open bite sem [recovered] / orthodontic courses by indian dental academy

INDIAN DENTAL ACADEMY

Leader in continuing dental education www.indiandentalacademy.com

www.indiandentalacademy.com

Open bite

DEFINITIONS

CLASSIFICATIONS

ETIOLOGY

DIAGNOSIS

TREATMENT

FINISHING & RETENTIONwww.indiandentalacademy.com

INTRODUCTION;

Open bite mal occlusion has long held fascination in orthodontics.

It is difficult to treat and relapse tendencies are strong.

- Young H. Kim AO 1987www.indiandentalacademy.com

Normal bite: It is defined as vertical overlap of the incisors. The lower incisal edges in relation to the lingual surface of the upper incisors present at or above the cingulam (normally there is 1-2 mm overbite)

DEFINITIONS;

OPEN BITE;

ANTERIOR OPEN BITE;

POSTERIOR OPEN BITE;

SIMPLE OPEN BITE;

COMPLEX OPEN BITE;

COMPOUND OPEN BITE;

IATROGENIC OPEN BITE;

Open bite as a consequence of orthodontic treatment.

Classificaton;

It used to visualize the problem, diagnosis and treatment plan.

Classified on developmental;

Primary; Mixed; Permanent;

Gum pads Temporary Persistent habits

Depend on site;

Anterior open bite; Posterior open bite;

Depend on position;

Intra arch

The tooth itself is malpositioned within arch creating open bite

- infraversion / inclination abnormally without root.

Inter arch;-No vertical overlap

-abnormality in upper/lower or both

- Ant/post segment

Ankerman profit; vertical relation

Anterior open bite Posterior open bite

dental skeletal dental

Depend on etiology;

Lateral open bite

Compound open bite

Iatrogenic open bite

ETIOLOGY OF OPEN BITE;

WHY OPEN BITE ?

- ENVIRONMENTAL FACTORS

- HABITS

- EPIGENETIC FACTORS

Pre – disposing factors;

Skeletal

Dental

Mandible

Excess eruption of posteriors

Decreased eruption of anteriors

maxilla

Various factors influencing open bite;

a) Disturbances in embryonic development;

1) Muscle dysfunction

2) Hemi mandibular hypertrophy

1) Muscle dysfunction;

- defect in the uterus.- Etiology;

- Pathology

- affect the particular muscle

Bone formation in the origin of muscle

Loss of musculature

Kiliaridis s, mejersjo c

- Ejo 1989

Underdevelopment of face

Muscular dystropy.

&Muscle weakness syndrome.

Muscle tonicity

Open bite www.indiandentalacademy.com

Mandible drops downwards away from maxilla

Anterior open bite due to increased eruption of posterior teeth.

2) Hemi mandibular hypertrophy

Bilateral

- unilateral

b) Genetic influence;

- A strong influence of inheritence on facial features is obvious at a glance.

- mal occlusion produced by inherited characteristic in 2 ways;

What it has to do with open bite ?

Long face pattern;King L, Harris EF, Tolley EA

- AJO 1993

Long face syndrome;

Genetic inheritence

Skeletal influence Dental influence

Open bite

Ackerman, Isacson, Shapiro- AJO 1970

c) Environmental influence;

The open bite can be produced by

1) equilibrium forces

2) Functional forces

1) Equilibrium forces;

It states that object subject to unequal forces will be accelerated and there by move to different space.

Proffit WR; AO 1978

Hence the equilibrium has to be maintained.

Altered equilibrium due to increased tonque pressure.

a) Juvenile equilibrium;

The teeth that are in function parallels the rate of vertical growth of mandibular ramus

The rate of eruption is controlled by forces opposing direction, not those promoting it.

2) Functional forces;

Biting force and eruption

Downward growth of mandible

Open bite

Masticatory muscle gains strength at puberty.www.indiandentalacademy.com

HABITSDefinition;

It is the tendency towards an act of repeated performance relatively fixed or consistent and ease to perform by an individual.

