra-oral pictures after 12 months of treatment. Up to this point, the mandible continues to be displaced to the right side. MEAW was used in both the upper and lower dentition, While torque was being controlled, the upper and lower arches were being aligned. Short class II elastic was used in the anterior teeth,80 8. Traatment of Class Il Open Bite Fig. 814 Inra-oral pictures 14 months folowing the slart of treatment Fig 8-14 shows the intra-oral pictures 14 months following the start of treatment, The mandibular displacement to the right was corrected through the MEAW. The mandibular midline was moved to the left to be in line with maxillary midline, To correct the discrepancy of the vertical dimension in the left and right side of the maxilla, a step down bend was done in the horizontal loop of the upper right canine, Since there was discrepancy in the upper and lower dental arch width, a Mulligan arch was used to gradually expand the maxillary dental arch width in order to align with the lower dental arch width. At this time, the mandible anteriorly rotated associated with a reverse occlusion in the anterior area, A short class II elastic and box elastic was used at the left and right side respectively8. Treatment of Class Il Open Bile 81 = Fig, 816 Inta-ral pictures during the completion ofthe dynamic treatment, afer 20 months of realment Step 4: Detailing, harmonizing of the upper and lower occlusal planes Fig 8-15 shows the intra-oral pictures 17 months following the start of treatment. The lateral displacement of the mandible has been corrected and the upper and lower midline was in place. A step down bend was done in the plain MEAW of the maxilla to flatten the occlusal plane in the upper molar area. A box elastic was used in both the left and right molar area to establish the premolar intercuspation. Fig 8-16 shows the intra-oral pictures 20 months following the start of treatment. A lingual fixed retainer was used in the upper and lower anterior segment to prevent the recurrence of crowding. In addition, lingual buttons were applied to the upper and lower lateral incisors. Vertical elastics in the anterior area was used in the evening to prevent relapse. Moreover, a bionator (to close) was used together with the vertical elastics,82 8. Treatment of Class II Open Bite Fig. 8-17 Panoramic xray after post reatment Fig, 8-18 Lateral view cephalometric raliogram post treatment Fig. 8-19 Frontal view cephalometric ragiogram post treatment 4. ‘Treatment Results During the 20-month treatment period, MOAW was used for 6 months and MEAW for 12 months in the upper dentition. In the mandibular dentition, MOAW was used for 4 months and MEAW was 15 months. Intermaxillary elastics were used for 18 months. Fig 8-17 shows the panoramii ray during the completion of the dynamic treatment. Fig 8-18 shows the lateral view of cephalometric radiogram,8, Trealment of Class l Open Bite 83 in compl ao name Fearon Based on the lateral cephalometric radiogram, the root apex of the upper I" molar was intruded into the maxillary sinus. When looking at the lateral cephalometric tracings, closure of the anterior openbite by 2.5 mm and a 2 mm anterior position of the chin were observed due to the anierior rotation of the mandible (fig 8- 20, 8-21a). When comparing the superimposed cephalometric tracings of pre and post treatment, the upper molar has distally moved by 3 mm and intruded by 2 mm as shown in the palatal plane. The upper premolar teeth has. distally moved by 2 mm and intruded by 2 mm. Upper anterior teeth have elongated by 2.5 mm (fig 8-21b). In the lower dentition, the 2 molar has been intruded by about | mm in the distal area. In addition, elongation in the lower 1* molar was not observed, The lower anterior teeth have elongated by 7 mm (fig 8 2c). As a result, the steep ocelusal plane in the molar area has flattened and the reverse curve of Spee in the mandible was also improved obtaining a stable intercuspal position, Overjet was +2mm and overbite was +2mm, ‘The step bends in MEAW regulates the vertical dimension of both the left and right side. With that, the mandibular position has been corrected