Upload File

a funcional approach to treatment of skeletal

15
A functional approach to treatment of skeletal open bite Rolf Frllnkel and Christine Frlnkel Zwichau, German Democratic Republic In general orthopedics the relationship between postural behavior and skeletal deformities has long been recognized. The primary therapeutic problem in functional orthopedics is to overcome functional disorders. In this article the applicability of this functional concept to orofacial orthopedics is discussed on the basis of a longitudinal study of skeletal open bite. A comparison of a series of lateral cephalograms of thirty patients with skeletal open bite who were treated with functional regulators developed by Frankel and those of eleven untreated open bite cases suggests that some dentofacial deformities in the skeletal open bite cases can be corrected to the average norms. In addition, as a result of overcoming the poor postural pattern of the orofacial musculature and re-establishment of a competent lip seal, a considerable change in the soft-tissue profile occurred. Key words: Skeletal open bite, Frankel method, dentofacial orthopedics, abnormal posture S keletal open bite is produced by a combi- nation of dental and skeletal irregularities, the latter of which is the more dominant. The facial morphology of this dysplasia is characterized primarily by striking vertical disproportions caused by abnormal ratios be- tween anterior and posterior facial heights (AFH/PFH) and between upper and lower anterior facial heights (UFH/LFH). A short ramus and an increased gonial angle also contribute to the hyperdivergent skeletal pat- tern. As there is normal biologic variation, so each dentofacial malformation has its own characteristics and uniqueness. Therefore, the type of skeletal open bite must be defined by various additional parameters. The skeletal pattern of such a severe dysplasia as skeletal open bite is difficult to change by means of conventional orthodontic appliances. Some clinicians have warned against any orthodontic treatment and, instead, recommend corrective measures such as surgi- cal and prosthetic intervention. It is not surprising, therefore, that the hyperdivergent pattern of this dys- plasia is assumed to be primarily the expression of in- herited vertical proportions. This view is substantiated by the results of Hunter’s’ investigations which support the hypothesis that vertical dimensions of the craniofa- cial skeleton are more genetically controlled than are anteroposterior dimensions. However, as claimed by Dullemeijer,’ all structures are genetically and en- vironmentally influenced. In view of the character of This study is part of an investigation entltled “Functional Aspects of Skeletal Open Bite” submitted by Christine Frlnkel in fulfillment of the requirements for the doctoral degree at the University of Jena, German Democratic Republic. 54 biology, it is impossible to study form without also studying function, and vice versa. There is a specific order to the influences of each structure. As the skeletal unit is the last unit to exert its influence, its shape is completely subordinate to the other elements or to the functional matrices in Moss’ terminology. Poulton’j holds that the recurrence of some anterior open bite problems is the result of muscle imbalance creating a dentofacial problem. The teeth and jaws may be brought into a position of excellent anatomic function, but if the muscles which work together to close the jaws remain weak and flaccid, the open bite may reappear. Corrective therapy in these situations must include work to build up the strength and function of the weak muscles if long-term stability is to be achieved. The purpose of this article is to test the hypothesis that a functional approach will provide a better under- standing of how local environmental factors contribute to the development of the hyperdivergent pattern in the facial skeleton. On the basis of our clinical experience, we will attempt to show that the principles of general orthopedics can be successfully applied to the treatment of skeletal open bite. We believe that this type of treat- ment allows a more optimistic attitude to be taken to- ward the long-term stability of skeletal open bite cases treated by dentofacial orthopedics than by other treat- ment methods. DEVELOPMENT OF A FUNCTIONAL STRATEGY FOR TREATMENT OF SKELETAL OPEN BITE It was Edward Angle,4 the founder of modem ortho- dontics. who emphasized the morphogenetic relevance

Upload: renan-mota

Post on 18-Aug-2015

215 views

Category:

Documents


0 download

Report

Tags:

