Manual for the Clinical Application of MEAW Technique

MEAW 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

Tt has bcen more than 20 years sincc the Multiloop Edgewise Arch-Wire (MEA W) was
introduccd in Japan. It was primarily used to treat open bite conditions but its usage has gone far
beyond what it was originally designcd for. lt is now being used for the treatmcnt or almost ali
types of malocclusions. In fact, most of the dcntists and orthodontists in Japan use MEAW to treat
thcir orthodontic cases. 1-lowever, textbooks about the use ofMEA W for orthodontic treatment
have not been availablc and numerous practitioners have bcen requesting for it. Indeed there is a
great demand for such a book and I had relayed this request lo Dr. Young 1-l. Kim, the author and
proponent of MEAW, but unfortunately, due to his hectic schedule he was not able to complete
it. Thus; the publication ofa book on MEAW did not materialize.

Thus, for this reason, this textbook on the use ofMEA W in orthodontic treatment was
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 thc basic concept and tcchnique
of using MEAW in the treatment of malocclusion.

Needless to say that the most important aspect in the treatment of malocclusion is the
knowledge about it. Tf one lacks the knowledge about the strategic treatment and problem points
of each malocclusion, the condition will not improve even with the use ofMEAW. Dr. Y.H. Kim
once said that MEAW is only a too! for treatment and nothing else. The use ofMEA W is only
significant once a treatment plan has been established based on the understanding ofthe malocclusion
and its accurate diagnosis.

In this book, the treatment proeedures applied with the use of MEA W 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 treatrnent methods may vary from the ones discussed
hcre, the ones used on each patient in this book werc based on the patients's condition.

Lastly, the publication of this book has been made possible with the encouragement and
advice or Mr. Fujiwara of the Daiichi Shika Publications, lnc. and I would like to thank him from
the bottom of my heart.

Sadao Sato
Autumn 2001
 Table of Contents

Preface............................................................................................................3

1. Structure and Function of MEAW /9 (Sato)

l. Structure of MEA W ..................................................................................1O
II. Function of MEA W .................................................................................. 11
111. Moclification of MEA W ............................................................................13

2. Bending Method Used in MEA\V /15 (Sato)

l. Basic Structure of MEA W ........................................................................... 16
II. lnstruments and MateriaIs Neecled for MEA W Construction............................... 16
111. First Order Bend ...................................................................................... 17
IV. Second Order Bencl (Horizontal loop bend). ....................................................... 17
V. Third Order Bencl (Tor que bend) ...................................................................18
VI. Heat Treatrnent of MEA W .......................................................................... 18

3. Adjustment Methods Used in MEAW /19 (Sato)

Adjustment Methocls Used in MEAW ....................................................................20
1. Ti p-back activation...............................................................................20
2. Tip-back deactivation..........................................................................20
3. Step up bend.....................................................................................21
4. Localized tooth intrusion ........................ ...............................................22
5. Tip back bend without altering the occlusal plane.........................................22
6. Curve of Spee ..................................................................................22

4. Patient Evaluation and Treatment Plan /23 (Sato)

l. Recorcls used for diagnosis .............................................................................24
11. Kim's Method ofanalysis............................................................................24
1. ODJ (Overbite Depth lndicator)................................................................. 24
2. APDI (Anlcroposterior Displasia lndicator) ...................................................25
3. CF (Cornbination Factor)........................................................................25
111. Denture frame analysis .............................................................................26
IV. Occlusal p lane ancl denture frarne .................................................................26
5. Treatment of Class 111 Malocclusion (High Anglc) /29 (Shirasu)
l. General Characteristies ofClass 111 reversed oeclusion (High Angle)...........................30
11. Morphological Charaeteristies ol'Class 111 reversecl occlusion (High Angle)..................30
111. General Treatment Objectives ror Class 111 reversccl occlusion {I-ligh Angle)................31
IV. Treatment Proceclurcs lor Class I I I rcvcrsed occlusion (1-Iigh Angle)..........................31
1. Paticnt's history...................................................................................33
2. Diagnosis ancl treatmcnt plan..................................................................34
3. Treatment progress... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .. 35
4. Treatment results........................................................................ 41

6. Treatmcnt of Class 111 Malocclusion (Low Angle) /45 (Shirasu)

J. General Characteristics ofClass 111 Malocclusion (Low Angle)........... ...........46
11. Morphological Characteristics ol'Class 111 Malocclusion (Low Angle)..................46
11 l. General Treatment Objectives ror Class 11 l Malocclusion (Low Angle) .................47
IV. Trcatment Proceclurcs for Class 111 Malocclusion {Low Angle) ..........................47
l. Paticnt's history.........................................................................49
2. Diagnosis ancl treaunent plan... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ..... 5 O
3. Treatment progrcss ... .................. ......... ... ... ... ...... ....................... 5 1
4. Treatment results......... ............................................................... 5 7

7. Treatment for Class I Open Bite /61 (Akirnoto)

l. General Characteristics ofClass I open bite.................................................... 62
1. Main causes ofopcn bite................................................................. 62
2. Abnormalities rclatecl to open bite....................................................... 63
11. Morphological Characteristics ol'Class I Open Bite........................................... 64
111. Evaluation ofocclusal plane.................................................................... 64
IV. Trcatmenl objectives for class I open bite ..................................................... 65
V. Treatment procedures for class I open bite .................................................... 66
1 . Patient's history ........................................................................... 66
2. Diagnosis ancl treatment plan .............................................................66
3. Treatment progress........................................................................ 68
4. Comparison of" the pre and post trcatment results ...................................... 70
8. Treatment for Class H Open Bite /71 (Matsumoto)
l. General Characteristics ofClass 11 open bite................................................... 72
11. Morphological Charactcristics ofClass II Open Bite......................................... 72
III. Treatment objectives for class 11 open bite.................................................... 73
IV. Treatmenl procedures for class 11 open bitc...................................................73
1 . Patient's history........................................................................... 73
2. Diagnosis and trealment plan............................................................. 76
3. Treatment progress........................................................................ 77
4. Trcatment results .......................................................................... 82
5. lmportanl points and treatment methods usecl for this patient......................... 85

9. Treatmcnt of Class 11 Deepbite /87 (Matsumoto)

l. General Characteristics ol'Class 11 deep over bite............................................. 88
11. Morphological Charactcristics ol'Class 11 cleep overbite......................................88
111. Treatment objectives for class 11 cleep ovcrbite .............................................. 88
IV. Treatment proceclures lor class 11 deep overbite ............................................. 89
l. Patient's history........................................................................... 89
2. Diagnosis ancl treatmenl plan............................................................. 92
3. Trealment progress........................................................................93
4. Trealment results .......................................................................... 98
5. Trcatment methods usecl and Sorne I mportan! points to consider
in the Treatment or Class 11 Deepbitc rvtalocclusion..................................1 O 1

1 O. Trcatmcnt for Mandibular Lateral Dcviation / I 03 (Akirnoto)

l. Definition or mandibular lateral cleviation....................................................104
l. Main causes or mandibular lateral dcviation .......................................... 104
2. Abnormalitics relatcd to mandibular lateral cleviation ............................... 1 04
11. Characteristics of'mandibular lateral deviation..............................................105
1. Morphological Characteristics or mandibular lateral deviation..................... 105
2. Functional Charactcristics ofmandibular lateral dcviation...........................106
111. Trealment objectives l'or mandibular lateral deviation .................................... 107
IV. Treatment proccclures lor mandibular lateral deviation ................................... 109
1. Patient's history.........................................................................109
 2. Diagnosis and trealmcnt plan ..........................................................11 O
3. Trcalmcnl progress ......................................................................111
4. Comparison of Lhe preand post treaunenl rcsults ....................................1 1 4

11. Trcatment for Crowding /115 (Sato)

l. General Characteristics of'crowding ...........................................................1 16
11. Morphological Characteristics or crowding.......................................................116
111. General TrealmcnlObjectives for crowding .................................................117
IV. Treatmenl Proccdures for crowding.......................................................... 117
1. Patient's history .........................................................................118
2. Diagnosis and Lreatmcnt plan ..........................................................120
3. TreaLment progress .....................................................................120
4. Treatmenl results ........................................................................127

12. Trcatment of Malocclusion with TMJ Dysfunction /129 (Yoshida)

l. General Characleristics ofmalocclusion with TMJ dysíunction .............................130
11. Charactcristics of malocclusion wiLh Tl'v1.I dysfunction .....................................130
Case 1: Closed locked TMJ due Lo mandibular lateral deviation (right).....................130
Case 2: Closed locked TMJ dueto mandibular lateral deviation (left)......................130
Case 3: Closed locked Tr'v1.I due to bilateral loss of·occlusal support ........................1 30
111. General TreatmentObjectives for malocclusion with TMJ dysfunction....................134
1. Splint usage .................................................................................... 1 34
2.Orthodontic occlusal reconstruction ......................................................135
IV. Treatmenl Procedures for malocclusion with TMJ dysfunction ................... ....... 1 36
1. PaLient's history..........................................................................136
2. Diagnosis and Lreatment plan........................................................... 140
3. Treatment progress ......................................................................142
4. TreaLment results........................................................................ 1 48

References ...........................................................................................154
lndex .................................................................................................. 157
 1. Structure and Function of MEAW 9

l. Structure and Function of MEAW

(Sadao Sato)
1O 1. Structure and Function of MEAW

1. 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).
The archwire is usually made up of 0.016" x 0.022"
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:

l. Decrease the load/ deílection 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 welI as the torque
adjustment easy. Figure 1-2 Structure of the ideal arch

4. With the aid of elastics, it can reconstruct the

occlusal plane.

Fig 1-3 shows the horizontal loop ancl its parts. Their functions will be cliscussed later.
 1. Structure and Function of MEAW 11

1. Horizontal loop: the majar part of tbe

archwire; it relieves the vertical force Horizontal loop
and regulates the vertical rnovernent
of the tooth.

2. Breaker: it regulates the horizontal

movement of the tooth and simultaneously
moves each tooth and detailing rnay be
Horizontal part of archwirc Loop base
done as wel 1.

3. Loop base: it regulates the tip back bends Fig. 1-3

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 prornoting an ideal tooth
movement of the entire dentition.

11. MEAW Function

MEAW as shown in figure 1-4 consists of a tip back bend. The tip back
bend varies frorn one patient to another depending on the treatment approach
to the occlusal plane. But usually the tip back bend on each tooth is 2° - 3º
and 15 ° - 20 ° for the entire dentition. The application of this archwire intra­
orally and the use of elastics in the anterior teeth will improve the entire dentition.

Fig. 1-4. Tip back bend

12 1. Structure and Function of MEAW

a d

b e

Fig. 1-5a-f Various types of elastic application

The following are the variations in the elastic position (Fig 1-5 a-t)

l. Vertical elastics (a)

2. Short class II elastics (b)
3. Short class IlI elastics (e)
4. Triangular elastics (d)
5. Box form elastics (e)
6. Check elastics (f)

The synergistic effect of MEAW and elastics provide tbe following:

1. Alignment of the dentition

2. Control tipping of the occlusal plane
3. Control vertical dimension
4. Establish good intercuspation
5. Control the tooth axis especially those with mesial tipping
 1. Structure and Function of MEAW 13

111. Modifications of MEAW

MEAW is such a versatile wire and can be usecl in different types of

malocclusion. The following are the different modifícations ofMEAW, each
one applicable to a specific type of malocclusion.

1. The different types of adjustments (fig l .6a-e)

a. No adjustment
b. Tip back bend
c. Tip back bend ( for no occlusal plane changes)
el. Continuous step bend
e. Partial step bend

During the treatment period, adjustment of the horizontal loop to a

certain degree is possible when needed. ( fig 1.7a-d).

a
a

b
b

d e

e d

Fig. 1.6 Types of bend adjustments Fig. 1.7 MEAW loop adjustments
14 1. Structure and Function of MEAW

Fig. 1-8 MOAW Fig. 1-9 SMOM

2. Modified Offset Arch Wire (MOA W) (Fig 1-8)

MEA W with offset in the premolar region is used in paticnts where vertical
control ancl 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 MEA W (SMOM) (Fig 1-9)

When sectional MEA W is attacbed to the premolar and molar teeth, vertical
control can be applied to the said tccth, while with the application of an
offset MEA W, thcre is antcropostcrior control to the anterior teeth.
This can be used for TMD cases with retruded mandibular position to
obtain occlusal support ancl anterior guiclance for the manclible.
 2. Bending Method Used in MEAW 15

2. Bending Method Used in MEAW

(Sadao Sato)
16 2. Bending Method Used in MEAW

l. The Basic Structure of MEAW

MEA W 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
I\ \,,,,,, lose!

I
and bucea! surfaces of teeth) is incorporated in the Canine offset

MEAW.
1. First Order Bend: bend in the horizontal
,
direction of the dentition, it includcs the � Molar offset
lateral inset, canine offse t (eminence)
and molar o ffset.
2. Second Order Bend: the bend following the
first order bend. Horizont al loop is
incorporated in this step.
3. Third Ordcr Bend: p assive ancl active
torque to control the tooth angulations.
a. Passive torque: Torquc incorporated
into the archwire to pr event any
changes to the angulations of the
teeth. The purpose of thc torque is to
conform the shapc of the wire to
thc labial and bucea! surfaces of the
teeth. Fig. 2.1
b. Active torque: the wire is twistecl/bent
to change the tooth angulations.

11. lnstruments Needed in MEAW construction

1. O.O 16 x 0.022 inch rectangular wire (stainless steel or Blue Elgiloy wire)
2. Arch lwTet (arch forrner)
3. Pliers
a. Kim pliers
b. Tweecl pliers
c. Nance pliers
 2. Bending Method Used in MEAW 17

111. 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, bencl the wire inwards mesially ancl outwards clistally bilaterally.
Determine thc clegree of inset at this stage.

IV. Second Order Bend (horizontal loop)

The proceclure in creating a horizonlal loop, which is Lhe basic element

in MEA W, is shown in fig 2-2a. The plier to be used in this proceclure is the
Kim plier. The horizontal loop of the upper ancl lower wire is arouncl 18-20
clegrees. After placing the first arder bends and horizontal loops in the
archwire, it is impo1iant to have symmetry of the right ancl the left side of the
archwire.

-¡
2

11

�o�==---
1 8

Fig. 2.2a MEAW bend Fig. 2.2b MEAW bend Fig. 2.2c MEAW bend
18 2. Bending Method Used in MEAW

V. Third Order Bend (torque bend)

Wl1en MEA W 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. 1-lowever, there
are cases where torque adjustment is needed
during the orthodontic treatrnent procedures. In
this regard, the principie behind the torque bcnd
has to be understood.

There are basically 3 elements for torque

bend.
l. Dental curve (First order bend)
2. Straighten the curve of the first order Fig. 2.3

bend
3. Twist of wire

To do a labial crown torque in the anterior part of the MEA W, 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 actívate the wire, it is subjectecl to a 5-1 O minute heat treatment at

500 C, with the use of an electropolishing treatment, before thc MEA W is
º

inserted into the patient's mouth. In the absence of a furnace, an alcohol lamp
can be used. Heat the wire until the color changes to golden brown. Make sure
that the color is even.
 3. Adjustment Methods Used in MEAW 19

3. Adjustment Methods Used in MEAW

(Sadao Sato)
20 3. Adjustment Methods Used 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
either activation for the progression of the treatrnent or could be adjusted for
deactivation purposes. The basic adjustment techoiques are discussed below.
l. Tip-back activation
In order to incorporate tip back bends into the archwire, adjust the horizontal
loop of the MEA W 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.

Fig. 3.1 MEAW adjustment, Tip-back bend

 3. Adjustment Methods Used in MEAW 21

Step-down

Step-up

Fig. 3.2 MEAW adjustment, Step-bend Fig. 3.3 MEAW adjustment, Step bend

3. Step-down bend

To selectively extrude a tooth, MEA W is adjusted through a step bend.

To do this, expand the horizontal loop using the plier and bend the anterior
portien of the horizontal loop to lower the loop base.

To make a step bend during the t:reatment, insert the plier into the horizontal
loop and cr eate a new pennanent shape (fig 3-2). In c ase the degr ee of
step is i nsuffici ent, do the adjustment as shown in fig 3-3.
22 3. Adjustment Methods Used in MEAW

Fig. 3.4 Tip-back 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..
6. 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

4. Patient Evaluation and Treatment Plan

(Sadao Sato)
24 4. Palien! Evaluation and Treatment Plan

l. Records Needed for the Diagnosis

Below are the records needed for the case analysis of a patient with malocclusion.

1. Patient's dental history

2. Jntra-oral photos
3. Facial profile photos
4. Panoramic radiograph
5. Cephalometric radiograph
6. 0iagnostic dental cast (mounted)
7. Record of condylar movement (axiograph)
8. 0thers: TMJ x-ray, MRf etc.

The basis for tbe morphological characteristics of the patient at this stage
is not sufficient but can be substantiated by doing a cephalometric analysis.