as shown in fig 8-19, Overall results showed a corrected condylar position, improved TMJ function, and attainment of an excellent profile (fig 8-22).84 8, Treaiment of Cass Il Open Bite Fig. 8-23 Intra-oral piclures 1-year post tention Chart 8-1 Results ofthe taleral cephalometric analysis SNA mca NB aio | 81s ans “AN 40 30) | FMIA. 420 600 U1-SN 1200 1150 Facial Axis 81.5 825 Facial Depth 86.6 875 Mandibular Plane 36.0 345 Lower Facial Ht 53.0 50.0 Mandibular Arc 21.0 20.0 Convexity 60 5.0 4-APO (ram) 85 55 1-APO (deg.) 39.5 210 ePrv 25.5 25 Lower Lip-E Plane Oe | 70) | upper OP (1-6) a ‘upper OP (6-7) _ Ws ee ODI 695 | 605 APDI 79.5 81.0 cr 139.0 141.5 ‘There was no apparent sign of relapse 1- year post retention. Because of that, the use of intermaxillary elastics was discontinued and only the lingual anchorage in the upper and lower anterior area was retained for retention (fig 8-23). Chart 8-1 shows the results of the cephalometric radiogram analysis.8, Treatment of Class ll Open Bite 85 ut Method Used for ( Patient Important Points and the Treatm Avoid surgical operation as treatment for a severe open bite condition with a skeletal factor. However, load to the teeth and periodontal tissue cannot be avoided when planning for the individual’s orthodontic treatment. Ther itis fore, nportant to examine the periodontal condition pre-treatment to determine whether it can withstand the treatment. 2. Plan for the habit modification Myofunetional therapy restores the oral lip closure function and trains, the masticatory muscles as well as the muscles surrounding the oral cavity. This will allow the mandible to adapt through anterior rotation 3. In order to eliminate posterior discrepancy, the upper 2" molars were extracted after determining through the x-ray that the 3"! molars could serve to replace the 2™ molars. The 3“ molars started to erupt afier a month following the 2“ molar extraction and after 7 months had reached the line of occlusion especially because buccal tubes were bonded to them. At age 16, eruption of the upper 3" molars started a month following the upper 2 molar extraction suggesting that this was the result of posterior discrepancy =xtraction of the upper 2" molar and lower 3" molar can also be done to attain the correct vertical dimension. 4, There are cases where there is a need to use a maxillary expansion device to allow harmony of the symmetry of the upper and lower dental arch, In this case, the devices used are Mulligan arch, Quad Helix, Rapid Expansion, and Trans-palatal bar. 5. Leveling (strategie leveling) In this patient, correction of the upper and lower occh 1 planes done during the leveling period, In other words, the final flattening of the occl plane in the upper molar area was done. Initially, a MOAW (Modified Offset Arch-wire : 0,016 x 0.022 inch blue elgiloy wire) was used to intrude and distally move the upper f This is also effective in improving the class II molar relationship, At this point, reinforcement of anchorage (lingual arch) was done in the upper premolar area of both the left and right side. The anchorage unit was from the premolar teeth to the anterior segment. At this stage, crowding ‘was not yet eliminated, During the improvement of the upper anterior crowdin, the needed space was obtained first to avoid flaring and elongation after which leveling was done. The use of intermaxillary elastics was necessary. The lingual arch in the upper premolar area was removed. After which MEAW (Multiloop edgewise archwire : 0.016 x 0.022 inch blue elgiloy wire) was applied for alignment and distal movement of the maxillary dentition, In the mandibular dentition, MOA W was applied to avoid flaring and excessive elongation of the st mola86 a, Treatment of Class il Open Bite anterior teeth through the alignment and intrusion of the lower 2" molar. MEAW was then applied to simultaneously align the mandibular dental arch, A flat MEAW was initially used instead of a MEAW with a tip back bend. The reason for that is because mesial tipping is possible even with the use of a plain MEAW. Moreover, the use of an intermaxillary elastic (class I, vertical or check