We are just beginning to realize how common and varied the vicious habits of lip and tongue, and how power full and persist to overcome

- Angle.www.indiandentalacademy.com

Earliest writings;

- causes of irregularities through habits that pushes teeth forward.

- Lefoulon 1839

- balance of force to retain teeth in position.- Desirabode 1843

- “lateral pressure theory”- Bridgeman 1859

- “Sim Wallace theory”- Bennett

Classify;

1) useful

harmful

Tongue thrusting

When persists

2) Pressure Sucking ( lip, thumb)

Non pressure Mouth breathing

Thumb sucking;

Definition;It is defined as the placement of thumb or one/more fingers in varying depths into the mouth.

Klein AJO 1979

Physiological condition;

-It is considered normal till 3 – 4 yrs.

- It is an non nutritive sucking habit

- Recent studies indicate that thumb sucking is practised even during the intra – uterine life.

Pathological condition;&

Clinical features

It occurs through altered equilibrium not just pressure through fingers.

Open bitewww.indiandentalacademy.com

Sucking habits;

Theories;

1) Freudan theory;

1- 3 years – oral and anal phase.

2) Oral drive theory of sears and wise; 1950

Prolonged habit leads to thumbsucking.

3) Benjamins theory;

Thumbsucking develops in infants due to the rooting reflex/placing reflex.

4) Psychological aspects;

Children develop this habit as a feeling of insecurity, when they are deprived of love, care and affection.

Phases of thumbsucking;

Phase – 1;- First three years of life.

- sub clinically significant.

Phase - 2;- 3 – 6 yrs of life.

- clinically significant.

Phase - 3;

- beyond 5 – yrs.

- intractable sucking.

- Its an alert to an dentist.

DIAGNOSIS;

- Check for childs emotional status.

- feeding habits

- Intra – oral examination;

- incissors

- open bite

- Clean nailswww.indiandentalacademy.com

TREATMENT;

1) Psychological approach;

Beta hypothesis theory by Dunlop Consious purposeful repeatation.

2) Mechanical aids;

Basically reminders

3) Chemical approach;www.indiandentalacademy.com

TONGUE THRUSTING

DEFINITION;

It is defined as the forward movement of the tongue tip between the teeth to meet the lower lip in deglutition and in sounds of speech so that the tongue becomes interdental.

Tulley AJO 1969

Classification;

According to moyers;

Simple complex

- To establish lip seal

- Anterior open bite

- abnormal mentalis

- Contraction of circum – oral muscles.

- diffuse open bite.

- poor occlusion.

Simple tongue thrust.

According to James s. Braner and holt

Type 1 - Non deforming tongue thrust.

Type 2 – Deforming anterior tongue thrust.

Type 3 – Deforming lateral tongue thrust

Type 4 – Deforming ant; & lat; tongue thrust

Etiology ;

According to fletcher;

1) Genetic factors;Neuromuscular variations in oro facial region.

2) Learned behaviour;

Prolonged action & gum tenderness.

3) maturational;Age – swallow pattern.

4) Mechanical restrictions;- macroglossia.- arch constricted.

5) Neurological disturbances;

- motor disability

6) Psychogenic factor;

- discontinuation of other habits.

DIAGNOSIS;

- Size of the tongue

- posture of the tongue

- Function of the tongue

- Structure of the tongue

1) Size of the tongue;

Why asses the variations ?

Variations in tongue size ,

Reaches its adult size by the age of 8 years.

True macroglossia Pseudo macroglossia

Macroglossia;

The whole oral cavity is filled with the tongue mass, presence of indentations on the periphery.

Etiological factors;

congenital Acquired

- muscular hypertrophy

- glandular hyperplasia

- lymphangioma

- Downs syndrome

- Acromegaly

- myxedema

- amyloidosis

- tertiary syphylisCyst/tumors involving tongue.

Pseudo macroglossia;Forward posture of tongue

- Low palatal vault

Etiological factors;

- habitual posturing of the tongue.

- hypertropied tonsils and adenoid tissue.