11. Kim's Method of Analysis

l. ODI (Overbite Depth lndicator)

This is used as an indicator for vertical types of malocclusion which are
the open bite and deep overbitc conditions. In 001, the main element for
measurement is the AB-MP angle. This angle is a reliable indicator ofthe 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 rnandible. Therefore, the angle measurement should be
undcrstood as a figure representing thc corrclation of skeletal aclaptation in
occlusal function.

Two greatest factors which decreases 001

l. High angle open bite condition resulting from mandibular

hyperdivergence
2. Class 111 condition resulting from the anterior adaptation ofthc mandible
Either ofthese two factors may affect the vertical dimension ofmalocclusion.
To determine whether a case is a low or high angle is not thc only important
aspect in diagnosis. What is more significant is to be able to discover the cause
of such conclitions.
 4. Patient Evaluation and Treatment Plan 25

-¡
ODI: 3+4
APDI: 1+2+3
CF: ODl+APDI

Fig. 4-1 Kim's analysis

2. APDI (Anteroposterior Dysplasia lndicator)

APDI, as the word implies, is the indicator ofthe antera-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 antera-posterior relationship
of the upper and lower jaw. This is self-explanatory.

3. CF (Combination Factor)
CF is a combination of 0D1 and APDI. CF represents the tendency of the
mandible to open. A high CF indicatcs a tendency for low angle but when the
CF is low, it shows the tcndency for high angle. According to Dr. Kirn, 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.
26 4. Patient Evaluation and Treatment Plan

111. Denture Frame Analysis (Fig 4-2)

Dentme frame is the occlusal component

of the basic facial skeleton which consists of
the palatal plane in the basal plane of the maxilla,
í -
1
-¡
the AB plane in the anterior limit of the upper
and lower jaw, and the mandibular plane (MP),
known as the triangular pattem. The balance of
this tTiangular 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.

L
Fig. 4-2. Denture frame analysis

IV. Occlusal plane and the Denture Frame

Occlusal plane is the rnost important plane for the function of the masticatory
organ. The mandible functionally adapts to this occlusal plane. Therefore, any
change in the occlusal plane will affect the mandibular position as well as the
balance of the clenture frame.

Below are the characteristics of the denture frame.

l. Class III Malocclusion (Fig 4-3 a,b)
ín a class III skeletal pattern, the occlusal plane is ílat. Since the vertical
dimcnsion is excessively high, the mandible aclapts through an anterior rotation
resulting to Class Ifl 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 I11 Low Angle. lt is therefore important
to understand clearly each patient's characteristics in creating a treatmcnt plan.
2. Open bite (Fig 4-4 a,b)
Open bite is divided into two major types, the Class JII and Class II open
 4. Palien! Evaluation and Treatment Plan 27

Fig. 4-3a Class 111 High Angle

L Fig. 4-3b Class 111 Low Angle
__J

Fig. 4-4a Class 111 Open Bite Fig. 4-4b Class II Open Bite

bite conditions. The basic trcatment 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 TI open bite displays a posterior rotation of the mandible
related to a steep occlusal plane.
28 4. Palien! Evaluation and Treatment Plan

l
)
,.....--y
.....,-_ J 1 <\
FH FH
.
I
/
1
/¡ \.

1
/ J

MP

Fig. 4-Sa Class II High Angle Fig. 4-Sb Class II Low Angle

l
3. Class II Malocclusion (Fig 4-Sa, b)
The common type of cl ass lI
malocclusion is usually characterized by a
steep occlusal plane. This type of Class II
problem, therefore, resulted from the failure
of tbe mandible to adapt anteriorly.
However, in patients with sufficient
occlusal support due to the excellent vertical
growth of the mandibular ramus, the maxilla
rot ates an ter iorly a llowing occlusal
adaptation. The occlusal plane, in this case,
is flat.
4. Lateral Displacement of the Mandible
(Fig. 4-6)
In patients manifesting a lateral displace­
ment of the mandible, the occlusal plane on
both sides usually differs. Tbe mandible Fig. 4-6. Lateral displacement of 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 irnpor tant to
consider these factors i n establ ishing a
treatrnent plan.
 5. Treatment of Class 111 Malocclusion (High Angle) 29

5. Treatment of Class 111

Malocclusion (High Angle)

(Akiyoshi Shirasu)
30 5. Treatment of Class 111 Malocclusion (High Angle)

l. General Characteristics of Class 111

Malocclusion (High Angle)

Class m 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-postcrior growth of the
maxilla and excessive growth of the mandible. The usual treatment for this type
of malocclusion is through t:he use of a rnaxillary protraction device, chin cap
appliance and surgery.
When this patient is examined carefully, the maxillary occlusal plane is
flat. This resulted from molar crowding (posterior discrepancy) related to the
insufficient eruption space caused by the insufficient antera-posterior diameter
due to an increased vertical growth of thc maxilla. Consequently, it caused the
supraeruption of the molars resulting to an open bite condition bringing about
a high vertical dimension. This phenomenon could cause some molar inte1ference
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.

11. Morphological Characteristics of Class 111

Malocclusion (High Angle)

The morphological characteristics 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 displacemcnt, weak bone tissues
and an obtuse Ff-1-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 antera-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 111 Malocclusion (High Angle) 31

111. General Treatment Objectives for Class 111

Malocclusion (High Angle)

The treatment objeclive for Class 111 reversed occlusion (High Angle)
includes the attainment of a dynamic harmony of the cranio facial skeleton
by restoring a functional mandibular movcment and a hannonious skeletal
framework. This can be done through an approach that focuses on the occlusal
system. This requircs an understanding of the dynamic mechanism of the entire
craniofacial skeleton and the morphological characteristics of malocclusion.
There are two treatment objectives far this type of case which are:
1. To eliminate posterior discrepancy
2. To stcepen the occlusal plane (tipping thc occlusal planc and decreasing
the ve1tical dimension in the molar area)

IV. Treatment Procedure for Class 111

Malocclusion (High Angle) (Fig. 5-1)

Elimination of posterior discrepancy is initially needed. ln order to attain

this, the mandibular 3 rd molars, and thc maxillary 2 nd (or 3 rd molars) are
cxtracted.
The treatment procedures are as follows:
1. Step l. Lcveling. 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 lnterference. Attach the MEAW appliance
to the upper and lower teeth, use a tip back bcnd activation from thc
premolar to the molar areas. Elimination of lhe interference in the
molar area can be done through alignment and intrusion. (Fig 5-1 b)
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-lc)
4. Stcp 4. Occlusal Plane Reconstruction. Remove the tip back bend
in the entire MEA W appliance and use a step up bend in the molar
area of the lower jaw to steepen occlusal plane. Step down bend can
be aclcled to the anterior teeth of thc upperjaw for occlusal reconstruction.
(Fig 5-ld)
5. Step 5. Obtain a physiologic occlusion. Do a tooth axis control
(torque control), adjust tbe occlusal guidance and obtain a good
intercuspation. (fig 5-1 e)
32 5. Treatment of Class 111 Malocclusion (High Angle)

a b

1
1
1

L_, d e
j

Fig 5-1 lllustration of the Treatment Proce dure for Class 111 Malocclusion (High Angle}

a. Leveling
b. Elimination of interference
c. Establish the mandibular position
d. Reconstruction of lhe occlusal plane
e. Obtain a physiologic occlusion
 5. Treatment of Class 111 Malocclusion (High Angle) 33

Fig. 5-2 Facial profile (pre-treatment)

Fig. 5-3 lntra-oral pictures showing !he occlusal condition (pre-treatment)

J. Patient History
Chief Complaint: lower jaw protrusion
Age: 12y 9mos. Sex: Female
Facial profíle: 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 TTT with an overjet of - I .4 mm, and an overbite of- 0.2
mm. (fig 5-3)
Cephalometric radiogram: SNA 77.1 º, SNB 77.6 ° , ANB -0.5 °, showing
a protrusion of the mandible. FH-MP is 38.1 º, PP-MP is 40.9° showing a
tendency for High Angle. Antera-posterior dimension ofthe maxilla A'-P' is
46.2 mm, UOP (P) 81. l º, displaying a ilat occlusal plane.
34 5. Treatment of Class 111 Malocclusion (High Angle)

Fig. 5.4 Panoramic x-ray (pre-treatment)

According to Kim's analysis, an ODI of 49.0°, APDl 87.3° , CF 136.3° is

indicative of a class lll high angle condition with a low CF value. This will require
tooth extraction (fig 5- l 7a, b, chart 5-1 pre-treatment).
Panoramic x-ray: Absence of upper yct molars, and presence of only the left
mandibular 3rd molar (fig 5-4).

2. Diagnosis and Treatment

This patient was diagnosed to have a skeletal class lll 1-ligh Angle condition
due to an FH-MP of 38.1 °, which is obtuse, and a PP-MP of 40.9°. The antero­
postcrior diameter of the maxilla A'P' is short, 46.2 mm. It was observed tbat the
upper 3 rd molars are not present and only the lower left 3rd molar is present. This
is considcrcd to be a case of a strong skeletal factor.
In this type of case, the usual or traditional treatment of choice for tbe skeletal
problem is through the use of a chin cap appliance for the inhibition of mandibular
growth, and the facemask to stimulate maxillary growth. However, a significant
treatment effect cannot be expected from these typcs of appliance in terms of
improving the disharmony of the entire craniofacial skcleton.
Thc trcatment objectives after the extraction of thc lower 3rd molar were to
obtain a dynamic harmony of the craniofacial skelcton, resto re the dynamic
mandibular movcment through stabilizing thc dishannonized craniofacial skeleton
and thc active approach to improve the occlusal system through the use of the
upper ancl lower MEAW.
 5. Treatment of Class 111 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 111011th later, MEA W was applied to both the upper and lower dentition in
order to eliminate 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 elastic and a short class III elastic (3/16 .inch, 6 oz) in the anterior
teeth ( fig 5-6).

Fig. 5-5 lntra-oral pictures during the start of leveling

Fig. 5-6 1 st month: Stage of interference elimination with MEAW

36 5. Treatment of Class 111 Malocclusion (High Angle)

Fig. 5-7 2 nd month: Elimination of interference stage

Two months latcr, an additional 5 ° tip back bend in the molar area was done
and alignment ancl intrusion were conlinued. Moreover, a step clown and a step
up bend was clone in the upper and lower premolar areas respectively, where
infraversion of the saicl 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 (ftg 5-7).

Step 3: Establishing mandibular position

On the 3 rd month, after the interference has been eliminatecl through alignrnent
ancl intrusion in the molar area, mandibular position was distally guided through
the decrease of vertical dimension in lhe molar area. Thc anterior teeth overlap
has primarily deepenecl. To erupt the infra-erupted premolars, a step clown 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 (fíg
5-8). On the 5 th rnonth, 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 rnandible to a stable position. The anterior teeth overlap
was improved by obtaining a physiologic vertical dirnension. The tip back bend
was removed in the upper molar area. A vertical elastic was used in the anterior
tceth (fig 5-9).
 5. Treatment of Class 111 Malocclusion (High Angle) 37

rd
Fig. 5-8 3 month: Stage where mandibular position was established

th
Fig. 5-9 5 month: Stage where mandibular position was established
38 5. Treatment of Class 111 Malocclusion (High Angle)

♦iB·i•

1h
_[
Fig. 5-10: 6 month: Stage of occlusal plane reconstruclion

Fig. 5-11: i" month: Stage of occlusal plane reconstruction

 5. Treatment of Class 111 Malocclusion (High Angle) 39

Step 4: Occlusal plane reconstruction

On lhe 6 th month, the tip back bend in the lower molar area was removed
and the MEA W was flattened because lhe molar interferencc has been eliminated,
vertical dimcnsion in the premolar arca was improvcd, a physiologically stablc
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 lll
elastic and a shorl class II elastic was uscd in thc right and lcft sidc rcspcctively,
to improve thc miclline (fig 5-1O).
Sevcn monlhs since thc start oí lrcalment, a stcp down bcnd was placed in
the upper caninc and anterior arca lo iniliale the stccpcning oí the maxillary
occlusal plane. A Mulligan appliancc was used to expand thc maxillary dental
arch. In addition lo lhat, the Curve oí Spee was placed lo actively erupt thc
lower molars. To rnaintain a stablc mandibular occlusion, lhc step up bend was
removed in thc lower dentition exccpl on the anterior arca. A beller intercuspation
was achicvcd dueto the removal oíthe step up bend. Vertical elastic and a shorl
class 11 clastic was used in the right and left side rcspcclivcly (fig. 5-11).

Step 5:
On thc 10 th month, the reverse bcnd in the lower molar arca was replaced
with a step down bend. The improvcmcnt of occlusal guiclancc and intercuspation
was clone lhrough torque control and cletailing. A goocl occlusal relationship
was thcn attained. A vertical clastic was used in thc anterior area (fig 5-12).

11
Fig. 5-12 10 ' month: Attainment of a pt1ysiologic occtusion stage
40 5. Treatment of Class 111 Malocclusion (High Angle)

Fig. 5-13 11 month: Attainment of a physiologic occlusion stage

th

Fig. 5-14 13 th month: Start of retention

During the 1 1 th month, the step up bend in the lower molar area was
removed and the intermaxillary elastic was discontinued (fíg. 5-13).

Step 6: Retention
A stable occlusion was obtained on the 13 th month of the treatment
period. The entire appliance was removed and a tooth positioner was used to
start the retention ( fig. 5-14).
 5. Trealment of Class 111 Malocclusion (High Angle) 41

Fig. 5-15 Facial profile (post-orthodontic treatment)

Fig. 5-16 lntra-oral pictures showing the occlusal condition (post-orthodontic treatment)

4. Treatment Results

An approach to the occlusal system and improvement of the disharmony

of thc entire maxillo facial skeleton was clone 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 I canine and molar relationship, overjet of 3.5 mm, overbite of J .O mm,
showing a significant improvement (fig. 5-16). The lateral cephalometric
radiogram showed an improvement in thc mandibular protrusion with an SNA
of79.0 ° , SNB 76.6° and ANB of2.4 ° (fig 5-17c, d, chart 5-1 post treatment).
UOP (P) of7 l. l O shows the tipping of the occlusal plane, functional movement
ofthe mandible was restored and dynamic hannony of the craniofacial skeleton
was attained.
42 5. Treatment of C\ass 111 Malocclusion (High Angle}

a b

e d

e
Fig. 5-17 Lateral cephalometric radiogram
and superimposed tracings

a. Tracings (pre-treatment)
b. X-ray (pre-treatment)
c. Superimposed tracings of
pre and post-treatment
d. X- ray (post-lreatmenl}
e. X-ray (2 years alter retention)
 5. Treatment oí Class 111 Malocclusion (High Angle) 43

Chart 5-1 Cephalometric Analysis

Denture Frame Analysis Norm Pre-TX Post-TX '2 years Post-TX

°
FH-MP 25.9 38.1 37.4 37.2
°
PP-MP 24.6 40.9 42.2 41.8
°
OP-MP 13.2 26.7 26.4 25.5
OP-MP/PP-MP 54.0% 65.3 62.6 60.9
°
UOP (A) 77.5 75.5 73.5 72.1
°
UOP (P) 77.5 81.1 71.1 72.0

°
FACIAL Angle 84.9 87.8 87.3 87.5
°
SNA Angle 83.3 77.1 79.0 79.7
°
SNB Angle 78.9 77.6 76.6 76.6
º
ANB Angle 3.4 -0.5 2.4 3.1
°
U1-FH (degree) 111.1 108.1 110.0 115.3

Overjet (mm) 2.5 mm -1.4 3.5 4.0

Overbite (mm) 2.5 mm -0.2 1.0 2.5
°
AB-MP 71.3 51.8 56.7 56.9
A'-P' 50.0mm 46.2 49.3 50.3
A'-6' 23.0mm 26.1 26.5 25.7
A'-6'/A'-P' 46.0% 56.5 53.8 51.1
°
U 1-AB (degree) 31.7 18.0 24.1 29.4
U1-AB (mm) 9.5mm 5.0 7.7 9.0
°
L1-AB (degree) 25.4 21.5 16.4 20.1
;
L1-AB (mm) 6.2mm 6.4 4.3 5.3
°
lntermolar 174.0 176.7 179.8 177.8
°
FH-PP 1.3 -2.8 -4.9 -4.6
! Kim Analysis Norm Pre-TX Post-TX 2 years Post-TX
°
. ODI 72.0 49.0 51.8 52.3
°
APDI 81.0 87.3 81.1 81.3
1 COMBINATION FACTOR
°
153.0 136.3 132.9 133.7 j

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 Class 111 Malocclusion (High Angle)

1h
Fig.5-1811 month: lntra-oral pictures showing the occlusal condition 2 years post-retention

Fig. 5-19 Panoramic x-ray showing the occlusal condition 2 years post retention
 6. Treatment of Class 111 Malocclusion (Low Angle) 45

6. Treatment of Class 111

Malocclusion (Low Angle)

(Akiyoshi Shirasu)
46 6. Treatment of Class 111 Malocclusion {Low Angle)

l. General Characteristics of Class 111

Malocclusion (Low Angle)

Class Ilf 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, therc is a disharmony in thc relationship
between thc vertical dimension and thc vertical growth ofthe mandibular condyle.
Normally, the antero-posterior growth of the maxilla is not the problem.
The deep overbitc reversed occlusion is due to the excessivc anterior rotation
of the mandible related to the insufficicncy of the vertical dimcnsion.
This problcm is generally or traditionally corrected through the use of a
FKO appliancc, which is a functional orthodontic appliancc, a chin cap appliance
for growth control, and alveolar movcmcnt Cor occlusal reconstruction. How­
ever these appliances deliver an enormous load to the patient and lengthen
the treatment pcriod.
The main problcm ofthese cases is the dishannony of thc vertical dimension
which ought to be addrcssed and improved.