elastic) for 24 hours must be determined. After confirming the proper usage of the intermaxillary elastics, a tip back bend of about 10° can be done for alignment. * In case of a moderate discrepancy, a 0.016-inch of NiTi wire or a 0.016-inch of a round Australian wire can be used. Afier leveling, distal movement and simultaneous alignment (uprighting) of the entire dentition through MEAW can be done, + In case of a severe discrepancy, the concomitant use of a round Australian wire with open coil spring can be done or else a MOAW can be used. Alignment and distal movement is done from the 2 molar, which is the terminal molar, Then conduct a strategic leveling. That is why, before improving the anterior teeth crowding, do leveling only after the space needed for anterior teeth alignment has been obtained and the posterior molar area is aligned. Which is then followed by the distal movement and simultaneous alignment of the entire dentition through MEAW. 6, Intrusion of the molar teeth through the use of extra oral force If needed, use an extra oral anchorage appliance (high pull headgear) to apply an intrusive force to the upper molar teeth, However, molar intrusion is difficult because of the closeness of the upper alveolar bone and the basal maxillary sinus, An orthodontic implant, which will serve as an anchorage unit to intrude the molar area, is known to be an effective method. At this point, it is important to consider how the ocelusal plane will be reconstructed before the operation, 7. The use of intermaxillary elastic The appropriate use of the intermaxillary elastic is indispensable. Therefore itis important to let the patient understand and cooperate well with its usage. Excessive elongation due to intermaxillary elastic can possibly cause gum recession, induce involution or cause tooth root resorption, When using elastics, consider the thickness of the alveolar bone of the upper and lower anterior teeth and the thickness of the gums. 8. Thoroughly clean the oral cavity to prevent the occurrence of ca Good oral hygiene procedures will help maintain the healthy condition of the periodontal tissues.9. Treatment of Giass II Deep Overbite 87 (Atsushi Matsumoto)88 9. Treatment of Class II Deep Overbite General Characteristics of Class Il Deep Overbite This is classified as a type of malocclusion where the vertical growth of the maxilla is insufficient. Because of this, the vertical dimension in the molar area is insufficient resulting to the disharmony of its relationship to the vert growth of the mandible. Though there is not much of a problem with the anteroposterior diameter of the maxilla, there is a characteristic sudden tipping of the occlusal plane in the molar area. With the steepening of the occlusal plane in the posterior, the mandible cannot adapt anteriorly. Instead it adapts posteriorly due to the occlusal interference in the molar arca. cal Il. | Morphological Characteristics of Class II Deep Overbite 1. Lip incompetence 2. The reverse rotation of the lower lip during the resting phase 3. Excessively small vertical dimension 4, Insufficient eruption of the molar teeth (infraeruption) 5. Accentuated Curve of Spee 6. Two ocelusal planes + Flat occlusal plane in the upper anterior area + Steepening of the occlusal plane in the upper posterior area 7. Discrepancy in the upper and lower dental arch width 8. Labial tipping of the upper anterior teeth 9. Occlusal interference in the molar area 10, Insufficient occlusal support 1, Functional failure due to poor anterior guidance Ill. Treatment Objectives for Class Il Deep Overbite 1. Habit modification like tongue thrusting and abnormal swallowing. with respiratory problems, treatment of enlarged pharynx and tonsils, oral respiration, allergic rhinitis and other otorhinologic related disea For patien es.9. Treatment of Clase Deep Overbite 89 Eliminate the functional factor and obtain a physiologic condylar and mandibular position, 4, Increase the maxillary height and vertical dimension iminate the discrepancy in the upper and lower dental arch width through lateral expansion of the maxilla, 6. Improve the class II molar rela to its appropriate position. 