DESCRIPTION

A Funcional Approach to Treatment of Skeletal

TRANSCRIPT

Afunctionalapproachtotreatment ofskeletalopenbite RolfFrllnkelandChristineFrlnkel Zwichau,GermanDemocraticRepublic Ingeneralorthopedicstherelationshipbetweenposturalbehaviorandskeletaldeformitieshaslongbeen recognized.Theprimarytherapeuticprobleminfunctionalorthopedicsistoovercomefunctionaldisorders.Inthis articletheapplicabilityofthisfunctionalconcepttoorofacialorthopedicsisdiscussedonthebasisofa longitudinalstudyofskeletalopenbite.Acomparisonofaseriesoflateralcephalogramsofthirtypatientswith skeletalopenbitewhoweretreatedwithfunctionalregulatorsdevelopedbyFrankelandthoseofeleven untreatedopenbitecasessuggeststhatsomedentofacialdeformitiesintheskeletalopenbitecasescanbe correctedtotheaveragenorms.Inaddition,asaresultofovercomingthepoorposturalpatternoftheorofacial musculatureandre-establishmentofacompetentlipseal,aconsiderablechangeinthesoft-tissueprofile occurred. Keywords:Skeletal open bite,Frankel method,dentofacial orthopedics, abnormal posture Skeletalopenbiteisproducedbya combi- nationofdentalandskeletalirregularities,thelatterof whichis themoredominant.Thefacialmorphologyof thisdysplasiaischaracterizedprimarilybystriking verticaldisproportionscausedbyabnormalratiosbe- tweenanteriorandposteriorfacialheights(AFH/PFH) andbetweenupperandloweranteriorfacialheights (UFH/LFH).Ashortramusandanincreasedgonial anglealso contributeto thehyperdivergentskeletalpat- tern.Asthereisnormalbiologicvariation,soeach dentofacialmalformationhasitsowncharacteristics anduniqueness.Therefore,thetypeofskeletalopen bitemustbedefinedbyvariousadditionalparameters. Theskeletalpatternofsuchaseveredysplasiaas skeletalopenbiteisdifficulttochangebymeansof conventionalorthodonticappliances.Someclinicians havewarnedagainstanyorthodontictreatmentand, instead,recommendcorrectivemeasuressuch as surgi- calandprostheticintervention.Itisnotsurprising, therefore,thatthehyperdivergentpatternofthisdys- plasiais assumedtobeprimarilytheexpressionofin- heritedverticalproportions.Thisviewis substantiated bytheresultsofHuntersinvestigationswhichsupport thehypothesisthatverticaldimensionsofthecraniofa- cialskeletonaremoregeneticallycontrolledthanare anteroposteriordimensions.However,asclaimedby Dullemeijer,allstructuresaregeneticallyanden- vironmentallyinfluenced.Inviewofthecharacterof ThisstudyispartofaninvestigationentltledFunctionalAspectsofSkeletal OpenBitesubmittedbyChristineFrlnkelinfulfillmentoftherequirements forthedoctoraldegreeattheUniversityofJena,GermanDemocraticRepublic. 54 biology,itisimpossibletostudyformwithoutalso studyingfunction,andviceversa.Thereisaspecific ordertothe influencesofeach structure.As theskeletal unitisthelastunittoexertitsinfluence,itsshapeis completelysubordinatetotheotherelementsortothe functionalmatricesinMossterminology.Poultonj holdsthattherecurrenceofsomeanterioropenbite problemsis theresultofmuscleimbalancecreatinga dentofacialproblem.Theteethandjawsmaybe broughtintoa positionofexcellentanatomicfunction, butifthemuscles whichworktogetherto close the jaws remainweakandflaccid,theopenbitemayreappear. Correctivetherapyinthesesituationsmustinclude worktobuildupthestrengthandfunctionoftheweak musclesiflong-termstabilityis tobeachieved. Thepurposeofthisarticleis totestthehypothesis thatafunctionalapproachwillprovidea betterunder- standingofhowlocalenvironmentalfactorscontribute tothedevelopmentofthehyperdivergentpatterninthe facialskeleton.Onthe basis ofourclinicalexperience, wewillattempttoshowthattheprinciplesofgeneral orthopedicscan be successfullyappliedto thetreatment ofskeletalopenbite.Webelievethatthistypeoftreat- mentallowsa moreoptimisticattitudetobetakento- wardthelong-termstabilityofskeletalopenbitecases treatedbydentofacialorthopedicsthanbyothertreat- mentmethods. DEVELOPMENTOFAFUNCTIONALSTRATEGY FORTREATMENTOFSKELETALOPENBITE Itwas EdwardAngle,4thefounderofmodemortho- dontics.whoemphasizedthemorphogeneticrelevance Volume84 NumberI Functionalapproachtotreatmentofskeletalopenbite55 ofthesoft-tissueenvironmenttothedentition.Angles beliefthatrelapseis causedbyforcesontheteethre- sultingfromanimpropersoft-tissueenvironmentap- peared to bea rationalconclusionfroma biomechanical pointofview.AfterWorldWarII,interestintherole ofthesofttissuesintheetiologyofmalocclusionin- creased enormously.Withregardto thedevelopmentof anopenbite,particularemphasiswasplacedonab- normalpatternsoftonguebehavior.Deviantpatternsof swallowingortonguethrustwereconsideredtobe a majorfactorinopeningthebite.Clinically,theadvo- catesofmyofunctionaltherapyrecommendedvari- ous kindsofexercises toovercometheabnormalbehav- iorpatternofthetongueincombinationwithspeech therapy.