11. Morphological Characteristics of Class 111

Malocclusion (Low Angle)

In class 111 malocclusion (Low Angle), the vertical growth ofthe mandibular
condyle is very active clue to an insufficient vertical growth of thc maxilla,
comparativcly longcr antero-posterior diameter of thc maxillary basal bone than
high angle cases, mi Id posterior discrcpancy, tipping of thc occlusal plane in the
uppcr molar arca, significant Curve of Spec, and insufficicnt vertical dirnension,
showing a deep anterior overbite and a reversed occlusion due to the excessive
anterior rotation of the mandible.
Below are the morphological charactcristics:
l. Thick bone tissue, weak eruptive force of the teeth, and clinically short
tooth crown length.
2. Exccllcnt growth ofthe mandibular condyle, but low vertical dimension.
 6. Treatment of Class 111 Malocclusion (Low Angle) 4 7

111. The General Treatment Objectives for Class 111

Malocclusion (Low Angle)
Thc usual trcatrnent approach in this type of malocclusion is corrcction
of the negative ove1:jet through the movcment of the dento-alveolar bone with
the use of a finger spring, lingual arch appliance, and FKO appliance.
Howevcr, these are not thc appropriatc treatment methods for this type of
malocclusion.
The treatrnent objective íor this case should be the inhibition of an excessive
functional mandibular rotation by incrcasing the vertical dimension and maxillary
height. 1 f the occl usal supporl is secured with the increase of intermaxillary
distancc, the growth of the sphenoid and ethmoid bones are stimulated through
the maxillary and temporal bones duc to mastication and various functions of
the oral cavity. This secondarily restares thc hannony of the craniofacial skcleton.
Below are the treatment objectives for this case:
1. lncreasc maxillary hcight
2. lncreasc vertical dimension (ílatten the occlusal plane which is steep
in the upper molar arca)
3. lnhibit excessive functional anterior rotation of the mandible

IV. Treatment Procedure for Class 111

Malocclusion (Low Angle) (fig 6-1)

To flatten the occlusal plane, the lower yd molars, and either the upper
2nd or thc yd molars can be cxtractcd. Thc upper 2nd and lower 3rd molars were
extractcd in the case presented below and the following were the treatment
procedures:

t. Step l. Lcveling. Attach thc brackets to thc entirc dentition (tubes on

the terminal molars) and start leveling using a O.O 14-inch roundwire.
(fíg. 6-1 a)
2. Step 2. Elimination of lnterfercnce. Place thc MEA W on both the
lower and upper dentition and put a tip back bend in the molar area
to eliminate molar interference, through alignment and intrusion.
Make a stcp bend in the premolar area to improve thc vertical dimension
and raise the bite. (fíg 6-1 b)
3. Step 3. Establishing mandibular position. Strengthen the tip back
bend in the molar arca. In addition, strcngthen the step bends in tbe
premolar area in arder to obtain the appropriate vertical dimension.
Establish a physiologically stable mandibular position through bite­
raising and the eruption of the premolar teeth. (fíg 6-1 c)
4. Step 4. Occlusal Plane Reconstruction. After the improvement of
the physiologic vertical dimension and the attainment of a stable
mandibular position, the tip back bcnd in the MEA W is entirely
removed. A step clown bend is then done to flatlen the occlusal
 48 6. Treatment of Class 111 Malocclusion (Low Angle)

a b

e d

L__

Fig. 6-1 lllustraiion of the treatment procedures for Class 111

reversed occlusion (Low Angle)

a. Leveling stage
b. Elimination of interference stage
c. Establish mandibular position stage
d. Reconstruction of occlusal plane stage
e. Attainment of a physiologic occlusion stage

plane in the upper molar area, which erupts e

the molar teeth, and reconstruction of the
occlusal plane is being done. (fig 6-1 d)

5. Step 5. Attainment of Physiologic

Occlusion. Do tooth axis control (torque

_]
control), regulate the occlusal guidance and
atlain a good intercuspation. (fig 6-1 e)
 6. Treatment of Class 111 Malocclusion (Low Angle) 49

Fig. 6-2 Facial profile (pre-treatment)

Fig. 6-3 lntra-oral pictures showing !he occlusal condition (pre-treatment)

1. Patient's History

Chief Complaint: Protrusion ofthe mandible

Age: 14 Sex: Female
Facial profile: Face is small, and shows protrusion of the lower jaw
(fig. 6-2)
lntra-oral findings: the occlusal relationship of the canine and molar
teeth is Angle Class 111, overjet is -2.5111111 and overbite is 6.0mm. (fig.
6-3)
50 6. Treatment of Class 111 Malocclusion (Low Angle)

Fig. 6-4 Panoramic x-ray (pre-treatment)

Facial cephalometric radiogram: SNA 81.7 °, SNB 82.2° , ANB-0.5°, indicative

of a mandibular protrusion. FH-MP is 22. l º, PP-MP is 21.9° , a low angle
tendency. The antera-posterior diameter ofthe maxilla A'-P' is 46.8mm, UOP
is 61.9º showing a steepening of the occlusal plane. Based on Kim's analysis,
ODI is 63.8º , APDI 94.4° , CF 158.2° , displaying an Angle's class lTI condition
( fig 6-l 7a, b, chart 6-1 pre-treatment).
Panoramic x-ray: upper and lower y d molars are present (fig 6-4).

2. Diagnosis and Treatment Plan

This patient was diagnosed to have a class Jll reversed occlusion (low angle)
with the following characteristics: anterior rotation ofthe mandible, insufficient
vertical dimension and steepening of the posterior occlusal plane as evident in
the Ff-I-MP of22.1º, 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
patient is to inbibit the excessive functional rotation of the mandible by increasing
the ve,tical dimension and maxillary height, consequently rest01ing the craniofacial
hannony by achieving a pbysiologic intermaxillary distance.
Therefore, as part of the treatment plan, alignrnent is done on the lower
molar area, where mesial tipping is evident, and extraction of the lower 3 rd
molars is done for bite raising in the premolar area. Extract both the upper
2nd molars to facilitate the correction of the maxillary occlusal plane.
 6. Treatment of Class 111 Malocclusion (Low Angle) 51

3. Progress of Trcatment
Step t: Leveling
The molar tubes and standard edgewise brackets were attached to the
upper and lower dentition. Leveling was started with the use of an O.O 14-inch
super elastic wire (fíg 6-5).
Step 2: Elimination of occlusal intcrference
MEA W was placed a month aftcr the onset of treatment, and alignment
and intrusion in thc molar arca was startcd by using a tip back bcnd of 25º to
eliminate molar intcr ference. In addition, a step down and step up bend was
done in the premolar area to improvc thc vertical dimcnsion. A vertical elastic
and a short class 111 clastic (3/16 inch, 6 oz) was uscd in thc anterior tccth (fig

♦iN·I-

♦W•t•
Fig. 6-5 lntra-oral pictures during the start of leveling

Fig. 6-6 1 st month of treatment: Elimination of interference stage and MEAW illustralion
52 6. Treatment of Class 111 Malocclusion (Low Angle}

Fig. 6-7 2nd month: Stage of eliminating interference

6-6). On the 2 nd month of treatment, alignment and intrusion was continued

witb an increase of 5 ° on the tip back bend of the molar area. Vettical 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 elastic 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 rd month, a step up bend was created in the anterior and canines
to obtain an appropriate increase of the ve1tical 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 th month, the appropriate vertical
dimension was obtained and a stable mandibular position was achieved.
Furthennore, anterior negative ove1jet was improved. The step up bend behveen
the molar and premolar teeth was removed and the occlusion was allowed to
stabilize. A class 111 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. Treatment of Class 111 Malocclusion (Low Angle) 53

9�« �g
1
¿J¿j« �cJc]
rd
Fig. 6-8 3 month: Stage in establishing the mandibular position

9 � «===,¡� ¡
a
ú"'=======(

¿J ¿j «"=====9� e �..---,
1h
Fig. 6-9 4 month: Stage in establishing the mandibular position
54 6. Treatment of Class 111 Malocclusion (Low Angle)

♦W•i•

=l g ú"'====;( 1� 9)

a ¿j
Fig. 6-10 5 th month: Occlusal plane reconstruction stage
K
1� ªº"'===='
=
e �

g g« 1� et l
a« 1�
�
1�
[ �[ �

111
Fig. 6-11 6 month: Occlusal plane reconstruction stage
 6. Treatment of Class 111 Malocclusion (Low Angle) 55

Step 4: Reconstruction of occlusal plane

On thc 5 111 month, thc step bcnd betwecn the uppcr canine and premolar
tccth as well as the bend betwccn the lowcr 1nolar and premolar tccth wcrc
removed to flattcn the occlusal plane in the uppcr and lowcr molar areas. Anterior
ovcrbite has dccpened sccuring a stablc occlusion. A vertical component box
typc clastic was used (fig 6-1 O). On thc 6 th month, the step up bend in the maxilla
was cntirely removed and a reverse bend was used in thc molar area to flattcn
thc occlusal planc. The stcp up bcnd in the lower dentition cxcept thc anterior
arca was removed to flattcn the occlusal planc. Removal of the stcp up bcnd
allowcd a closcr occlusal rclationship in the anterior area. A vertical clastic was
uscd in the anterior arca (fig 6-11 ).

Step 5: Attainment of a physiologic occlusion

On the 7 1 h 111011th, thc step up bcnd in the lower anterior area was maintained
but the reverse bcnd in thc uppcr molar area was removed. Axis control was
done to obtain a good intercuspation and to adjust the occlusal guidancc, rendering
a closer occlusion. The intermaxillary elastic was discontinued (fig 6-11 ).
On the 8 th rnonth, thc step up bcnd was cntirely removed (fíg 6-13).

g g «=====,,� g
¿;J «�'� �====-'� aa
1
Fig. 6-12 ? " month: Stage of attaining a physiologic occlusion
56 6. Treatment of Class 111 Malocclusion (Low Angle)

1
Fig. 6-13 8 " month: Stage of attaining a physiologic occlusion

th
Fig. 6-14 9 month: Start of retention

Step 6: Retention
On the 9 th 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. Treatment of Class 111 Malocclusion (Low Angle) 57

Fig. 6-15 Facial profile (posl-orthodonlic treatment)

Fig. 6-16 lntra-oral pictures showing the occlusal condition (post-orthodontic treatment)

4. Treatmcnt results
After 9-months of treatment aimed at inhibiting the excessive functional
mandibular movement and actively increasing the maxillary length and ve1iical
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 1 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 º,
showing an improvement in the mandibular protrusion. FF-MP was 24.2 º, and
PP-MP became 23.7 º. UOP (P) was 85.4º, evidenl of a ílat occlusal plane
58 6. Treatment of Class 111 Malocclusion (Low Angle)

a b

e d

e
Fig. 6-17 Facial cephalometric radiogram and the
superimposed pre and post-treatment tracing

a. Pre-treatment tracings
b. Pre-treatment x-ray
c. Superimposed tracings al
pre and post-treatment
d. Post-treatment x-ray
e. X-ray after a 2-year retention
 6. Treatment of Class 111 Malocclusion (Low Angle} 59

Chart 6-1 Cephalometric Analysis

Denture Frame Analysis Norm

--
Pre-TX
- Post-TX 2 years Post-TX

FH-MP 25.9 22.1 24.2 23.8

°

PP-MP 24.6 21.9 23.7 24.8

°

OP-MP 13.2 9.8 16.8 17.5

°

OP-MP/PP-MP 54.0% 44.8 71.0 70.6

UOP (A) 77.5 76.3 81.4 80.4
°

UOP (P) 77.5 61.9 85.4 84.0

°

FACIAL Angle 84.9 92.O 91.0 91.2

°

SNA Angle 83.3 81.7 81.1 80.5

°

SNB Angle 78.9 82.2 80.1 79.3

°

ANB Angle 3.4 -0.5 1.0 1.2

º

U1-FH (degree) 111.1 118.7 122.8 123.0

°

Overjet (mm) 2.5 mm -2.5 3.5 2.2

Overbite (mm) 2.5 mm 1 6.0 1.1 1.9
AB-MP 71.3
°
63.6 65.5 65.6
A'-P' 50.0mm 46.8 47.1 46.4
A'-6' 23.0mm 25.4 24.4 24.9
A'-6'/A'-P' 46.0% 54.2 51.8 53.7
U1-AB (degree) 31.7
°
24.4 32.5 32.4
U1-AB (mm) 9.5mm 2.1 4.8 6.0
L1-AB (degree) 25.4
°
24.3 10.7 18.6
L1-AB (mm) 6.2mm 5.5 1.5 4.2
lntermolar 174.0 176.6 177.2 178.3
°

FH-PP 1.3
°
0.1 0.5 -1.0
Kim Analysis Norm Pre-TX Post-TX 2 years Post-TX
- ---
ODI 72.0
°
63.8 66.0 64.5
APDI 81.0
°
94.4 90.9 89.6
l COMBINATION FACTOR 158.2
153.0 156.8 154.1
°

( fig 6-17e, b chart 6-1 post treatment).

Thcre were no s ignificant c hanges in the intra-oral findings and
the cephalometric radiograph even after the 2-year retcntion period ( fig 6- l 7c,
chart 6- 1, 2 ycars treatment). The intra-oral x-rays even showed the no rmal
eruption of the maxillary 3 rd molars (fig 6-19) and a stable occlusion.
60 6. Treatment of Class 111 Malocclusion (Low Angle)

Fig. 6-18 lntra-oral photos showing the occlusal condition after 2-years of retention

Fig. 6-19 Panoramic x-ray showing the occlusal condition after 2-years of retention
 7. Treatment of Class I Open Bite 61

7. Treatment of Class I Open Bite

(Susumu Akimoto)
62 7. Treatment of Class I Open Bite

l. General Characteristics of Class I Open Bite

Class l open bite has a normal antero-posterior occlusal relationship.

Occlusion 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 difftcult 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 etc.
2. Respiratory: tonsillar enlargement, enlargement of the adenoid, oral
rcspiration, allergic rhinitis etc (fig. 7-2)
3. Posterior discrepancy: insufficient eruptive space for the molars
(fig.7-3). This could Iead to their supraeruption.
4. Others: Incorrect dental treatment (restorative material is too high),
Iarge tongue, heredity etc.

Fig. 7-1 Cephalometric tracing of a patient Fig. 7-2 Cephalometric radiogram showing the areas
with an open bite condition of soft tissue defect (T: enlargement of the tonsils,
A: adenoid enlargement. E: allergic rhinitis)
 7. Treatment of Class I Open Bite 63

Fig. 7-3 In posterior discrepancy. occlusal interference in the molar area easily occurs due to the squeezing effect in the teeth.
J
When this interference develops, the mandible anteriorly rotales associated with its anterior transversion, making the occlusion
to adapt to il. In worst cases, the mandible rotales posteriorly, resulting to an open bite condition.

The greatest difference betwecn thc traditional rnelhod oftreatment using

thc multi-bracket systcm and the treatmcnt 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 lurn resulls
to the decrease in the vertical clirnension which is uscful in improving the negative
overbitc in the anterior teeth. However, this is considered a symptornatic approach
to treatment. The most important aspccl in ali types of orthodontic treatment is
to idcntify the cause and eliminate it. Thus providing an extremely simple kind
oftrealment possiblc. In this case, onc of the most important aspects to consider
is lhe clase relationship of the open bite and the presence of the 3 rd molars. ln
this light, posterior discrepancy is the cause of the open bite condition.
2. Abnormalities due to Open Bite
1. Facial asymmetry
2. Functional abnorrnalities: mastication, swallowing, pronunciation,
tongue, lips etc.
3. Psychological abnonnalities
64 7. Treatment of Class I Open Bite

11. The Morphological Characteristics

of Class I 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 ofthe lower occlusal plane, upward tilting ofthe palatal plane etc.