- arch deficiency in all dimensions.

- severe mandibular deficiency.

- cyts/tumors that displaces the tongue

Clinical assessment;

1) macroglossia.

2) microglossia.

- Tulley AJO 1969.

MACROGLOSSIA;Signs and symptoms.

- Open bite (ant/post)

- Diastema (mx/md)- Accentuated curve of spee in maxillary arch

- Reverse curve of spee in mandibular arch.

- difficulty in swallowing

- mandibular prognathism.

- Larry M. WOLFORD, AJO 1996www.indiandentalacademy.com

Cephalometric & Radiographic assessment.

- over angulation of upper and lower anteriors.

- Dispropotionately excessive mandibular growth.

- increased gonial angle.

- increased occlusal and mandibular plane angle.

- David A. AJO 1996.www.indiandentalacademy.com

Cephalometric evaluation;

Lateral ceph with sufficient exposure to evaluate the soft tissue.

Reference lines;

I , V , M , O .

Criteria for evaluation;

- The greatest possible area of tongue should be above reference line.

- The base line is independent of skeletal structures.

- The tongue should not change with position of the mandible.

Menstrual data through template;

Template evaluation;

2) Posture of tongue;

The posture is evaluated for various open bite tendencies.

It can be flat/arched, protracted/retracted, narrow/long.

ANTERIOR POSTURE;

LATERAL POSTURE;

STRUCTURE OF TONGUE;

In infancy the extrinsic suspensory muscles attach the tongue to various osseous structures largely resposible for gross movements in horrizontal plane.

- It has the property of elasticity & contractility ----- tongue thrust.

Acts through all / none law.www.indiandentalacademy.com

FUNCTION OF TONGUE;

DEGLUTATION

According to moyers;

Depend on the characteristic;

1) Infantile swallow ---- 12 - 18 mnths.

2) Mature swallow ----2 - 4 yrs

INFANTILE SWALLOW;

Central furrow & gum pads.

MATURE SWALLLOW;

SHALLOW TONGUE;

Do tongue thrust cause open bite ?

Pressure on teeth by swallow - 1 secs

Individual swallow – 800/dy - & few in sleep.

Total 1000/dy

Treatment;

- habit breaking appliance.

- muscle exercise through elastics.

Defect in posture;

Defect in size;

- Glossectomy..

- surgical correction.www.indiandentalacademy.com

Glossectomy;

Pseudo macroglossia True macroglossia

Procedures;- Midline wedge resection with base in the anterior tongue.

- Midline elliptical excision.

- Marginal excision.

- “Keyhole” or combined technique.www.indiandentalacademy.com

Keyhole technique;

Midline elliptical incision

Anterior wedge resection

- AJO -96www.indiandentalacademy.com

SEQUENCE OF PROCEDURES;

STAGE I : GLOSSECTOMY

ORTHOGNATHIC SURGERY

- Psychological approach.

- No IMF

- No air way obstruction.

STAGE 2 :ORTHOGNATHIC SURGERY.

GLOSSECTOMY

- If occlusal stability is a concern.

STAGE 3 :COMBINED

- Both the procedures combined together at a same surgical stage.

MOUTH BREATHING;

Definition;

It is defined as the the pattern of breathing totally / partially through oral cavity due to anatomical / functional variations.

Classify;

a) Obstructive.

b) Habitual.

c) Anatomical.

ETIOLOGY;

Mouth breathing primarily has effect on

- posture of jaws.

- Position of tongue

- posture of head.

Altered equilibrium

Tooth positionGrowth

Mouth breathing

Mandible lowered Tilted head lowered tongue

LFH Change of 5 degree cranio vertebral angle

Mandible rotated

Open bite Obstruction relievedwww.indiandentalacademy.com

Mandible lowered;

Ant; open bite.

Change in cranio vertebral angle;

Physiological variations;

All humans are some mouth breathers.

Average breathing air flow ------ 20 – 25/L/mnt

Partial mouth breathing --------- 40 – 45 L/mnt

Transitional stage ----------- 80 -

Mintz S, Shepard RJ.