7. If the patient seeks treatment during the growth period, obtain anterior position of the mandible through growth guidance. 8. Align every single tooth based on the appropriate curve of Spee. And finally, flatten the occlusal plane in the molar area, 9. Increase the vertical dimension through upper and lower molar eruption. Obtain an occlusal support. 10, Improve overbite (deep bi 11, Obtain an appropriate occlusal and anterior guidance. 12. Obtain normal intercuspation, 13, Attain an excellent profile. 14, Consider relapse as over-correction. nship by retraction of the upper dental arch IV. Treatment Procedures for Class II Deep Overbite 1. Patient’s History Age: 16 ylo Sex: Male Chief complaints: Protrusion of the anterior teeth Facial profile: Brachycephalic and convex profile, overjet is +1 1mm, overbite is +1 1mm (fig 9-2). Panoramic x-ray: all the four 3" molar teeth are impacted (fig 9-3). Cephalometric radiographic findings: Based on the lateral view, there isa slight anterior position of the maxilla, and posterior position of the mandible. Mandibular angle is small because of the excessively low mandibular height, This is also classified as brachyeephalic facial type (fig 9-4). It was observed through the lateral cephalometric tracings that there was a severe curve of Spee showing a steepening of the occl plane in the molar area and a remarkable labial tipping of the occlusal plane in the upper anterior teeth (fig 9-5). Fig 9-6 shows the frontal view cephalometric radiogram.00 9. Treatment of Class lI Deep Overbite Fig. 9-1 Facial rofl during the inal examination Fr Fig. £2 Intraoral pictures during the inital examination Fig. 93 Panoramic xray during he fist examination9, Treatment of Class! Deep Overbite 91 4 Lateral cophalometrc radiogram Fig. 9-5 Lateral cephalometric tracings during the inal examination Sian th tal natn Fig 9-6 Frontal view cephalometric radiogram during the inital examination92 9, Treatment of Class ll Deep Overbite Fig 9-7 Mustraton ofthe tooth movement and reatment plan fr clase Il deep averbite contion 2. Diagnosis and Treatment Plan In this patient, it was noted that the curve of Spee was deep with steep occlusal plane in the molar area, showing an interference in the posterior region, Therefore it resulted to class II because of the inability of the mandible to anteriorly adapt leading to its retrusion, The occlusal support is also insufficient because of the excellent vertical growth of the mandibular ramus, leading to occlusal adaptation, allowing the maxilla to anteriorly rotate. Incl II deepbite, the anterior rotation of the mandible through occlusal reconstruction is best desired. First, it is important to eliminate the functional causes of the mandibular retrusion (cuspal and occlusal interference). In this, case, a physiologie condylar and mandibular position can be attained. With this, posterior molar interference is eliminated with the alignment of the lower 2"! molar, correcting the excessive curve of Spee. Secondly, it serves to flatten the occlusal plane in the upper molar area. In order to get a sufficient occlusal support, the upper and lower molar teeth are supra-erupted to increase vertical dimension. With this process, the class II mola lationship is improved due c maxillary position through alignment and retraction of the maxillary dentition. Fig 9-7 shows the illustration of the treatment plan and tooth movement. to the appropr8, Treatment of Class II Deep Overbite 93 Fig, £9 intra-oral pictures S months folowing the start of treatment 3. Progress of Treatment Step 1: Correction of the Upper Dental Arch/Reconstruction of the Occlusal Plane in the Lower Posterior segment Fig 9-8 shows the intra-oral pictures a month following the start of treatment, A Quad helix was used (o laterally expand the maxillary dental arch width, An 0.016-inch round Australian wire was placed in the mandible and elimination of the curve of Spee was started. Retraction of the upper anterior teeth has not yet started, Fig 9-9 shows the intra-oral pictures 5 months following the start of treatment, The intereanine width of the maxilla was