111. Evaluation of the Occlusal Plane

The examination of occlusal 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).

l. Normal occlusal plane

The incisa! edge of the upper central
incisors should be 3-4mm below the lip line
(when the mouth is closed) while the incisa! edge
of the lower central incisors should be within
the same level of the lip line. Once the line
connecting the midpoint ofthe upper and lower
central incisa! edge and tip ofthe mesial cusp of
the molar, also known as the occlusal plane, is
extended, this will almost pass through the center
Fig. 7-4 Generally, a common occlusal plane is established
height ofthe mandibular ramus. far both the upper and lower dentition. However, in patients
wilh open bite conditions, the occlusal plane is established
separately.
2. Maxillary occlusal plane
This is evaluated by connecting the line between the upper 1 s1 molar and
the incisa! edge of the upper central incisors.
3. Mandibular occlusal plane
This is evaluated by connecting the line between the lower Is, molar and
the incisa! edge ofthe lower incisors.
4. Occlusal plane evaluation in both the upper and lower dentition of
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
coITected in both the upper and lowerjaw, MEAW is then applied to both arches.
 7. Treatment of Class I Open Bite 65

IV. Treatment Objectives for Class 1

Open Bite Malocclusion
l. Leveling
The first step in treatment is level ing. In patients with tooth crowding,
refer to the leveling method used in Chapter 11. In patients without tooth
crowding, proceed to leveling.

2. MEA W application
Apply MEA W 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 oz) in the anterior
teeth. In the part where occlusal plane correction is not needed, a plain archwire
can be applied. A kobayashi hook or a consolidation arch can be applied to the
area adjacent to the canine (fíg 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 disocclude
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 ofposterior teeth disocclusion.
3. Completion
In the final stage oftreatment, ideal archwire is utilized. However, MEA W
can be continuously used as an ideal arch.

Fig. 7-5 In this illustration, a MEAW for the maxilla, a consolidation arch for the mandible, and a vertical elastic were used to
corree! the rnaxillary occlusal plane. A tip back bend was done to the MEAW in the upper dentition for activation.
66 7. Treatment of Class I Open Bite

4. Precautions
The use of a ve11ical 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 I Open Bite

In an open bite condition during the permanent dentition period, elimination

of posterior discrepancy is important. Normally, the maxillary and mandibular
3 rd molars are extracted but the upper 2 nd molars can be extracted in young
patients. In case the patient practices some bad habits, a myof-tmctional therapy
(MFT) can also be done. Desired results will not be altained when these factors
are not considered dw-ing the treatment period. Once these factors are disregarded,
this coulcl becorne the cause of relapse even if treatment was successful.

l. Patient's history

Age: 25y 8 mos. old Sex: Female

Chief complaints: Incorrect bite, pronunciation is not normal
Patient's history / Present syrnptoms: had tonsillectomy at age 24y l l mos.
old. Has chronic fever and tonsillitis.
Facial profile: Face is oval-shaped, pro file is straight (fig 7-6).
lntraoral findings: overjet = +4mm, overbite = -3mm, a case of Angle class
I open bite (fig7-7).
Panoramic x-ray: Ali yc1 molars have erupted, with complete set of teeth
(fig 7-8).
Cephalometric radiogram: Infraversion of the upper and lower central
incisors (fig 7-9).
Cuspal inter ference in the right 3 rd molar was observed through the SAM
articulator. It was also observed that there was distraction and cornpression in
the right and left TMJ respectively. Based on Kim's analysis, ODI was 71 º,
which is alrnost 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, ali the 3 rd molars were extractecl.
MEAW was then applied to both the upper and lower dentition simultaneously
to control the maxillo-mandibular occlusal planes.
 7. Treatment of Class I Open Bite 67

Fig. 7-6 Pre-treatmenl Frontal and Facial profile

Fig. 7-7 Pre-treatment lnlraoral pholos

Fig. 7-8 Pre-treatment Panoramic x-ray

68 7. Treatment of Class I Open Bite

Fig. 7-9 Pre-treatment cep11alometric 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 ali gn ment and intrusion
of the molars of the upper and lower arches. Vertical elastic 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 2nd molars (fig 7-11).
On the 6 1h month, a positive overbite was observed. The adjustment made
in the MEAW (i.e. 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 81h month. Only the wire was
removed. Two months later, bracket debonding was done (fig 7-13).

At I 0.4 month, after debonding, it was noted that there was a slight decrease
in the overbite. However, the occlusal condition remained to be relatively normal
(fig 7-14).
The active treatment periocl was 8.6 months.
 7. Treatment or Class I Open Bite 69

Fig. 7-10 Pre-lreatment intra-oral photos

Fig. 7-11 lnlra-oral photos 3 months from !he start or treatment

Fig. 7-12 lntra-oral photos 6.5 months from the start or treatment

Fig. 7-13 lntra-oral photos 2.2 months post treatment

Fig. 7-14 lntra-oral photos 10.4 months post treatment

70 7. Treatment of Class I Open Bite

Chart 7-1 Cephalometric Analyses

pre and post treatment
Pre Post
ODI 71 75
APDI 86 87
SNA 81 81
SNB 78 79
ANB 3 2
FMIA 61 61
IMPA 89 90 ':S-::
FMA 30 29
FH-PP 3 -�/
FH-OP (Upper) 9 13 IJ
·v-
- -----
FH-OP (Lower) 17 9 :/. ¿;:_._____---
-.,,,�,.;,,_
�\:i
Ramus inclination 89 90
1. Superimposition at SN plane ·:�---

2. Superimposition at
l
the palatal plane

L 3. Superimposition at MP

Fig. 7-15 Superimposition of the pre 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 ODJ improved to 75 ° from 71 ° and the MP
closed by 1 º. The occlusal plane in both the upper and lower dcntition 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 I st molar was not observed,
instcad alignment was apparent.
 8. Treatment of Class 11 Open Bite 71

8. Treatment of Class 11 Open Bite

(Atsushi Matsumolo)
72 8. Treatment of Class 11 Open Bite

l. General Characteristics of Class II Open Bite

This is classified as the type ofmalocclusion where the antero-posterior

growth of the maxilla is poor and the ability of the mandible for an anterior
adaptation is insufficient. This can be due to the cuspal and occlusal interference
in the posterior teeth related to their excessive elongation caused by posterior
discrepancy. Tn an open bite condition associated with a mandibular distocclusion,
it cloes not mean that excessive elongation ofthe molars is always prcsent. There
are instances where the adaptive force is insufficient due to the posterior rotation
of the mandible related to the steepening ofthe occlusal plane in thc molar area.

11. Morphological Characteristics

of Class II Open Bite

1. Excessively high anterior facial hcight

2. Excessively low posterior facial height
3. Steep mandibular plane
4. Obtuse mandibular angle
5. Growth tendency of the mandible is in an inferior
direction with posterior rotation
6. Excessive vertical dimension
7. Exccssive elongation of the molars (supraversion)
8. Two occlusal planes
• Occlusal planc in the upper anterior tceth area is flat
• Occlusal planc in the upper posterior area is steep
9. Abnormal curve of Spee (reverse curve)
1 O. Asyrnmetrical maxillo-mandibular dental arch width
1 1. Cuspal interference in the molar area
12. Occlusal interference in the molar area
13. Unstable occlusal support
14. Absence of anterior guidance
 8. Treatment of Class 11 Open Bite 73

111. Treatment Objectives for Class II Open Bite

1. Habit modification (i.e. abnormal swallowing and tangue thrusting, etc.) In

cases when the tengue is observed to be large, glossectomy can be done.
2. For respiratory-related problcms, address the enlargement of the pharynx
and tonsils, oral respiration, allergic rhinitis and other otorhinologic related
diseascs.
3. Eliminate the functional factor and obtain a physiologic condylar and
mandibular position.
4. Stimulatc an anterior rotation of the mandible (during the growth period,
anterior position can be expcctcd through mandibular growth guidance).
5. Eliminate posterior discrepancy (intrusion and extTaction of upper and Iower
molars) to control the vertical climension within the denture frame.
6. Align every single tootb based on the appropriate curve of Spee. Flatten thc
occlusal plane in the molar area.
7. Eliminate discrepancy of the upper and Iower dental arch.
8. Retract the upper dental arch to its appropriate position and improve the
molar class 11 relationship.
9. Allow to a certain degree anterior teeth elongation to improve the negative
overbite (open bite).
10. Obtain an occlusal support ancl stabilize occlusion.
I l. Obtain an appropriate occlusal and anterior guidance.
12. Improve midline discrepancy.
13. Obtain a normal physiologic occlusion.
14. Attain an excellent profilc.
15. Consider over-con-ection for si ight relapse and choose a stable retention
method.

IV. Treatment Procedures for Class II Open Bite

l. Paticnt'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, ove1jet of
+2mm, overbite of-l0mm. 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 al Class II Open Bite

Fig. 8-1 Facial Phatas befare treatment

Fig. 8-2 Pre-treatment intra-aral phatas

Fig. 8-3 Pre-treatment Panoramic x-ray

 8. Treatment of Class 11 Open Bite 75

- 7

Fig. 8-4 Pre-treatment Cephalometric radiogram Fig. 8-5 Pre-treatment cephalometric tracing

Panoramic x-ray results: The four 3 rd molars

wcre impacted (fig 8-3).
Cephalometric radiogram fíndings: There was
no abnormal antera-posterior position of the maxilla
observed in the lateral cephalometric radiogram. A
severe hyperdivergence was noted due to the opening
of the mandibular angle and excessive mandibular
height. The mandible showed a posterior rotation.
This can be classified into a Dolichocephalic facial
type. The maxillary molars were suspected to have
supracruptcd. Prcscnce of mesial tipping in thc upper
and lower molars were also obscrved (fíg 8-4). Based
on the cephalometric tracings, it was observed that
thcre was steepcning of thc occlusal planc in the
upper posterior area (6-7), and flattening of
the occlusal p lane in the upper anterior area
( 1-5) (fig 8-5). The mandiblc showed a si ight dis­
placement to the right side as shown in the frontal
view cephalometric radiogram (fig 8-6). Fig. 8-6 Pre-treatment P-A Cephalometric x-ray.
76 8. Treatment of Class 11 Open Bite

Fig. 8-7 lllustration of the treatment plan and the different phases of tooth movement for class II open bite

2. Diagnosis and Treatment Plan

In this patient, anterior rotation of the mandible is not possible because
of the supraeruption 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 supraernption.
In patients with class II open bite, reconstruction of the occlusal plane in
the molar area is importan t. 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 nd 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 reconstrnction. Tllustration of the treatment plan and tooth movernent
phase is shown in fig 8-7.
 8. Treatment of Class 11 Open Bite 77

Fig. 8-8 lntra-oral photos 2 months after start of treatment

3. Progress of Treatment
Step l: Distal movement and
intrusion of the upper and lower
posterior teeth to reconstruct
the occlusal plane in the maxillo­
mandibular molar area.
Fig 8-8 shows the inh·a-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 1111pr ove class 11
relationship and crowding, distal
movement and intrusion of the
upper molar teeth are done. The Fig. 8-9 Adjustment method done in MOAW for this palien!
use of leveling for the anchorage
of upper anterior teeth crowding was held back. In order lo 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 11 Open Bite

Fig. 8-1 O lntra-oral pictures alter 4 months of treatment

Step 2: Leveling and reconstruction of the occlusal planc in the upper and
lower molar area
Fig 8-10 shows the intra-oral pictures 4 months following thc start of the
treatment. Alignment was in progress and intrusion of the lower I si molar with
lhe use of MOAW. In order to improve lhe crowding in the upper anterior area,
the lingual arch was removed. An O16-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 elastics.
Fig 8-1 1 shows the intra-oral pictures 6 months fol lowing 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 rd molars
to allow eruption and at the same time induce their mesial tipping. A plain
MEAW (Multiloop Edgewise Arch-Wire: O.O 16 x 0.022 inch, blue elgiloy wire)
was installed in thc upper and lower dentition for simultaneous alignment. The
open bite condition in the incisor area has improved. The gap in the upper molar
was used to eliminate crowding. Vertical elastics were used in the anterior teeth.
Fig 8- l 2 shows the intra-oral pictures 9 months since the start of treatment.
To improve the class 11 relationship, MOAW was applied in the maxilla with
the objectivc of eliminating cuspal intcrfcrence in lhe posterior molar arca
lhrough intrusion and distal movement of the y c1 molar with mesial tipping.
AA.er which, the upper 1 51 molar distally moved again through the upper MOAW.
To flatten the mandibular occlusal plane, a slight reverse curve was applied to
the MEA W. Vertical elastics were used in the anterior teeth.
 8. Treatment of Class II Open Bite 79

Fig. 8-11 lntra-oral pictures after 6 months of treatment

Fig. 8-12 lntra-oral pictures after 9 months of treatment

Step 3: Attainment of a physiologic conclylar and mandibular position

Fig 8-13. lntra-oral picturcs after 12 months of h·eatment. Up to this point,
thc mandible continues to be displaced to thc right side. MEAW was uscd in
both the upper and lower dentition. While torque was being conb·olled, the upper
and lower arches wcre being aligned. Short class II elastic was used in the
anterior teeth.
80 8. Treatment of Class II Open Bite

♦iii11►

Fig. 8-13 lntra-oral pictures after 12 months of treatment

Fig. 8-14 lntra-oral pictures 14 months following !he start 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 tlu·ough the
MEA W. 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 wiclth.
At this time, the mandible anteriorly rotated associated with a reverse occlusion
in the anterior area. A sho1t class II elastic and box elastic was used at the left
and right side respectively.
 8. Treatment of Class 11 Open Bite 81

Fig. 8-15 lntra-oral pictures 17 months following the start of treatment

Fig. 8-16 lntra-oral pictures during the completion of the dynamic treatment, after 20 months of treatment

Step 4: Detailing, harmonizing of the upper and lower occlusal planes

f ig 8-15 shows the intra-oral pictures l 7 months following the start of
t:reatment. The lateral displacement of the rnandible has been corrected and the
upper and lower midline was in place. A step down bend was done in the plain
MEA W 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. Moreovcr, a bionator (to close)
was used together with the vertical elastics.
82 8. Treatment of Class 11 Open Bite

Fig. 8-17 Panoramic x-ray alter post treatment

Fig. 8-18 Lateral view cephalometric Fig. 8-19 Frontal view cephalometric
radiogram post treatment radiogram post treatment

4. Treatment Results
During the 20-month treatment period, MOA W was uscd for 6 months
and MEA W for 12 months in the upper dentition. In the mandibular dentition,
MOA W was used for 4 months and MEA W was 15 months. lntermaxillary
elastics were used for 18 months.
Fig 8-17 shows the panoramic x-ray during Lhe completion of the dynamic
treatment. Fig 8-18 shows the lateral view of cephalomctric radiogram.
 8. Treatment of Class 11 Open Bite 83

Fig. 8-20 Lateral Cephalometric tracings after b

the completion of 1he dynamic treatmen1.

Based on the lateral cephalometric radiogram,

the root apex orthe upper I st molar was intruded
into the maxillary sinus. When looking at the
lateral cephalometric tracings, closure of tbe
anterior openbite by 2.5 mm and a 2 mm
anterior position of the chin were observed due
to the anterior rotation of the mandible (fig 8-
20, 8-21 a).
When comparing the superimposed
cephalometric tracings of p re and post
trcatment, 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 Fig. 8-21 Superimposed tracings of the pre and post treatment
2.5 mm (fig 8-21 b). In the lower dentition, the
2nd molar has been intruded by about I mm in
the distal arca. ln addition, elongation in the
lower I st molar was not observed. The lower
anterior teeth have elongated by 7 mm ( fig 8-
21 e). As a result, the steep occlusal 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 MEA W regulates the vertical
dimension of both the left and right side. With
that, the mandibular position has been con-ected Fig. 8-22 Facial profile post dynamic treatment
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. Treatment of Class II Open Bite

Fig. 8-23 lntra-oral pictures 1-year post retention

Chart 8-1 Results of the lateral cephalometric analysis

. Pte-treatment ; Posí-t;;atm�;tT" '1 year

--- ; ---··--
Pºst]1
--4--:dfilftQD�
Paramete rs 16y 2mos. old · 1�Y..4'J'RS. eld · r-��s..
,
ºld,.
SNA 85.0 84.5 84.5
1

SNB 81.0 81.5 81.5

ANB 4.0 3.0 3.0
FMIA 42.0 60.0 60.0
U1-SN 120.0 115.0 115.0
Facial Axis 81.5 82.5 82.5
Facial Depth 86.5 87.5 87.5
Mandibular Plane 36.0 34.5 34.5
Lower Facial Ht. 53.0 50.0 50.0
Mandibular Are 21.0 20.0 20.0
Convexity 6.0 5.0 5.0
1-APO (mm) 8.5 5.5 5.5
1-APO (deg.) 39.5 21.0 21.0
6-PTV 25.5 22.5 22.5
Lower Lip-E Plane 7.0 7.0 7.0
upper OP (1-6) -3.0 6.5 6.5
upper OP (5-7) 11.0 6.0 6.0
ODI 59.5 60.5 60.5
APDI 79.5 81.0 81.0
CF 139.0 141.5 141.5

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. Treatmenl of Class 11 Open Bite 85

5. lmportant Points and thc Treatment Method Used for this Paticnt
1. Avoid surgical operation as treatment for a scvcrc open bite condition
with a skeletal factor. Ho\vever, load to the teeth ancl pcriodontal tissue cannol
be avoided when planning for the individual 's orthodontic treatment. Therefore,
it is important to examine the pcriodontal condition pre-trcatment to determine
whether it can withstand the treatrnent.
2. Plan for the habit modification
Myofunctional therapy rcstores 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 eliminare posterior discrepancy, the upper 2nd molars were
extracted after deterrnining through thc x-ray that the 3" 1 molars could serve to
replace the 2nd molars. The 3 rd molars started to erupt after a month following
the 2nd molar extraction and after 7 months bad reachecl the line of occlusion
especially because buccal tubes were boncled to thcm. Al age 16, eruption of
the upper 3rd molars started a month following the uppcr 2'"1 molar extraction
suggesting that this was the result of posterior discrepancy.
Extraction of the upper 2nd molar and lo\.vcr 3rd molar can also be done
to attain the correct vertical dimension.
4. Thcre are cases wherc therc is a need to use a maxillary expansion
device to allow harmony of thc symmetry of the uppcr and lower dental arch.
fn this case, the devices used are Mulligan arch, Quad l-lelix, Rapid Expansion,
and Trans-palatal bar.