Pathological variations;

It becomes a habit when the breathing persists even when the obstruction is removed.

Opposing principles;

Total nasal obstruction

Increased LFH

Battgel J BJO - 1996www.indiandentalacademy.com

Clinical features;

Malocclusion associated with the mouth breathing.

Long face syndrome/classical adenoid facies;

DIAGNOSIS;

- Nasal obstruction.

- Adenoids.

- hyoid triangle analysis.

NASAL OBSTRUCTION

- AJO 1998

Choanal atresia & treacher collins syndrome in infants ----- tracheostomy

How much obstruction has to occur for effect on growth ?

- It depends on location of the obstruction.

- nasal function

Methods in assessing the nasal obstruction.

- Cross sectional area.

- Peak nasal air flow

- Nasal resistance.

- Respiratory mode (oral/nasal air flow ratio)

-AJO 1998

Rhinomanometric studies;

Study of air flow with flow meters, and pressure gauges.

Cleft lip and palate patients increase tendency of mouth breathing ?

- AJO 1998

Posterior nasal obstruction by pharyngeal flaps.

ADENOIDS;

Enlargement of adenoids relation to mouth breathing. www.indiandentalacademy.com

Hyoid bone position;- AJO 1984.

In 1981 Bibby and Preston.

Hyoid bone is not fixed to a space by any bony articulations.

Hyoid bone is determined by muscles and ligaments attached to structures above and below it.

- It is influenced by the tongue posture and mandibular position.

it signifies

TREATMENT;

- Removal of the cause.

- Interception of the habit.

- Rapid maxillary expansion.

- orthodontic + surgery

Nasal obstruction; - AJO 1998

- vertically repositioning of maxilla predictably reduce the nasal resistance.

Not nasal air flow

The highest correlation between these parameters are 0.24 %---- 0.74%

Breathing mode is behavioral determined than structurally determination

Adenoids;

- Adenoidectomy.- AJO -94

Ten yr old

No change in breathing pattern;

Rapid maxillary expansion;

For maxillary deficiency

Increase nasal air flow

Reduction in nasal resistance was frequently measured.

Rhinometric studies;No change in breathing mode.

DIAGNOSIS;

Early detection of symptoms is recommended, so that treatment can be provided in time whatever the cause may be.

- Subtenly, AO 1954

- Ricketts, AO 1968

How to decide for open bite ?

It is the ability to recognize vertical growth in routine treatment mechanics.

Commonly clinicians evaluate

Mandibular plane for open bite.

DIAGNOSIS;

- SKELETAL OPEN BITE

- DENTAL OPEN BITE.

- ANTERIOR OPEN BITE.

- POSTERIOR OPEN BITE.

Skeletal open bite;

Posterior open bite;

- Failure of posterior tooth to erupt fully in occlusion producing lateral open bite.

Mechanical interference.

Disturbance of eruption mechanism.

GROWTH PATTERN ;

Its purpose was to assess skeletal factors associated with development of vertical facial disproportions.

Horrizontal facial planes tends to be steeper and more divergent with lower facial height.

Steeper planes;

1) Mandibular plane;Favoured --- Nanda.Not favoured --- Skiller/Bjork.

2) Gonial angle;

3) Palatal plane;

4) Occlusal plane;

5) Cranial base;Larger cranial base and corresponding positional deviations of mandible associated with open bite.

Enlow -

Posterior dips

Steeper

Angle. Bjork –no change

CEPHALOMETRIC EVALUATION;There are six specific cephalometric angular measurements for identifying the vertical dysplasia.