expanded through the use of Quad helix. Retrusion of the upper anterior area has not yet started, Brackets, were bonded and leveling was started. An 0.016-inch round Australian wire and 4 Utility arch made from an 0.016 x 0.016 inch blue elgiloy was used in the94 9. Treatment of Class II Deep Overbite Fig. 9-11 Inra-orat pictures 15 months ater stat of treatment mandible for bite rising and elim n of the curve of Spee as well as for closure of spaces. (Note: At this stage, the use of MEAW in the mandible is also possible). Step 2: Closure of Space and Occlusal Plane Reconstruction in the Upper and Lower Molar Area Fig, 9-10 shows the intra-oral pictures 10 months following the start of treatment. A consolidation arch of 0.016 inch green elgiloy was used to close the spaces in the maxilla, Improvement for the excessive curve of Spee in the mandibular arch was continued. A reverse curve was done in the 0.016 x 0.016 inch blue elgiloy applied in the mandible. (Note: At this stage, the use of MEAW in the mandible is also possible). Fig. 9-11 shows the intra-oral pictures 15 months following the start of treatment, MEAW (Multiloop edgewise archwire: 0.016 x 0.022 inch, blue elgiloy) was applied to the maxilla for space closure, alignment of the dental9, Treatment of Class i Deep Overbite 95 Fig, 9-13 intra-oral pictures 24 months following the stat of teoatmant arch, and bite rising. Improvement of the curve of Spee in the mandibular dental arch was continued, A reverse curve was done in the 0.016 x 0.016 inch blue elgiloy applied in the mandible. The space in the mandible has almost closed. (Note: At this stage, the use of MEAW in the mandible is also possible), Step 3: Bite Raising / Molar Relationship Correction Fig, 9-12 shows the intra-oral pictures 19 months following the start of treatment. A step down bend was done in the MEA W (0.016 x 0.022 inch blue elgiloy wire) for maxillary bite rising. A reverse curve was done in the 0.016 x 0,016-inch blue elgiloy wire in the mandible. Space in the mandible has closed and the mandibular arch has been aligned. (Note: At this stage, the use of MEAW in the mandible is also possible), Fig. 9-13 shows the intra-oral pictures 24 months following the start of treatment, A DAW (double archwire) of 0.016 x 0.016-inch blue elgiloy was96 9, Troatment of Class ll Dosp Overbite Fig, 9-16 Inra-oral pictures during the completion ofthe dynamic treatment, 34 months following the start of treatment8. Troatment of Class II Deap Overbito 97 applied for bite rising in the maxillary dental arch, A step down bend was done in the horizontal loop of the upper right canine (upper sectional arch 3-5). A plain MEAW (Multiloop edgewise archwire: 0.016 x 0.022 inch blue elgiloy wire) was applied to the mandible to simultaneously align the dentition, ep 4: Bite Rising / Detailing Fig. 9-14 shows the intra-oral pictures 27 months following the start of treatment. The four upper anterior teeth have intruded, Step down bend was done to simultaneously align the dentition, In the mandible, a step up bend and reverse curve was done to the MEAW for bite rising. Fig. 9-15 shows the intra-oral pictures 32 months following the start of treatment. A step down bend was done in the MEAW of the maxilla for bite rising. In the mandible, a step down bend was done in the MEAW (Multi-loop edgewise archwire : 0.016 x 0.022 inch, blue elgiloy wire) for bite rising Fig. 9-16 shows the intra-oral pictures 34 months following the start of treatment. MBA of the upper and lower jaw was removed, Fig. 917 Panoramic x-ray during the dynamic treatment Fig, 9-18 Lateral cephalomeliicradiogram Fig, 9-19 P-A cephalometric radlogram ‘uting the dynamic treatment ting the dynarnic treatment98 9. Treatment of Class Il Deep Overbite mann CTV La ) Fig. 9-20 Lateral cephalometric adiogram tracing after the ‘completion ofthe dynamic treatment 4. Treatment Results ‘The dynamic treatment period lasted for 34 months. The use of Quad helix in the maxilla lasted for 7 months, DAW was 3 months, and MEAW was 17 months. In the mandible, utility arch was used for 5 months and 16 months for MEAW. The use of intermaxillary elastic