5. Leveling (strategic leveling)

r n this patient, correction of the upper and lower occlusal planes was
done during thc leveling period. In othcr words, the final flattening of the occlusal
plane in the upper molar arca was done. lnitially, a MOA W (Modified Offset
Arch-wire: O.O 16 x 0.022 inch blue elgiloy wire) was used to intrnde and dislally
move the upper first molars. This is also effective in improving the class II molar
relationship. At this point, reinforccment of anchoragc (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, crowcling
was not yet climinated. During the improvement of the upper anterior crowding,
the needed space was obtained fírst to avoid flaring and elongation after which
leveling was done. The use of intcrmaxillary elastics was necessary. The lingual
arch in the upper premolar arca was removed. After which MEA W (Multiloop
edgewise archwire : 0.016 x 0.022 inch blue elgiloy wire) was appliecl for
alignment and distal movement of the maxillary dentition. ln the mandibular
dentition, MOA W was applied to avoid flaring and excessive elongation of the
86 8. Treatment of Class II Open Bite

anterior tecth through tbe alignment and intrusion of the lower 2 nc1 molar. MEA W
was then applied to simultaneously align the mandibular dental arch. A flat
MEA W was initially used instead of a MEA W with a tip back bend. The reason
for that is because mesial tipping is possible even with thc use of a plain MEA W.
Moreover, the use of an intermaxillary elastic (class II, vertical or check elastic)
for 24 hours must be determinecl. After confirming the proper usage of the
intermaxillary elastics, a tip back bend of about I O º can be done for alignment.
• In case of a modera te discrepancy, a O.O 16-inch of Ni Ti wire or a
O.O 16-inch of a round Australian wire can be used. After leveling, distal movement
and simultaneous alignment (uprighting) of the entire dentition through MEA W
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 MOA W can be used.
Alignment ancl distal movement is done from the 2m1 molar, which is the terminal
molar. Then conduct a strategic leveling. That is why, befare improving the
anterior teeth crowding, do leveling only after the space needed for anterior
teeth align ment 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 MEA W.
6. lntrusion of the molar teeth through the use oí extra oral force
lf neecled, use an extra oral anchorage appliance (high pull headgear)
to apply an intrusive force to thc upper molar teeth. However, molar intrusion
is diffícult because of the closeness of the upper alveolar bone and the basal
maxillary sinus. An orthodontic implant, which \vill serve as an anchorage unit
to intrudc the molar area, is known to be an e ffective method. At this point, it
is important to consider how the occlusal plane will be reconstrncted befare the
operation.

7. The use of intermaxillary elastic

The appropriate use of the intermaxillary elastic is indispensable.
Thereforc it is 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 thickncss of the gums.

8. Thoroughly clean the oral cavity to prevent the occurrence of caries.

Good oral hygiene procedures will help maintain the healthy condition of the
periodontal tissues.
 9. Treatment of Class II Deep Overbite 87

9. Treatment of Class 11 Deep Overbite

(Atsushi Matsumoto)
88 9. Treatment of Class II Deep Overbite

l. General Characteristics
of Class II Deep Overbite

This is classifíed as a type of malocclusion where Lhe vertical growth of

the maxilla is insufficient. Because of this, the vertical dimension in the molar
arca is insuffícient resulting to the disharmony of its relationship to the vertical
growth of the mandible. Though there is not much of a problcm with Lhe
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 rnandible cannot adapt anteriorly. Tnslead it adapts
posteriorly due to the occlusal interference in the molar area.

11. Morphological Characteristics

of Class II Deep Overbite

1. Lip incompetencc
2. The reverse rotation of the lower lip during the resting phasc
3. Excessively small vertical dimension
4. Insufficicnt eruption of the molar teeth (infraeruption)
5. Accentuatcd Curve of Spee
6. Two occlusal planes
• Flat occlusal plane in the upper anterior area
• Steepcning of thc occlusal plane in thc upper posterior area
7. Discrepancy in the upper and lower dental arch width
8. Labial tipping of lhc upper anterior teeth
9. Occlusal interferencc in the molar area
1 O. lnsuffícient occlusal support
11. Functional failure clue to poor anterior guidance

111. Treatment Objectives for Class II Deep Overbite

1. Habit modifícation like tangue thrusting and abnonnal swallowing.

2. For patients with respiratory problems, trcatmcnt of cnlarged pharynx and
tonsils, oral respiration, allergic rhinitis and other otorhinologic relatcd
diseases.
 9. Treatment of Class II Deep Overbite 89

3. Eliminate the functional factor and obtain a physiologic condylar and

mandibular position.
4. Increasc the maxillary height and vertical dimension
5. Eliminate thc discrepancy in thc upper and lowcr dental arch width through
lateral expansion of the maxilla.
6. Tmprove the class 1T molar relalionship by retraction of the upper dental arch
to its appropriate position.
7. lf the palient seel(s treatmcnl during the growth period, obtain anterior
position of the mandible through growth guiclance.
8. Align cvery single tooth based on thc appropriatc curve of Spee. And finally,
flatten the occlusal plane in the molar area.
9. Increasc the vertical dimension lhrough upper and lower molar eruption.
Obtain an occlusal support.
1 O. lmprove overbite (deep bite).
11. Obtain an appropriate occlusal and anterior guidance.
12. Obtain normal intercuspalion.
13. Attain an excellent profilc.
14. Consider relapse as over-correction.

IV. Treatment Procedures for

Class II Deep Overbite

1. Patient's History
Agc: 16 y/o Scx: Mate
Chief complaints: Prolrusion of the anterior teeth
Facial profile: Brachycephalic and convex profilc, overjet is + 11 mm,
overbite is+ 11mm (fig 9-2).
Panoramic x-ray: ali the four yct molar teeth are impacted (fig 9-3).
Cephalometric radiographic findings: Based on the lateral view, thcrc
is a slight anterior position of the maxilla, and posterior position of the
mandible. Mandibular anglc is small because of the excessively low
mandibular height. This is also classified as brachycephalic facial typc
(fíg 9-4). It was observed through the lateral cephalometric tracings that
therc was a severe curve of Spee showing a steepening of the occlusal
plane in the molar area and a remarkable labial tipping of the occlusal
plane in the upper anterior leeth (fig 9-5). Fig 9-6 shows the frontal view
cephalometric radiogram.
90 9. Treatment of Class II Deep Overbite

Fig. 9-2 lntra-oral pictures during the initial examination

Fig. 9-3 Panoramic x-ray during the first examination

 9. Treatment of Class 11 0eep Overbite 91

Fig. 9-4 Lateral cephalometric radiogram Fig. 9-5 Lateral cephalometric tracings during the initial examination
during the initial examination

Fig. 9-6 Frontal view cephalometric radiogram

during the initial examination
92 9. Treatment of Class 11 Deep Overbite

Fig. 9.7 lllustration of the tooth movement and treatment plan for class 11 deep overbite condition

2. Diagnosis and Treatment Plan

In this patient, it was noted that the curve of Spce was deep with steep
occlusal plane in the molar area, showing an interfcrence 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.
In class II deepbite, the anterior rotation of the mandible through occlusal
reconstruction is best clesired. First, it is important to eliminate the functional
causes of the mandibular retrusion (cuspal and occlusal interference). ln this
case, a physiologic condylar and mandibular position can be attained. With this,
posterior molar inter ference is eliminated with the alignment of the lower 2 nd
molar, correcting the excessive curve of Spec. Sccondly, it serves to flatten the
occlusal plane in the upper molar area. In order lo gel a sufficient occlusal
support, the upper and lower molar teeth are supra-erupted to increase vertical
dimcnsion. With this process, the class 11 molar rclationship is improved due
to the appropriate maxillary position through alignmcnt and rctraction of the
maxillary dentition. Fig 9-7 shows the illustration of the treatment plan and
tooth movement.
 9. Treatment of Class II Deep Overbite 93

Fig. 9-8 lntra-oral pictures a month following the start of treatment

Fig. 9-9 lntra-oral pictures 5 months following 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 to 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 intercanine 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
a 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. 9-10 lntra-oral pictures 10 months after start of treatment

Fig. 9-11 lntra-oral pictures 15 months afler start of treatment

mandible far bite rising and elimination of the curve of Spee as well as far
closure of spaces. (Note: At this stagc, the use of MEAW in the mandiblc is
also possible).

Step 2: Closurc of Space and Occlusal Plane Reconstruction in the Upper

and Lowcr Molar Area
Fig. 9-1O shows the intra-oral pictures I O monlhs following the starl of
treatment. A consolidation arch of O.O 16 inch green elgiloy was used to e lose
the spaces in thc maxilla. lmprovemcnt far the exccssivc curve of Spec in thc
mandibular arch was continued. A reverse curve was done in the O.O 16 x O.O 16
inch bluc elgiloy applied in the mandible. (Note: At this stage, the use ofMEAW
in the mandible is also possible).
Fig. 9-11 shows the intra-oral pictures 15 months following the start of
trcatmcnt. MEAW (Multiloop cdgewise archwire: O.O 16 x 0.022 inch, bluc
elgiloy) was applied to the maxilla far space closure, alignment of the dental
 9. Treatment of Class 11 Deep Overbite 95

Fig. 9-12 lntra-oral piclures 19 months following lhe start of treatment

Fig. 9-13 lnlra-oral pictures 24 months íollowing the start of treatment

arch, and bite rising. Tmprovement of the curve of Spee in lhe mandibular dental
arch was continued. A reverse curve was done in the O.O 16 x O.O 16 inch blue
elgiloy applied in the mandible. The space in the mandiblc has almost closcd.
(Note: At this stage, the use of MEA W in the mandible is also possible).

Step 3: Bite Raising / Molar Relationship Correction

Fig. 9-12 shows the intra-oral pictures 19 monlhs following the start of
treatment. A step down bencl was done in the MEA W (O.O 16 x 0.022 inch blue
elgiloy wire) for maxillary bite rising. A reverse curve was done in the O.O 16
x O.O 16-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 MEA W
in the mandible is also possible).
Fig. 9-13 shows the intra-oral pictures 24 months following the start of
treatment. A DA W (doublc archwire) of O.O 16 x O.O16-inch blue elgiloy was
96 9. Treatment of Class 11 Deep Overbite

Fig. 9-14 lntra-oral pictures 27 months following the start of treatment

Fig. 9-15 lntra-oral pictures 32 months following the start of treatment

Fig. 9-16 lntra-oral pictures during the completion of the dynamic treatment, 34 months following the start of treatment
 9. Treatment of Class 11 Deep Overbite 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: O.O 16 x 0.022 inch blue elgiloy
wire) was applied to the mandible to simultaneously align the dentition.

Step 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. [n the mandible, a step up bend and
reverse curve was done to the MEA W 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 MEA W of the maxilla for bite
rising. ln the mandible, a step down bend was done in the MEAW (Multi-loop
edgewise archwirc: 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. 9-17 Panoramic x-ray during the dynamic treatment

Fig. 9-18 Lateral cephalomelric radiogram Fig. 9-19 P-A cephalometric radiogram
during the dynamic treatment during the dynamic treatment
98 9. Treatment of Class II Deep Overbite

J
Fig. 9-20 Lateral cephalometric radiogram tracing after the
completion of the dynamic treatment
�
: : '
b

�
4. Treatment Rcsults
The dynamic treatment period !asted for
34 months. The use of Quad helix in the maxilla
!asted for 7 months, DAW was 3 months, and
MEAW was 17 months. In the manclible, 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 panornmic x-ray during

the dynamic treatment. Fig 9-18, ancl 9-19 show
t:he lateral and frontal cephalomelric radiogram Fig. 9-21 Superimposed tracings of the pre and post treatment
respectively. Based on the cephalometric tracings,
the vertical dimension has increasecl (fig 9-20).
The superimposecl tracings of the pre and post
treatment (fig 9-21 a) show a correctecl mandibular
position with a 6111111-increase of thc vertical
climension through thc movement of thc occlusal
system. Based on the superimposed tracings of
the maxillary palatal plane, the upper molar teeth
have moved anteroposteriorly with a 3mm
elongation. The incisa! edge of the central incisors
has retruded by 12 mm and extruded by 4 mm
(fig 9-21 b). The center of alignment was the 2nd
premolar teeth in the lower dentition as shown Fig. 9-22 Facial profile after the dynamic treatment
in the mandibular plane of the superimposed
tracings. This means that tbere was no
anteroposterior movement of the molar tooth
 9. Treatment of Class 11 Deep Overbite 99

crown. lnstead, it aligned whileelongating by 3mm. Moreover, the lower anterior

teeth were intruded by 3mm (fig 21 e). As a result, the stcep occlusal planc in
the molar arca, has flattened and the dual occlusal plane, which was causing
the deep curve of Spee, was improved. Ove1jet was +3111111 and overbite was
+5mm. A stable occlusion was attained as well as the excellent facial profíle
due to the correction of mandibular position (fíg 9-22).

A Begg type retainer was used for retention at daytime and a bionator (to
open) was used at night, which !asted for a year. Since thcre was no sign of
relapse, the patient was subjected to a periodic examination. Fig 9-23 shows the
facial profíle 5 years later and fig 9-24 shows the intra-oral pictures confir rning
a stable occlusion. Fig 9-25 is the panoramic x-ray and fig 9-26, 9-27 shows thc
lateral and frontal cephalometric radiograrn respectively. Results of the
cephalometric analysis are shown in chart 9-1.

Fig. 9-23 Facial profile 5 years post retention

Fig 9-24 lntra-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 radiogram Fig. 9-27 Frontal cephalometric radiogram
5 years post retention 5 years post retention
 9. Treatmenl of Class 11 Oeep Overbile 101

Chart 9-1 Resulls of lhe lateral cephalometric radiogram

Parameters
First examination
16y.o.
1 Completion of
treatment
1 18y 4mos old 1 Latest exam.
of the case
23y4mos old
SNA 82.0 82.0 82.0
SNB 78.0 80.0 80.0
ANB 4.0 2.0 2.0
FMIA 53.5 62.0 60.0
U1-SN 126.5 101.0 101.0
Facial Axis 92.5 94.0 94.0
Facial Depth 89.5 91.5 91.0
Mandibular Plane 14.0 11.5 11.0
Lower Facial Ht. 39.5 43.0 43.0
Mandibular Are 44.5 44.5 44.5
Convexity 2.5 O.O O.O
1-APO (mm) 3.5 1.5 2.0
1-APO (deg.) 32.5 29.5 29.5
6-PTV 27.0 25.5 26.0
Lower Lip-E Plane 3.5 -0.5 1.0

lJJ
upper OP (1-6) 2.0 1.5 3.0
upper OP (6-7) 14.0 1.5
ODI 79.0 75.0 .O
APDI 73.0 81.5 .5
CF 152.0 156.5 5.5

5. Treatment Method Used and Sorne lmportant Points to Consider in the

Treatment of Class II 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. Furthcrmore, the use of myofunctional therapy (MFT)
restares 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.
2. Expect anterior mandibular rotation (During the growth period, obtain
anterior mandibular position through growth guidance).
3. Control the vertical dimension in the denture frame and flatten the
occlusal plane in the molar area.
4. lmprove the dental arch through a maxillary lateral expansion device in
case the paticnt is manifesting inappropriatc 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, Quacl helix, expansion screw plate appliance
used for bite rising, Rapicl expansion)
102 9. Trealmenl of Class II Deep Overbite

5. In raising thc bite, erupt thc molar teeth and intrude the upper and lowcr
anterior teeth. A Double Archwirc 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. It is best to always rcfrain from doing
a premolar extraction.