1) SN --- (ANS – PNS);

2) SN --- MANDIBULAR PLANE;

3) GONIAL ANGLE;

Resultant uprighting of the ramus.www.indiandentalacademy.com

4) PALATOMANDIBULAR ANGLE;

Bimler used this angle for describing facial types. www.indiandentalacademy.com

5) SN --- OCCLUSAL PLANE;

6) CRANIAL BASE ANGLE;

LINEAR PARAMETERS;

GROUP 1;PFH/AFH ----- Sum of angle

-Jarabak

GROUP 2;UFH/LFH

Average --- 0.810Open bite ---0.686

OBJECTIVE OF OPEN BITE;

- AO 1998

1) Creating sufficient overlap with molar relation;

Incisal overlap0.5 --- 4.0 mm

Average – 2.8mm

- Kim 1974

Central incisor relative to lip line;

The dentition is placed in proper three dimensional perspective to ensure stability.

- Antero – posterior aspect.

- Vertical aspect.

- Transverse aspect.

Axial inclination; ------ open bite

Axial inclination ----- deep bite.

Eliminate Blocks:

In order to eliminate blocks the molar are distally tipped.

Extraction ( 1/2/3) molar Non extraction

TREATMENT;

It depends on etiology and location

- Dento alveolar open bite.

- skeletal open bite.

TIMING OF TREATMENT;

Not too early not too latewww.indiandentalacademy.com

TREATMENT DURING PRIMARY DENTITION;

Dental open bite;

- Habits ---- after 3 yrs.

Screening therapy.

Skeletal open bite;

- Habit control secondary.

- Growth modification not indicatedwww.indiandentalacademy.com

TREATMENT ON EARLY MIXED DENTITION;

Dento alveolar open bite;

- Screening therapy

- Behavior modification.

Screening appliances;

Vestibular screen ------------ digit sucking

Vestibular screen ------ Its modifications.

Tongue crib ------ tongue thrust.

Posterior tongue crib -------- lateral tongue thrust

Activator ----------- Tongue thrust and finger sucking ( work as a interceptor).

BEHAVIOR MODIFICATION;

COUNSELLING;

A straight forward discussion with the child during eruption of permanent incisors.

REWARD;

For not engaging in the habit.

REMINDER;

For the child who wants to quit.

QUAD HELIX;

Maxillary lingual arch with crib;

OPEN BITE IN LATE MIXED DENTITION;

Skeletal parameters;

- Major diagnostic criteria is either,

“ KEY “

maxilla mandible or both

Palatal plane Ramus

GROWTH MODIFICATION;

It varies depends on horrizontal/vertical growth;

High pull head gear to molars;

High pull head gear with maxillary splint;

Bite blocks with functional appliance;

Head gear with functional appliance and bite blocks;

Functional appliance;

Head gear with activator

Bite registration;

TREATMENT IN ADULT;

Correction of vertical relation

maxilla mandible

Vertical excess

anterior posterior

excesswww.indiandentalacademy.com

Maxillary excess;

Le Forte I

Reduce the nasal septum

Anterior open bite;

Anterior segment is moved more than posteriorwww.indiandentalacademy.com

Posterior open bite;

Segmental osteotomywww.indiandentalacademy.com

Mandibular surgery;

Surgery in the ramal part is done only to the secondary aspect to the maxillary osteotomy for the auto rotation of the mandible.

Advancement genioplasty

GENIOPLASTY;

Long face pts has excess eruption of lower anterior which is flared and unstable

Poor chin balance

Bony cut is given upward and forward angulated to advance it. www.indiandentalacademy.com

PRE – SURGICAL ORTHODONTICS;

allignment

levelling

Antero posterior incisor position

LEVELLING;

MAY OR MAY NOT BE DONE;- Depend on facial type.

Stabilizing arch wire;

18 slot ------- 17 x 25

22 slot ------ 21 x 25

POST SURGICAL ORTHODONTICS;

Until stabilizing arch wire is removed the teeth are held in tight position.

- four weeks Light vertical elastics

RETENTION

Removable Appliance with high pull head gear www.indiandentalacademy.com

Appliance with the bite block.

Force Amplified Retention1997 JCO Sheridan

Low profile lingual caplin hooks

Canine to canine intra oral elastics.www.indiandentalacademy.com

Conclusion;

THANK U

open bite sem [recovered] / orthodontic courses by indian dental academy

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