lasted for 24 months. Fig, 9-17 shows the panoramic x-ray during the dynamic treatment, Fig 9-18, and 9-19 show the lateral and frontal cephalometric radiogram respectively. Based on the cephalometric tracings, the vertical dimension has increased (fig 9-20). The superimposed tracings of the pre and post treatment (fig 9-2 1a) show a corrected mandibular position with a 6mm-inerease of the vertical dimension through the movement of the occlusal system, Based on the superimposed tracings of the maxillary palatal plane, the upper molar teeth have moved anteroposteriorly with a 3mm elongation, The incisal edge of the central incisors has retruded by 12 mm and extruded by 4 mm (fig 9-21b). The center of alignment was the 2! premolar teeth in the lower dentition as shown in the mandibular plane of the superimposed tracings. This means that there was no anteroposterior movement of the molar tooth He ee BIN LT se kN SU) Fig. 9-21 Superimposed tracings ofthe pre and post treatment Fig. 9-22 Facial profile ater the dynamic treatment98. Treatment of Class Il Deop Ovorbite 99 crown, Instead, it aligned whileclongating by 3mm. Moreover, the lower anterior teeth were intruded by 3mm (fig 21c). As a result, the steep occlusal plane in the molar area, has flattened and the dual occlusal plane, which was causing the deep curve of Spee, was improved. Overjet was *3mm and overbite was 45mm. A stable occlusion was attained as well as the excellent facial profile due to the correetion of mandibular position (fig 9-22). A Begg type retainer was used for retention at daytime and a bionator (to open) was used at night, which lasted for a year. Since there was no sign of relapse, the patient was subjected to a periodic examination, Fig 9-23 shows the facial profile 5 years later and fig 9-24 shows the intra-oral pictures confirming, a stable occlusion. Fig 9-25 is the panoramic x-ray and fig 9-26, 9-27 shows the lateral and frontal cephalometric radiogram respectively. Results of the cephalometric analysis are shown in chart 9-1 Fig 8-24 intra-oral pictures 5 years post retention100 9, Treatment of Class II Deep Overbite Fig. 9-25 Panoramic x-ray 5 years post retention Fig. 9-26 Lateral cephalometric adlogram Fig. 9.27 Frontal caphalometicraciogram 8 years post retention 5 yoars post retention8. Treatment of Ciass II Doep Overbite 101 Chat 9-1 Results ofthe lateral cephalometric radiogram ‘SNA ‘SNB ANB MA FMIA. 535 620 60.0 Ut-SN 1265 101.0 401.0 Facial Axis 92.5 94.0 94.0 Facial Depth 89.5 915 10 | Mandibular Plane 14.0 15 11.0 Lower Facial Ht 39.5 43.0 43.0 Mandibular Arc 44.5 445 445 Convexity 25 0.0 00 4-APO (mmm) Be 16 20 +-APO (deg.) 32.5 295 295 6-PTV 270 285 | 26.0 Lower Lip-E Plane 35 05 1.0 upper OP (1-6) 2.0 15 3.0 upper OP (6-7) 14.0 15 3.0 opt 73.0 75.0 760 APDI 73.0 81.5 79.5 162.0 156.5 155.5 oF a 3 L Lis aes = 5. Treatment Method Used and Some Important Points to Consider in the ‘Treatment of Class If Deepbite Malocclusion 1. Remove the functional cause and obtain a physiologic condylar and mandibular position. To do that, it is important to define the plans for habit modification, Furthermore, the use of myofunetional therapy (MFT) restores the function of oral lip closure and trains the masticatory muscles including the tongue and the muscles surrounding the oral cavity. This stimulates the adaptational capacity of the mandible to rotate anteriorly Expect anterior mandibular rotation (During the growth period, obtain anterior mandibular position through growth guidance). 3. Control the vertical dimension in the denture ind flatten the occlusal plane in the molar area ume 4. Improve the dental arch through a maxillary lateral expansion device in se the patient is manifesting inappropriate maxillary dental arch and retrusion of the mandible. This will allow more leeway for mandibular movement, obtaining a physiologic mandibular position. (Combination of MBA and Mulligan arch, Quad helix, expansion screw plate appliance used for bite rising, Rapid expansion)102 Treatment of Class Il Deep Overbite 6. In raising the bite, erupt the molar teeth and intrude the upper and lower anterior teeth. A Double