6. In occlusal reconstruction, eliminare the curve of Spce and flatten tbe occlusal
plane in the molar area. Simultaneously align each tooth through the use of
MEA W. At this point, bite raising was also accomplished (tip back bencl,
step benel, Reverse MEA W etc).
7. In the retraction of the maxillary clentition, improve the class II molar
relationship by using the entire mandibular dental arch as an anchorage
unit with thc use of intermaxillary elastics. ln case of severe maxillary
protrusion or absence of mandibular growth, extn1sion of the upper posterior
teeth and distal movement can be done. At this point, an extraoral anchorage
appliance can be used (MOAW, MEAW, Headgear, J-hook, GMD, pendulum,
Jones jig).
8. Obtain occlusal support and stabilize occlusion.
9. Obtain an appropriate occlusal and anterior guidance.
 10. Treatment of Mandibular Lateral Deviation 103

10. Treatment of Mandibular

Lateral Deviation

. •. 7-.

(Susumu Akirnoto)
104 10. Treatment of Mandibular Lateral Deviation

l. 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).

l. Main Causes of Mandibu]ar Lateral

Deviation
1. Bad habits: One-sided mastication, res­
ting the chin on one's band, one-sided posture.
2. Posterior discrepancy (fi.g 10-2):
Unilateral eruption space deficiency in the posterior
area. This could lead to 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 externa!
trauma, etc.
2. Abnormalities Caused by the Lateral
deviation of the Mandible
1 . Facial asymmetTy Fig. 10-1 The P-A cephalometric tracing of a palien! suffering
from lateral deviation of the mandible. The chin is usually
2. Functional abnormality: masticatory displaced on either the left or right side. Occlusal plane in
dysfunction, TMJ arthrosis etc. the molar area of the displaced side is low. The condyle of
the contralateral side is relatively positioned higher compared
3. Psychological to the other side (condyle position of the other side is lower).

rd
Fig. 10-2 In this palien!, the eruptive direction of the upper right 3 molar is observed to be abnormal. This
nd
led to the supraeruption of the 2 molar and eventually displacement of the mandible to the left side
occurred due to the interference.
 1O. Treatment of Mandibular Lateral Deviation 105

11. Characteristics of Mandibular Laterodeviation

1. Morphological Characteristics of Mandibular Lateral Deviation

1. Frontal view (Fig I O- 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 malocclusions 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 shou lders.

Fig. 10-3 Al age 12, upper and lower midline was

centered due to the absence of mandibular
displacement. Al age 19, the palien! carne with a
chief complai nt of mandibular lateral displacement
(fig 10-2 shows the panoramic x-ray of this patient).
Superimposed tracings of the frontal view
cephalometric radiogram is shown below.

-12y
·· ··--19y
106 1 O. 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
of a facebow transfer and articulator mounted
model, the difference in the height of the left
and right maxilla can be detennined (fíg 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 Fig. 10-4 The maxillary occlusal articulation model of a
interference is observed on the unaffected side palien! with mandibular lateral deviation (right side). The
and crossbite on the displaced side. mandible is displaced to the right side because of low vertical
dimension on the right side. The tipping in the upper molar
area of the displaced side is buccal.
In the buceolingual tipping of the molar
area, there is lingual tipping in the mandible
and buccal tipping in the maxilla of the affected
side. On the unaffected side however, there is
bucea! tipping in the mandible and lingual
tipping in the maxilla.
3. P-A cephalometric radiogram (fig 10-1)
There is lateral displacement of the chin as shown in the frontal view
cephalometric tracing. The occlusal plane in the molar area of the displaced
side is low. The mandibular condyle of the displaced sidc, when compared to
the other side, is relatively higher (the condyle of the unaffected side is lower
in position).
2. Functional Characteristics of Mandibular Lateral Deviation
1. TMJ arthrosis
Symptoms are usually present on the affected side but there are instances
that symptoms can be seen on both sides.
2. Mandibular movement (General)
The area of mandibular movement is wider on the a ffected side. However,
in patients where the articular disc of the unaffected side is anteriorly displaced,
condylar movemcnt is limited. The condylar angle of the displaced side is bigger
as well as the Bennet angle. Intercuspal position is compressed on the displaced
condyle, and distraction is present in the unaffected side. The customary
masticating side is usually the displaced side.
3. Electromyogram
The degree of muscle activity during mastication is relatively lower on
the displaced side. When occlusion is raised on this side, symmetrical difference
will become milder.
 10. Treatment of Mandibular Lateral Deviation 107

111. Treatment Objectives for Mandibular

Lateral Deviation

1. Leveling and consideration of the vertical

dimension (left and right side)
In this patient, the improvement of
discrepancy in the left and right vertical
dimension is especially important. Therefore,
normal leveling is not necessary at this point.
To control thc vertical dimension in the molar
area, MOA W, which is the appropriate
appliance to use to achieve this objective, can
be used even at the start of treatment ( fíg 10-
5). So in patients without crowding, application
of MEA W at the sta1t of treatment is possible.
It is important to c01Tectly diagnose any
lateral difference of vertical dimension in this
patient. Increase in height is not the only factor
that accounts for the differencc of vertical
dimension in the left and right side. Below are
sorne variations: (fig 10-6).

a. Vertical dimension of both sides is

high but the other side is higher (Bilateral class
Tfl)
b. Vertical dimension of both sides is low
but the other side is lower (Bilateral class II) Fig. 10-5 lf tip back bend is done at the center of the
MOAW offset, distal alignment is possible mainly on the
c. Vertical dimension of onc side is molar teeth. lf the tip back bend is in the mesial part of
the MOAW offset it applies an intrusive force while aligning
normal but thc other side is higher (Unilateral the molar teeth. And if tip back bend is done in the distal
class Tll) part of the MOAW offset wire, an elongative force is applied
while alignment is done.
d. Vertical climension of one side is
normal bul the other sicle is lower (Unilateral C.;se n��rq;;pif:1•hB· t,·:ü ,: : ·. �':::._,.n
class Il)
e. Vertical dimension of one side is high
OOmilllls WJ!!n!JIB2 t Mlmnil!ll!J +
and the other side is low (one-sidc class IIT,
one-side Class II) t
The orthodontic force for each of these
Mmilllla !WamMIJ8l r..1!� ¡
is shown in fíg 10-6. The discrepancy of the t
lcft and right vertical dimension of a patient
1
♦ ■
with mandibular lateral deviation as well as the
___. : Orthodontic force
abnormal anteroposterior relationship of class
Fig. 10-6 lllustration showing the various orthodontic force
II and class 111 are evident. applied to lateral discrepancy of vertical dimension.
108 10. Treatment of Mandibular Lateral Deviation

2. MOA W and MEA W activation

MOA W and MEA W activation in patients with mandibular lateral
deviation is mentioned in chapter 3 (Methods of MEAW Adjustments). With
reference to the treatment method used in class U and LII, it is important to
apply a different orthodontic force to both sides. For instance, class II force
on one side and class III on the other side.
3. Additional orthodontic force
The use of intermaxillary elastics as an additional orthodontic force
device is indispensable. Basically, vettical elastics are used in the anterior area
for class r, short class II elastics for class II, and short class III elastics for
class III. Moreover, concomitant use of a box type elastic, short class II, or
class III in the molar is also possible. Either of these elastics can be used for
as long as the vector force (specially the vertical vector) needed is well
understood.
4. Final stage
During the final stages, MEA W can be used continuously as an ideal
archwire.
5. Precautions
In principie, the use of a midline elastics for midline alignment is not
advisable. The midline elastic with consideration of its vertical vector could
aggravate the left and right tipping of the occlusal plane. As a result, the left
and right side tipping of the occlusal plane will worsen even if the midline has
aligned ( fig 10-7).

Fig. 10-7 The use of midline elastic greatly affect the tipping of the occlusal plane despite its positive
effect on the alignment of the upper and lower midline.
 10. Treatment of Mandibular Lateral Deviation 109

IV. Treatment Procedure for Mandibular

Lateral Deviation

A simple and specifíc orthodontic treatment for a patient with mandibular

lateral deviation during the permanent dentitioo period is through surgical
procedure. However, it has become possible to treat a patient without undergoing
surgery to eliminate posterior discrepancy. Cases related to permicious oral
habits will require habit modification.
Extraction of the upper and lower 3 rd molars is norma U y done to eliminate
the factor of posterior discrep ancy. However, like in other types of
malocclusions, extraction of the upper 2nd molars in young patients may be
done.
l. Patient's history

Age: 24y 2 mos. old Sex: Female

Cornplaints: The jaw protrudes during occlusion. The patient requested for
surgery to improve the facial asymmetry.
Intra-oral fíndings: The patient was diagnosed 2-3 years ago by 3 specialists,
an orthodontist, an oral surgeon and others and was told that the only treatment
possible for this case was through surgical operation. So she waited to reach the
age possible for operation. Her difficulty in breathing since age 22 has continued
up to this point. A tranquilizer was prescribed by an internist due to
hyperventilation syndrome. Other than that, everything was normal.
Facial profile: Face is oval in shape with the left displacement of the e hin.
Profile is straight (fig 10-8). lntra-oral findings show a 5.5mm mandibular
displacement to the left from the maxillary midline. OveLjet was 2mm, overbite
was 0mm, with a class llI occlusal relationship in the molar teeth (more severe
on the right side). Canine relationship is class JU on the right and class I on the
left side. Crossbite was evident in the upper right incisor, left canine and I st
premolar. AII the 3"1 molar teeth have erupted. Patient has a complete set of
dentition (fig 10-9).
Cephalometric radiograrn findings: frontal view - occlusal plane in the left
side is relatively higher which shows an upward tipping of occlusal plane on
the left side (fig 10-1 O).
Cephalometric radiogram fíndings: lateral view - skeletally, point B and
Pog is positioned anteriorly. Dentally, labial tipping of the maxillary anterior
teeth and lingual tipping of the mandibular anterior teetb was observed. In Kim's
analysis, ODl was 64° (open bite tendency), and APDI of 92º (reverse occlusion
tendency) was observed.
As shown in the SAM a,ticulator model, cuspal interference was observed
in the left 3rd molar. TMJ arthrosis on the left side was observed to have started
since age 13.
11 O 1 O. Treatment of Mandibular Lateral Oeviation

Fig. 10-8 Facial profile during the first examination

Fig. 10-9 lntra-oral pictures during the first examination

2. Diagnosis and Treatment Plan

Considering thc above data, correction or the

vertical dimension can be done in altering Lhe tipping
of thc occlusal plane of the left and right side a Her
poster ior cliscrepancy has been elimi nated.
Improvcmenl of the open bite and possiblc reverse
occlusion can be simultaneously done. A rnulti­
bracket appliance can be applied to t rcat thc
displacemcnt of the mandible to the left, which was
Fig. 10-10 Frontal view of the cephalometric
the chicf complaint. radiogram tracing
 1O. Treatment of Mandibular Lateral Deviation 111

Fig. 10-11 lntra-oral pictures during the application of the orthodontic appliance

3. Treatment Progress
The midline in the upper central incisors is not coinciding with the lower
midline. Since displacement of the rnandible to the left is apparent, a plain arch
was initially used in the maxilla and a MEAW was used in the mandible. MEAW
was bent more tightly on the right side for activation to not only treat the open
bite and reversed occlusion and apply intrusion and alignment but primarily for
the improvement of mandibular displacement. A short class lll elastic was used
in the anterior teeth and a class III component with a strong vector was used on
the right side to improve the left side displacement of the mandible ( fig J 0-11).
Since there was a difference in the vertical dimension between the left and the
right side, the MEA W, which was also applied in the maxilla was bent in order
to intrude the right side only. And since this patient had been suffering from left
TMJ arthrosis, the upper MEA W is bent on the left side in such a way that it
would increase the left vertical dimension (An opposite force system \Nas used
to improve the open bite and reverse occlusion).
4 months later, open bite and right lateral incisor crossbite was improved
as well as the alignment ofthe midline (fig 10-12). To continue the treatment,
the same force system was used and time was spent on improving the overlap
in the left canine. (At this point, a lingual button was bonded on the lingual
surface of the upper left canine. An intermaxillary elastic was used to shorten
the treatment period).
112 1 O. Treatment of Mandibular Lateral Deviation

Fig. 10-12 lntra-oral pictures 4 months following the start of treatment

Fig. 10-13 12 lntra-oral pictures 13 months following the start of treatment

On the 13 th rnonth, the midline was corrected and the severe class III
relationship of the right canine was improved. There was no more major problerns
notcd cxcept for a tcndency of class HI in the right 1 st molar teeth.
 1 O. Treatment of Mandibular Lateral Deviation 113

Fig. 10-14 lntra-oral pictures after the removal of the appliance

Fig. 10-15 lntra-oral pictures 1 year and 1 month following the removal of the appliance

Fig. 10-15 s hows the intra-oral pictures I ycar and I month following the
remov,11 of the appliancc. Thc dynamic treatment period ]asted for I year
and 4 months. The occlusion, 1 year and I month after the removal of th e
appliancc, was relatively stable with a slight: rclapse in the alignmcnt of the
midl inc (fig 10-15).
114 1 O. Treatment of Mandibular Lateral Deviation

1. Superimposed tracings lateral view 2. Superimposed tracings frontal view

(FH standard) (Zygomatic bone arch standard)

� ..•'
. .

3. Superimposed tracings of the maxilla

!J(Í.. '

4. Superimposed tracings of the mandible

(Palatal plane standard) (Mandibular plane standard)

Fig. 10-16 Superimposed tracings of the cephalometric radiogram of the pre and post treatment for both frontal and lateral view

4. Comparison of Pre and Post Trcatment Results (Fig l0-16)

Based on the lateral view superimposed tracings, the lips were protruded
clue to the anterior rotation of the manclible. The anterior teeth overlap has
improved with a positive ove1jet and overbite which was ncgative prior to
lreatment. /

Superimposed tracings of the maxilla revealed labial tipping in the anterior

tceth and a slight mesial tipping in thc molar tceth. Based on the superimposccl
tracings of the mandible, the anterior and molar teeth have been aligned. Thc
movement of these teeth (anterior and posterior teeth), was helpful in thc
improvement of overlap.
On the other hand, the frontal view superimposed tracings, shows the
complete alignmcnt of the midlinc. Chin alignment, though not pcrfectly aligncd
al the center, has greatly irnproved.
 11. Treatment of Crowding 115

11. Treatment of Crowding

(Sadao Sato)
116 11. Treatment of Crowding

l. General Characteristics of Crowding

Crowding is an abnormality of the dentition that frequently occurs in

malocclusion. The degree of crowding varíes from one patient to another. N01mally,
this problem arises due to discrepancy in the size of the teeth and the alveolar bone.
The most affected part of crowding starts from the molar area, lower anterior teeth,
upper canine area and the upper and lower premolar area. The degree of crowding
can be easily detennined through a mere dental examination. However, malocclusion
cannot be diagnosed that easily. lt is irnportant to be cautious about selecting the
tooth to be extracted, that is, opting to extract the premolars, alrnost routinely.
ln cases of severe crowding, mesial tipping is usually present in the premolar
and molar area. Elimination of crowding through the alignment in these areas is
also possible. Though there is a possibility that the treatment of crowding in the
molar area is overlooked, it is irnportant to note that the treatrnent of crowding in
the molar area (posterior discrepancy) is more important than the crowding in the
anterior teeth.

11. Morphological Characteristics of Crowding

All types of malocclusion are associated with crowding. Therefore the skeletal
characteristics of crowding are not well de:fined. However, in general, crowding
in high angle open bite and rnaxillomandibular protrusion is not common. Tt is
because crowding is closely related to the vertical dimension (occlusal support)
in the molar area. The increase of vertical dimension in the molar area leads to the
anterior tipping of the entire dentition and will result to an anterior open bite or
maxillomandibular protrusion to prevent the aggravation of crowding. Therefore
it is said that there is a clase relationship between an open bite or max.illomandibular
protrusion and crowding.
(Morphological Characteristics)
1. Skeletal type is usually Class 1. In Class III malocclusion, crowding is not
frequently seen in the mandibular dentition. On the other hand, crowding
is not common in the maxillary dentition in Class U cases.
2. The upper ante1ior teeth are aligned and usually a steep anterior guidance
path is observed.
3. Occlusal plane is usually tlat.
rd
4. Impaction or eruption of the 3 molar is usually dif:ficult.
 11. Treatment of Crowding 117

111. The General Treatment Objectives for Crowding

In planning thc trcatment lor this type of patienl, it is important to determine

initially the benclit of doing a labial tipping of the anterior tecth. In case of a
steepening of the anterior tceth guidance path, alignment starting from the
posterior teeth is impo11anl. This usually affects the improvcment of the anterior
teeth. It is becausc there is a big possibility that cluring the trcatment process,
molar alignment could cause open bite in the anterior teeth. However, this is
not a problem at ali. Since al this point, the vertical dimension in the molar area
is suflícient, mandibular displacemcnt and TMJ compression is not obscrved
duc to a high vertical climcnsion, then the second part of treatmcnt can be done,
which is the improvement 01 the open bite through the control of occlusal plane.
This will lead to the attainmcnt of a suffícient occlusal support resulting to a
stablc occlusion post treatment. Long term retention is needecl in cases of severe
tooth rotation to improve crowding or abnormal tooth position. However, In
cases 01 moderate crowding, retention is similar to other types of patients. In
either case, post treatment stability is greatly clepenclent on the functional element.
So the most important factor is to gel a stable occlusal support through an
appropriate occlusal guidance and an occlusion with the absence of cuspal
interfcrence.

IV. Treatment Procedures for Crowding

1. Bond the brackets and bucea! tubes to the entire clentition except for -ij-.

*.
Start leveling with the use of a O.O 14 inch round wire.

2. Replace the round wire with a O.O 16 size round wire and insert a coil spring
into the area without brackets. Start the alignmcnt of the

3. Bond the brackets to the ¾jt.-. Start the alignment of -¾f,- by inserting a coi]
spring into the 1f
4. Apply MEA W to the upper and lower clentitions and do a tip back bend to
align the entirc molar area.

5. Once the molars are aligned, remove the MEA W immecliately and rc-tie the
rounclwire to elirninate the crowding in the anterior area.

6. Once the crowding has becn entirely eliminatecl, a final adjustment in the
MEA W is done to control the tooth axis (torque control) improving the
intercuspation.
118 11. Treatment of Crowding

Fig. 11-1 Facial profile pre-treatment

Fig. 1 1-2 Occlusal condition pre-lreatmenl

1. Patient's history
Agc: _24y I O mos. old Sex: Female
Chief Complaints: Teeth crowding as well as pain and clicking in the
TMJ (fig l l-1).
Intra-oral findings: Occlusion in the molars is Class II angle, crowding
in the upper and lower anterior area is severe, palatoversion of the upper
nd
right 2 premolar, blocked out upper lcft canine as well as the lower
st
left l premolar (fig 11-2) wcre observed. Occlusion in the upper and lower
anterior teeth is edge to edge with a crossbite from the left lateral incisor to
the premolar area.
r cl
Panoramic x-ray: Ali thc four 3 molars were present but were
rd
all impacted except for the 3 molar in the upper right side (fig 11-3).
 11. Treatment of Crowding 119

Fig. 11-3 Panoramic x-ray pre-treatment

Fig. 11-4a Cephalometric tracing pre-treatment

r
Fig. 11-4b Cephalometric tracing post-treatment

:l
-•
� '·'
"
, X X
"
"
·•

1
. HCH
GI, 77
,, '
º'
EXCLRSION

SEN
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"""urt. ••• ,, '
º'· '·""
08
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HOI
1"-�
.. NLURS ION

o. 00
HCH
70, 57
••,c.
OOI

'·""
sz. 27
z
• e,.n
07. -z. 73 1Z. ,o -1. ez 70. 51

••• ,:i
-2. 19 1,.12 O.IX>
o.oc 01.e, ,,. 11 0.00
Fig. 11-4c Superimposed tracings of the pre-treatment OJ. 22 -2. 20 72. ◄7 o. •5 '"· J• o.., ?2,21) 0.97

.,

_Ll
01. ,, -z. g;¡ a�.12 O.In !llt. 34 -o. .ez 60. 50 l. J5
(dotted line) and post-treatment (solid line) o."º �o
º'
tlU, -2.1'5 b1 :SI. 78 -1. $7 01. 0,77
7 55. •2, 12 Co•. o, 0.-Jft ,,. 00 -1. J� 03. f!O o. 39

•l,n 1 •n o,
B :11.11
,·,. 31
-1. 91
-2. J,t
es. a, o. ,s
O. JS
,U,06 -o.,�
-o. 61
61. 31 o,ªº
-o. z,
••. º'
57. 70 41, IZ 58, 1ft
-� .... s, ., n '" " ,n .n •• o

Fig. 11-5 The mandibular condyle during the mouth

opening and closing movement (axiograph)
120 11. Treatment of Crowding

Cephalometric radiogram analysis: A remarkable skeletal displacement

was not observed. SNA was 86.5°, and SNB was 82.5°. With a FH-MP of 31 º ,
ODl of67 º and APDf of 86 ° , these shows a high angle class [Ir type. A CF of
153 suggests the importance oftooth extTaction. Discrepancy was very evident
because either the Steiner or Tweeds test, a test to determine the importance of
tooth extraction, shows positive results (fig I l -4a-c).
Axiograph: Mandibular movement to the anterior and lateral direction is
limited. There was no apparent difficulty during the mouth opening and closure
exercises but thcre was an asymmetry in the condylar path (fig 11-5).

2. Diagnosis and Treatment Plan

In this paticnt, the reason far the crowding and the functional abnormality
of the TMJ was the discrepancy in thc size of the tooth and the alveolar base.
There are also the following signs ora sleep upper anterior guidance, mesial
tipping in the premolar and molar teeth and retruded mandibular position. As
part of the trcatmcnt plan, a mild anterior movcment of the mandible through
correction in the occlusal plane is necessary whicb will evade the need far
rd
premolar extraction. The upper and lower 3 molars were extracted lo eliminate
discrepancy and obtain an appropriate occlusal guidance and occlusal support.
3. Treatment Progress
Step 1: An edgewise bracket appliance system was applied to the entire
st 1c1
dentition except to the I molars. Bucea! lubes were bondcd onto the i molars.
1c1
To align the i molars, an open coi! spring was attachecl to thc area of thc 1
st

molar and leveling was started through thc use ofa 0.014-inch australian wire
( fig 11-6, 1 1-7). Two months later, thc current wirc was replacecl with a O.O16
nd
australian wirc to continue the alignmcnt of the 2 molars. Three months later,
51
bancls were attached lo the lower 1 molars and the coi! springs were removed.
Lcveling was done. This process conscquently led to an anterior open bite.

Fig. 11-6 lntra-oral piclures during the slart of leveling

 11. Trealment of Crowding 121

Fig. 11-7 Force syslem of leveling. Alignmenl of 2 nd molar through the use of coil spring.

Fig. 11-8a 4 months since the start of treatment

Fig. 11-8b 7.5 months since the start of lreatmenl

Fig. 11-8c A year since the start of lreatment

122 11. Treatment of Crowding

Step 2: 4 months later, MEAW was applied to both the upper and lower
dentitions to align the premolar and molar teeth (fig l l-8a-c). The MEAW in
the maxilla was especially rnodified for thc distal movement of the molars (fig
l l-9a,b). On the right premolar area, a combination loop was incorporated. A
nd
vertical loop in the distal area of the 2 premolar was placed to allow its distal
movement. Vertical elastics were used in the upper and lower MEAW. 9 months
later, the palatoversion of the upper right premolar has been corrected, the space
for the left canine as well as the closure of the open bite condition in the anterior
area has been attained (fig 11-10a-k, 1 1-11 ).

« 1�
« n« rul
« 1� s� « �

« 1� s �
((
1�

Fig. 11-9 The use of combination loop to create space

Fig. 11-10a Occlusal plane during the start of leveling

 11. Treatment of Crowding 123

Fig. 11-1Ob 1.5 months following the start of treatment

Fig. 11-1 Oc 4 months following the start of treatment

Fig. 11-1Od 6 months following the start of treatment

Fig. 11-10e 7.5 months following the start of treatment

124 11. Treatment of Crowding

Fig. 11-1 Of 11 months following the start of treatment

Fig. 11-1 Og 1 year and 1 month following the start of treatment

Fig. 11-1 Oh 1 year and 4 months following the start of treatment

Fig. 11-10i 1 year and 8 months following the start of treatment

 11. Treatment of Crowding 125

Fig. 11-10j 1 year and 11 months following the start of treatment

Fig. 11-10k 2 years and 1 month following the start of treatment

Fig. 11-11 1 year and 4 months following the start of treatmenl

Step 3: 1 year and I month Iater, the upper left canines were well within
nd
the dental arch. However, the spacc necded for the right 2 premolar was quite
insufficient so a O.O 16-inch Australian wire was rcplaced into the maxillary
dentition and with the use of a coi( spring, a space was obtained. At l year and
8 months sincc thc start treatmcnt, thc entire dentition was aligned (fig l 1-1 Oi,
fig 11-11 ).
126 11. Treatment of Crowding

4iW·i•

Fig. 11-12a 1 year and 11 months following the start of treatment

Fig. 11-12b 2 years following the start of treatment

Fig. 11-13a Occlusal condition post orthodontic treatment (2 years and 4 months since !he start of treatment)

Fig. 11-13b 10 months post orthodontic treatment

Step 4: In the last stage of the orthodontic occlusal treatment, a 0.016

inch round australian wire was used to create the ideal arch for both the upper
and lower dentition. At this point, splicing was done in the adjacent surface of
each tooth from the t · molar to the 1 · premolar teeth of thc upper and lower
S( S(

dentition. A J-hook typc headgear and a short class lII elastic were used only
in the evening to improve the labial tipping ofthe anterior teeth (fig l l-l2a,
b). The said force was applied for 4 months. Two years and four months
after, ali the appliance was removed ancl the treatment was completed. (fíg
1 1-13, 1 1-14). Rctcntion wit:h the use of a Hawley type !asted for 6 months (fig
1 1-13).
 11. Treatment of Crowding 127

Fig. 11-14 Facial profile post treatment (10 months post orthodontic treatment)

Fig. 11-15 lntra-oral pictures post treatment (1 year and 1 month post orthodontic treatment)

4. Treatment Results
Though the crowding was severe, the molar area was aligned through the
rd
extraction of the 3 molars. The space needed for the alignment of teeth and
distal movement was acquired. During the final stage of the treatment, the use
of J-hook headgear and splicing on the adjacent surface was done. The labial
tipping in the anterior teeth was improved anda fine occlusion was attained (fig
11-13, 11-15). [n the superimposed tracings of the pre and post treatment
cephalometric radiogram, the irnprovement of the anterior teeth overlap due to
the labial tipping of the upperanterior teeth was evident. There was an apparent
distal movement of the molars and no remarkable skeletal changes were observed
(fig l l-4c).
128 11. Treatment of Crowding

In the treatmcnt of a patient suffering from crowding, open bite in the

anterior area may arise in the middle of the treatment process especially during
the tooth alignment period. This should be considered as an essential open bite
in the treatment of this condition. This explains the camouflage effect due to
thc vertical factor in crowding. Thcrc forc, alignment of thc molars as well as
the tooth leveling consequently induces open bite in the anterior teeth. It is
impo1tant tbat thc patient is well infom1ed about this fact before tTeatment begins.
This symptom of open bite is improved through the alteration of occlusal plane
in the upper and lower dentition. So even if this condition arises in the middle
of the treatment, this is not considered a problem at ali.
 12. Treatment of a Patient with TMJ Dysfunction 129

12. Treatment of a Patient

with TMJ Dysfunction

(Junzo Yoshicla)
130 12. Treatment of a Palien! with TMJ Dysfunction

l. General Characteristics of a
Patient with TMJ Dysfunction

TMJ dysfunction and malocclusion are closely relatcd. Premature contact,

occlusal interference, cuspal interference, and loss of occlusal support are the
causes of malocclusion. The movement of the mandible in turn avoids these
cuspal contacts and the neuromuscular system is activated to allow a wider
contact of the upper and lower dentition. Thus, tooth movement and mandibular
displacement occurs. The neuromuscular system is stimulated more by the
periodontal ligament than thc TMJ, and the muscular movement occurs to avoid
loading or the teeth. This consequently leads to the structural changes of the
TMJ and the abnormalities are evident in the symptoms presented. Therefore
the treatmcnt includes countermeasures for pain and abnormal movement as
well as establishing a normal mandibular position. Below are three patients with
acute dislurbance in mouth opening and the methods applied will be discussed
accordingly.

11. Distinct Characteristics of a Patient

with TMJ Dysfunction

Patient 1: TMJ closed lock (right) due to left mandibular lateral deviation
(fig 12-1)
In mandibular lateral deviation lo the left, the right TMJ is in a closed lock
position. Due to a narrow upper dental arch width, thc lower molars show
mesiolingual tipping. The low vertical dimension on the left side causes the
right condyle to be latcrally displaced, and mandibular condyle movemenl is
regulated by the ligaments and articular clise.
Patient 2: TMJ closed lock (left) due to left mandibular lateral deviation
(fig 12-2)
In left mandibular lateral deviation, similar to patient 1, the left TMJ is
in a closed lock position. In this patient, the maxillary dental arch width, when
compared to the mandibular arch width, is narrow leading to the left rotation
ofthe mandible to attain occlusion. Becausc of that, the left mandibular condyle
is postero-medially displaced and the ligaments and articular clise regulates the
movement of the mandibular condyle.
Paticnt 3: Closed lock duc to the bilateral loss of occlusal support (fig 12-3)
Both the left and right TMJ is in a closed lock position. However, lateral
deviation of the rnandible is not quite observed. More compression was present
on the sidc of mandibular condyle whcre vertical dimension is low, causing the
left TMJ to be in closed lock position. Eventually, the right TMJ resulted into
a closed lock position.
 12. Treatment of a Patient with TMJ Dysfunction 131

Fig. 12-1 Patient 1 : Pre-treatment

132 12. Treatment of a Patient with TMJ Dysfunction

Fig. 12-2 Patient 2 : Pre-treatment

 12. Treatment of a Palien! with TMJ Oysfunction 133

Fig. 12-3 Patient 3: Pre-treatment

134 12. Treatment of a Palien! with TMJ Dysfunction

111. General Treatment Objectives

for a Patient with TMJ Dysfunction

1. Usage of Splint
The use of splint is effective for pain relief during mouth opening
by eliminating interference, ensuring a vertical dimension leading to the
restoration of the appropriate mandibular position, as well as alleviating
masticatory muscle tension ancl fatigue.
1. Emergency splint
lmmecliate intervention is neecled during an acute trismus. The self­
curing resin can be immediately fabricated to serve as a mini-splint in the
frontal or molar area. A smooth splint is effective in guiding the mandible
to a specific position thus eliminating neuromuscular abnormalities and
symptoms related to muscular dysfunction.

2. Repositioning splint
In patients with TMJ dys function, the relationship of mandibular
condyle ancl disc is usually abnonnal due to incorrect mandibular position.
To restore the position of the mandibular condyle and clise, a repositioning
splint is usually e ffective through the guidance of the mandible. This
will guide the mandible to restore the physiologic position of the articular
disc. The use of axiograph, a device that records mandibular movement,
is effective in determining the mandibular position and conclition in
relation to the use of splint. (fig 12-4).
Repositioning splint restores the mandibular eondyle position. In
addition, it does not apply load to the masticatory muscles. Besides, it
allows average contact of the entire dentition with the objective of
creating variance in the oeclusal force. When used during an cmergency
case, this will lessen the pain, improve the closed loek into a non­
clicking condition, and restore mandibular movement, like mouth
opening, in 2-3 weeks. During this period, changes in the splint can be
done to obtain the normal mandibular position (fig 12-5).
Since patient I complained of only mild pain ancl with a mouth
opening of 40mm, orthodontic treatment was started without the use of
a splint. With patient 2, a splint was used due to a mouth opening of
28mm during the first examination, which became 35mm a month later.
Patient 3 also used a splint because of a 24mm mouth opening during
the first examination, which increased to 35mm after a month. At this
point, the pain was alleviated and orthodontic treatment for cach patient
was started.
 12. Trealment of a Palien! wilh TMJ Dysfunclion 135

Fig. 12-4 a. lnlercuspal posilion b. Splinl position during fabrication (patient 2)

a b

Fig. 12-5 a. Articulator position during fabrication b. Corrected position (patient 2)

3. Orthodontic Occlusal Reconstruction

TMJ dysfunction is usually associated with class l, JI, III, as well
as crowding, trismus or mandibular displacement. Thereforc occlusal
reconstruction can be patterned based on the lTeatment procedures discussed
in the previous chapters. However, it is important to understand the
structural changes of the TMJ, condition of condylc and articular disc
displacement, as well as the status of pre and post treatment.
136 12. Treatment of a Palien! wilh TMJ Dysfunclion

IV. Treatment Procedures for TMJ Dysfunction

l. Patient's history

Patient 1: l 7y I O mos. old, female. Complained of pain on the right TMJ

during mouth opening associated with trismus (maximum mouth opcning
40mm).
Patient 2: l 5y 11 mos. old, male. Complained of pain on the left TMJ
during mouth opening associated with trismus (rnaximum mouth opening
27mm).
Patient 3: l 8y 2 mos. old, female. Complained of pain on both TMJ
during mouth opening (maximum mouth opening 24mm).

Oral examination
Patient 1: Occlusal rclationship in the molar area for both sides is Angle
Class l. Crowding in the upper and lower anterior teeth. Slight crowding in
the upper molar area. Lingual tipping of the lower molars. Lower midline
is deviated to the left.
Patient 2: Occlusal relationship is Angle Class l and 11 for the right and
left molars respectively. Though crowding was not observed, there was a
slight crowding in thc upper molar arca. Lower midlinc is deviated to the
lefl.
Patient 3: Occlusal relationship in the molars for both sides is Angle
Class
l. Crowding in the upper and lower anterior teeth is apparent. Ovcrbite is
5.5mm.