Archwire can be used at this time. Generally, the intermediate tooth is extracted to increase the vertical dimension however this has been known to be difficult. Itis best to always refrain from doing a premolar extraction. In occlusal reconstruction, eliminate the curve of Spee and flatten the occlusal plane in the molar area, Simultaneously align each tooth through the use of MEAW. At this point, bite raising was also accomplished (tip back bend, step bend, Reverse MEAW etc) In the retraction of the maxillary dentition, improve the class Il molar relationship by using the entire mandibular dental arch as an anchorage unit with the use of intermaxillary elastics, In case of severe maxillary protrusion or absence of mandibular growth, extrusion of the upper posterior tecth and distal movement can be done. At this point, an extraoral anchorage appliance can be used (MOAW, MEA\W, Headgear, J-hook, GMD, pendulum, Jones jig). Obtain occlusal support and stabilize occlusion. Obtain an appropriate occlusal and anterior guidance.410. Treatment of Mandibular Lateral Deviation 103 (Susumu Akimoto)104 10, Treatment of Mandibular Lateral Deviation IL Definition of the Mandibular Lateral Deviation Mandibular lateral deviation is the lateral displacement of the chin to either the left or right side (fig 10-1). 1. Main Causes of Mandibular Lateral Deviation 1, Bad habits: One-sided mastication, res- ting the chin on one’s hand, one-sided posture. 2. Posterior discrepancy (fig 10-2): Unilateral eruption space deficiency in the posterior area, This could lead (o the supraeruption of the molars. 3. Others: Poor dental treatment (Difference in the height of the restorative material in the left or right side), TMJ arthrosis, history of external trauma, ete, 2. Abnormalities Caused by the Lateral deviation of the Mandible 1, Facial asymmetry 2. Funetional abnormality: masticatory dysfunction, TMJ arthrosis etc. 3. Psychological Fig. 10-1 The P-A cephalometic tracing of apt train lateral deviafon a the mandible The chin fs usually displaced on ether the let or igh side. Occlusal plane the molar area o tho displaced sid i ow. The condyle of Ine contaiateral sei retatvely postioned high compared tothe oer site (conde positon othe other se I ower) Fig. 10-2 inthis patient, the eruptive direction ofthe upper right 3° molars observed to be abnormal. This led to the supracruption of tho 2” molar and eventually displacement of the manclible to the left side ‘occurred due to the interference.10. Trealment of Mandibular Lateral Deviation 105) ll. Characteristics of Mandibular Laterodeviation 1. Morphological Characteristics of Mandibular Lateral Deviation 1. Frontal view (Fig 10-13) Facial asymmetry is apparently severe especially with the displacement of the chin towards either side. This is usually associated with TMJ arthrosis compared to other types of malocelusions as shown, with the difference in the height and size of the eye, tipping of the left and right palatal line, as well as difference in the height of the shoulders. Fig. 10-3 At age 12, upper and lower midline was contered due to the absence of mandibular displacement. At age 19, the patient came with a chief complaint of mandibular lateral displacament {fig 10-2 shows the panoramic x-ray ofthis patient), Superimposed tracings of the frontal view cephalometric radiogram is shown below.106 10. Treatment of Mandibular Lateral Deviation 2. Articulator model In mandibular lateral deviation, the mandible is not the only structure that is displaced but the maxilla as well. With the use ofa facebow transfer and articulator mounted ‘model, the difference in the height of the left and right maxilla can be determined (fig 10- 4). Normally, the chin displaces to the side where the maxillary height is low just to get an occlusion, More often than not, occlusal q Fig. 10-4 The maxilary occlusal articulation model of a imerference is observed on the unaffected side patient wth mandibular lateral deviation (rah side). The i ‘manelblo is displaced tothe right sido because of ow vertical patsetossiate on the laplared sldss

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