Panoramic x-ray (fig 12-6, 12-8, 12-1O)

Patient l: lmpacted lower 3 rd molars
Patient 2: Trnpacted upper and lowcr 3"1 molars, and slight morphological
changes on the left mandibular condyle
Patient 3: Tmpacted upper and lower 3'"d molars

Cephalometric radiogram analysis (fig 12-7, 12-9, 12-1 1)

Patient 1: Lateral view; ODl 88.0, APDI 79.0. Frontal view; left lateral
deviation of the chin and mandibular condyle displacement to the left.
Patient 2: Lateral view; ODl 73.5, APDT 82.5. Frontal view; left lateral
deviation of the chin and mandibular condyle.
Patient 3: Lateral view; ODJ 72.5, APDI 87.0. Frontal view; displaccmcnt
was not observed.
 12. Treatment of a Palien! with TMJ Dysfunction 137

a b

Fig. 12-6 Palien! 1: a. Pre-treatment b. Post-treatment

Fig. 12-7 Palien! 1: a. Pre-treatment b. Post-treatment

 138 12. Treatment of a Patient with TMJ Dysfunction

a b

Fig. 12-8 Patient 2: a. Pre-treatment b. Post-treatment

Fig. 12-9 Patient 2: a. Pre-treatment b. Post-treatment

 12. Treatment of a Palien! with TMJ Dysfunction 139

a b

Fig. 12-1 O Patient 3: a. Pre-treatment b. Post-treatment

Fig. 12-11 Patient 3: a. Pre-treatment b. Post-treatment

 ,­
140 12. Treatment of a Patient with TMJ Dysfunction

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Fig. 12-12 Patient 1: Pre-treatment

Axiograph (fig 12-12 to 12-14)

Patient 1: Right side is in closcd lock position. Extent of sliding movemcnt
of the left side is 12mm. A low 20º condylar rotation was noted.
Patient 2: Left side is in closecl lock position. Sliding movcment to thc
right side is not possible duc to pain. A low 15 ° conclylar rotation was notccl.
Patient 3: Both sides are in closed lock position. A low 15 º condylar
rotation was notcd.
2. Diagnosis and Treatment Plan
Patient 1: Alignment of the entire dentition, increase thc left vertical
dimension with reference to the right vertical dimension, restore TMJ through
securing an occlusal support and an appropriate occlusal guidance without
inter ference.
Patient 2: After the pain was lessened with the use of a repositioning
splint, occlusal reconstruction (likc patient 1) was done through the movement
of the mandible to the right sidc while the left vertical dimension is increased.
Patient 3: After pain was lessened tbrough the use of a splint, occlusal
rcconstruction applicable to crowding was done.
 12. Treatment of a Palien! with TMJ Dysfunction 141

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Fig. 12-13 Patient 2: Pre-treatment

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Fig. 12-14 Patient 3: Pre-treatment

142 12. Treatment of a Palien! with TMJ Dysfunction

Fig. 12-15a Palien! 1: tntra-oral pictures during leveling period

Fig. 12-15b Palien! 1: after 0.5 months of treatment

3. Treatment Progress (for Patient 1 only) (fig 12-16)

Step 1: St art of orthodontic treatment- Leveling (1998.8.26) (fig 12-1Sa)
A splint was not indicated for patient 1 because of the mild pain and
40mm mouth opening. Brackets and tubes were bonded to the entire dentition
and an ideal arch formed 0.014-inch round wire was used. The continuous
use of splint in sorne patients is allowed to prevent them from
worrying. However, due to tooth movement, the splint will no longer be
accommodated. At this point, the patient should be informed that the use
of the splint is unnecessary (fig 12-17). (Patient requested that only the
impacted 3 rd molar on the lower right be extracted).

Step 2: (1998.9.13-12.9) (fig 12-lSb)

A coil spring was used to align the molars and eliminate crowding.
Extraction ofthe lower right 3 rd molar was also done. Improvement ofthe
dental arch morphology was done through the use ofwire and increase in
the vertical dimension is expected due to the alignment of the posterior
teeth. (In this step, relationship of the condyle and articular disc was
improved in patient 3 where extent of mouth opening was increased to
41mm from 35mm).
 12. Treatment of a Patient with TMJ Dysfunction 143

Fig. 12-15c Patient 1: 3.5 months since the start of treatment

Fig. 12-15d: 8 months since the start of treatment

Step 3: MEAW Application (1998.12.9) (fig l 2- l 5c)

Though maxillary crowcling has been eliminatecl in step 2, mesial tipping
of the lower molars was still eviclent. However in patients with TMJ
clysfunction, the mandible anteriorly adapts to avo id loading of the TMJ,
thus flattening the occlusal plane. lt is therefore important to secure a high
vertical climension. When the ocelusal plane is inclined, the mandible aclapts
posteriorly. In this patient, flattening of the maxillary occlusal plane was
necessary to avoid mandibular retrusion. So the MEA W used in the upper
dentition was flat. Moreover, step bend was done in the molar loop to inereasc
the vertical dimcnsion and align the marginal ridge of the adjacent teeth. On
the other hancl, a progressive tip back bend was clone starting from the mesial
loop of the lower l st premolar and a 15 º adjustment was done for activation.
This will ílatten the occlusal plane and align the lower molars. Thc use of
elastics (6 oz, 3/ 16 inch) on the first tip back bencl affects the posterior tip
back bend. To align the marginal ridge, a step bend can be done to the
specific loop.

Step 4: (1999.1.12-4.25)
During this period, a O.O 16 wire without a loop was used because thc
patient was to take a university cxamination and the patient was due for
extraction of the lower left 3 rd molar. However, clicking and a closecl lock
of the lcft TMJ occurred.
Stcp 5: (1999.4.25) (fig 12-15cl)
Duc to a narrow maxillary dental width, the manclible deviates with
lingual tipping of the molars. There are many cases where intercuspation is
144 12. Treatment of a Patient with TMJ Dysfunction

Fig. 12-15e Patient 1: after 9 months of treatment

not obtained. At this point, a 0.7mm round overlay wire was applied above
the upper MEAW as shown in fig 12-1 Sd to expand the maxillary arch. In
this patient, expansion was done while waiting for the healing of the extracted
lower 3 rd molar. After expansion, bucea( movement of the molar teeth was
done after the presence of a space for the alveolar socket in the bucea! area
was determined. As a result, only clicking in the left TMJ was noted.
Step 6 (1999.5.15) (fig 12-15)
In this patient, the vertical dimension in the left side is lower when
compared to the right side. That is because in the left premolar, 1) tipping
is mesiolingual, 2) the needed space for tooth crown growth is insufficient.
Therefore, the same procedure with that of step 3 was done to the upper
MEAW and right lower MEAW.
Left side interventions:
a. To elongate the premolar teeth, a step bend was added to the loop to
induce balance of the marginal ridge and adjacent canine teeth.
b. To eliminate mesial tipping, an additional tip back bend was done.
c. To eliminate lingual tipping, a wire was used in the left molar area to
laterally expand.
d. A bucea) crown torque was done in the surface of the wire inserted in
the bracket slot to induce bucea( tipping of the tooth crown.
The reason for MEAW arch width expansion and additional bucea(
crown torque is because the dental arch was narrow and the intermaxillary
arch will pul) the tooth crown into the bucea! side from the top part of the
cusp, and the lingual vector is activated. A measure is needed to deactivate
this vector.
e. Attach elastics to the mesial loop of tbe 1 st premolar teeth. The flat
MEAW in the upper dentition eliminates mesial tipping of the occlusal
plane, guides the anterior rotation of the mandible, and lessens the load
to the TMJ.
 12. Treatment of a Patient with TMJ Dysfunction 145

Fig. 12-15f Patient 1: after 9.5 months of treatment

Fig. 12-15g Patient 1: after 10.5 months of treatment

Step 7: (1999.6.5) (fig 12-15f)

The occlusal plane flattens and the mandible is adapting anteriorly. The
mandible will rotate to the right side due to the increase of vertical dimension
in the left side. The anterior rotation is associated with the alignment of the
lower midline. Now the lower anterior teeth could push up the lingual side
of the upper anterior teeth. Thjs inte1ference will inevitably result to mandibular
retrusion, and its correct position will not be obtained, and load to the
masticatory muscles and TMJ will not be eliminated. Since this same
phenomenon happened to this patient, MEAW was usecl to expancl the upper
anterior arch. Lingual tipping in the lower anterior teeth was observcd
ancl, expansion should be done on both arches. At this point, the
upper dentition has to be prioritized so the use of elastics was considered
unnecessary.

Step 8: (1999.7.7) (fig 12-l Sg)

Mild clicking was still observcd in the left TMJ so thc following measw-es
were done:
1. lncrease vertical dimension and asce11ain posterior alignment through
intercuspation of I st and 2 nd premolar teeth. To do this, slightly tighten
the tip back bend starting from thc mesial side of thc 2 nd premolar.
146 12. Treatment of a Palien\ with TMJ Dysfunction

4ffe•#)

Fig. 12-15h Patient 1: alter 11 months oí treatment

Fig. 12-15i Patient 1: alter 1 year and 2 months of treatment

2. Use clastics to basten bite raising and improve lower molar intercuspation.
Apply this to the 2 nd loop of the uppcr dentition and 2 nd and 3rd loops of
the lower dentition, thus forming a Lriangle.

3. Whcn the left vertical dimension has increased, the mandiblc will rotate
to the right sidc and tbe lower right canine and premolar tecth will move
to the externa! right side. Therefore set the MEA W for externa! expansion
of thc upper right dentition to avoid interference in the right upper canine
and premolar tccth. Elastics should not be used on the right side to avoid
deterrence to the upper right expansion with the use ofMEAW. To align
thc marginal ridge of the lower left 2 nd premolar and 1 st molar, a step
bend was done in this area.
Step 9. ( 1999. 7.31-2000.1.8) (fig 12-1 Sh, T)
Though the mild click was already eliminated, left laterodeviation of the
mandible was still evident, and treatment was focused on the bite raising of
the left side and left molar intercuspation. Tip back bend on the left MEAW
was removed and elastics (8mm, 5/16) were used in the 2"'\ 3rd , and 4 th loops
of the upper MEA W with the 3rd , 4 1 1\ and 5 th loops of the lower MEAW.
This is effective in aligning the 5 th loop of the upper MEAW and the 5 th loop
of the lower MEAW. This is because thc force of the elastics resists tooth
tipping and aids in the right rotation of the rnandible.
This application !asted until ali the appliances were removed. The
treatment period was long because a stable TMJ and occlusion had to be
attaincd.
 12. Treatment of a Patienl with TMJ Dysfunction 14 7

1999.5.15

Additional step up bend

The same bend but jusi Oatlen

lhe wire

Fig. 12-16 Patient 1: Adjustments to MEAW

Fig. 12-17 Patient 3: During the start of treatment (a patient still using a splint)
148 12. Treatment of a Patient with TMJ Dysfunction

Fig. 12-18 Patient 1: post treatment

4. Treatment Results ( fíg 12-18 to 12-20)

Desired results were obtained as sbown in tbe axiograph ( fig 12-21 to 12
-23), ODI and APDI. Results of the ODI and APDT post treatment are as
follows:
 12. Treatment of a Patienl with TMJ Dysfunction 149

Fig. 12-19 Palien! 2: Post treatment

Patient 1: ODI 86.0° , APDJ 80.0°

Patient 2: ODI 73.0° , APDI 83.0°
Patient 3: ODI 66.5 ° , APDJ 84.0°
The dynamic treatment period !asted for 17 months for patients 1, and 2, and
12 months for patient 2.
150 12. Treatment of a Palien! with TMJ Dysfunction

Fig. 12-20 Patient 3: Post-treatment

 12. Treatment of a Patient with TMJ Dysfunction 151

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Fig. 12-21 Patient 2: Post-treatment

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152 12. Treatment of a Palien! with TMJ Dysfunction

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Fig. 12-23 Patient 3: Post-treatment

Fig. 12-24 Proper occlusal guidance

To obtain a successful occlusal treatment in any type of case, the following

3 points should be established:
1 . Restore the appropriate TMJ functions
2. Proper occlusal guidance (fig 12-24)
3. Stable occlusal support with the absence of interference in the molar
area.
Patients where restoration of a normal TMJ structure due to the changes
in the articular disc and condyle is difficult is att1ibuted to numbers 2 and 3 of
this item.
(Details of tbe case of patient 2 was discussed in quarterly publications
of Dental Treatment Autumn 1999, Daiichi Shika Publications)
154 References

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137, 1983.
2) Bishara SE, Burkey PS: Second molar extraction; A review. Am. J.
Orthod. 89:415-424, 1986.
3) Chang YI, Moon SC: Cephalometric evaluation of the anterior openbite
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malocclusion. Am. J. Orthodont. 86: 277-290, 1984.
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1O) Han UK, Kim YH:Determination of Class f1 ancl Class JJJ skeletal pattems:
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 References 155

17) Kim Yl-1: Treatment of anterior openbite and deep overbite malocclusions
with the multiloop edgewise archwire (MEAW) therapy. In: McNamara
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The University ofMichigan pp175-202, 2000.
18) Kim Y H: Anteroposterior Dysplasia r nclicator: an acljunct to ccphalometric
differential diagnosis. American .Journal or Orthodontics 73: 619-635,
1978.
19) Owen, 111. A.1-l.: Orthodontic/orthopcdic treatment of craniomandibular
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20) Pearson LE: Vertical control in treatment of patients having backward­
rotational growth tendencies. Angle Orthod 48: 132-40, 1978.
21) Petrovic A: Mechanisms and regulation ofmandibular condylar growth.
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22) Protacio C. Sato S: The role of posterior discrepancy on the development
of skelctal Class m malocclusion - lts clinical importance. r nternational
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 12. lndex 157

lndex
A M
Active torquc 16 Mandibular lateral deviation 28
APDI 25 Mandibular lateral deviation, treatmcnt procedurc of 109
Axiograph 140 Mandibular lateral deviation, characteristies of 105
Mandibular lateral dcviation, definition of104
8 Mandibular lateral deviation, lreatmcnt objec1ives of 107
Bite raising 47, 95 MEAW 10
Breaker 1 1 MEAW, adjustment of20
MEAW, basic structure of I O
e MEAW, bcnding of 17
CF 25 MEAW, function of 11
Check clastic 12 MEAW, hcat treatment of 18
Class I open bite. general characteristics of 62 Midline clastic 108
Class I open bite. morphological characteristics 64 MOAW 14, 77
Class I open bite. treatrnent objectives of 65
Class I open bite, 1reatmen1 procedures of 66 N
Class 11 open bite, general charaeteristics of72 Neuromuscular system 130
Class II open bite, morphological charaeleristics 72 o
Class JI open bite, treatment objective of 73 Occlusal intcrferencc 130
Class 11 open bite, treatment procedures of 73 Occlusal plane 26, 3 1
Class II deep overbite, general characteristics 01"88 Occlusal plane, evaluation of 64
Class 11 deep overbite, morpho. characs. of 88 Ocelusal support 47
Class II deep ovcrbitc, treatment objeetives of' 88 ODI 24
Class II deep overbite, treatmem proeedures of 89 Open bite 26
Class II elastic 12
Class II malocclusion 28 p
Class 111 clastie 12 Passive torque 16
Class 111 malocelusion 26 Posterior diserepancy 30, 62, 116
Class 111 reversed ocelusion (high angle), general R
charaetcristics or 30 Repositioning splint 134
Class 111 reversed occlusion (high angle), general
treatment objectives of 3 1 s
Class 111 reversed occlusion (high anglc), Second arder bcnd 17
morphological characteristics of 30 SMOM 14
Class 111 reversed occlusion (high angle), 1rea1ment Spee curve 22
procedures of 31 Splint 134
Class 111 reversed occlusion (low anglc). general Step bcnd 13
Step-up bend 21
characteristics of' 46
Class 111 reversed occlusion (low anglc), general T
t.reatment objectivcs of 47 Third arder bend 16, I 8
Class 111 revcrscd occlusion (low angle). Tip-back activation 20
morphologieal eharacteristics of46 Tip back bend I J
Class 111 rcvcrscd occlusion (low anglc). 1rea1111ent Tip-back deactivation 20
procedurcs of 47 TMJ. closed loek position of130
Crowding, general characteristies of 116 TMJ dysfunction, distinct characs. ofTMJ 130
Crowding, general treatment objectivc of' 117 dysfunction, general characteristics of 130
Crowding, morphological characteristics of 1 16 TMJ dysfunction, general trcatmcnt objcctivc 134
Crowding, trealmcnt procedures of 1 17 TMJ dysfunction, trcatment proccdures of 136
Torquc 18
D
Dcmure framc analysis 26 Triangular clastic 12
Trismus 130
E
Emergency splint 134 V
Vertical dimension 46
F Vertical clastic 12
First arder bcnd 16, 17

H
1-lorizontal loop 11
Horizontal loop, bcnding of 17
 The English translation of this book was
a collaborative project of the MEAW Study
Club of the Philippines and Ms. Cindy Cabading.
fSBN4-924858-J
0-7 C3047