- Analternativetherapeuticapproachto thetreatment ofopenbiteatthattimewastheuseofapalatalcrib attachedtoeitherfixedorremovableappliances.In the1950sweusedsuchtongue-habitappliances, andtheywerequitesuccessfulina highpercentageof cases in whichan anterioropenbitehad persistedtothe ageof6 or7years.However,somepatientsexhibited relapseaftertreatment.Wethoughtthatthedurationof treatmentwithtongue-habitappliancesmighthave beentooshorttore-educatetonguebehaviorinthese cases.However,relapseoccurredevenafterrenewed treatmentwitha palatalcribappliance. Inanattempttofinda plausiblereasonforthere- lapseinthesepatients,weexaminedthemandfound thattheyallshoweda markeddiscrepancybetweenlip lengthandlowerfaceheight.Thisfindingcorre- spondedtoBallardssuggestionthat,inanevaluation ofhabitbehaviorsandtheirclinicalrelevance,more attentionshouldbe paidtothesize andshape ofthesoft tissues.Hestatedthateachcasemustbejudgedin relationtodisproportionsinthefacialskeletonand, fromhisclinicalobservations,concludedthattongue thrustas themajorcause ofopen bitehad beenoverem- phasized.Hearguedthatthefaultyinterdentalposture ofthetongueappearedtobeacompensatoryoradap- tivebehaviorwhichestablishedananteriororalseal whenthelipswereincapableofdoingso. Itwasduringthissame periodthatwewerework- ingonthedevelopmentofa functionalorthopedicap- proachusingskeletalvestibularshields.-Incontrast toastructuralconcept,webelievedthatlipincompe- tencewasnota consequenceofa discrepancybetween skeletalandsoft-tissuegrowth.Therefore,wehypoth- esizedthatthedeficiencyofanoralseal mightbe due, at leastin part,toa poorposturalbehaviorofthefacial musculature(particularlyintheliparea),evenincases ofskeletaldiscrepanciesassociatedwithasteepman- dibularplane.Thus,wedecidedtoinstitutefunctional therapywithvestibularshieldsandlip-sealtrainingfor anterioropen-biterelapsepatients.Afterarelatively shorttreatmenttime,weobservedthata normalover- bitewasestablishedand remainedstable,providedthat a competentanteriororalseal wasalsoestablished. Theclinicalexperiencegainedinthetreatmentof open-biterelapsepatientswasfundamentaltothe furtherdevelopmentoffunctionalorofacialorthope- dics.Theclinicalobservationthatanopenbitecan be closedwithoutusinganydevicewhichinterfereswith tonguemovementortongueposturesuggeststhat tonguethrustalonemaynotbetheprimarycauseof thatmalocclusionandthattheremaybeafunctional relationshipbetweentheposturalbehaviorofthe tongueandlips.Theimpactofposturalbehaviorpat- terns has beensubstantiatedby themorerecentworkof Proffitwhichdealswiththeorofacialmuscularenvi- ronmentanditsinfluenceonthemorphologyofthe dentition.Proffitsuggeststhatrapid-movementfunc- tions,suchasswallowing,chewing,andspeaking, havelittleimpactonthemorphologyofthedentition, whiletheimpactofposturalalterationsleadingto changesinlipandtonguerestingpressure andposture issignificant. Sincethelate1800sgeneralorthopedistshave learnedagreatdealabouttheform/functionrelation- shipinskeletalmorphogenesis.Inthelast50yearsan evolutionhasoccurredinthedevelopmentofafunc- tionalconcept.Clinicalevidenceaccumulatedduring thislongperiodsupportstheideathat,as faras func- tionalfactorsare concerned,aberrantposturalbehavior doesplayaprimaryroleintheetiologyofskeletal deformities.Biostatisticalstudiessuggestthatapoor posturalperformanceaffectingrelatedmusclesplaysa partinthedevelopmentofskeletalmalformations.la In generalorthopedics,therefore,functionaltherapyis commonplace,andtheprimarytherapeuticproblemin functionalorthopedicsis toovercomea faultypostural performancepattern.Thus,itseems logicaltoexamine whetheraberrantposturalbehavioroftheorofacial musclesplaysacausativeroleinthedevelopmentof dentofacialdeformities.Therefore,indevelopinga functionalapproachtoorofacialorthopedics,theortho- dontistshouldlooknotonlytohisowntrainingas a specialistofdentistrybuttothefieldofgeneralortho- pedicsas well.Forexample,incontrasttothetrunk andlimbs,thetwenty-twobonesoftheskullare almost exclusivelyofmembranousorigin.Theintermediate connectivetissues haveanadaptiveandcompensatory growthcapacitywhichishighlysusceptibletobio- mechanicalinfluencesandhencetofunctionalforces. Therefore,thereis reasontobelievethattreatmentde- signedtoovercomea poorposturalperformancewould beeffectiveintheorofacialcomplex. Therearecertainlydifficultiesindevelopinga TableI.Averagechangesbetweentheinitialandfinalcephalometricmeasurementsinthenontreatedgroup N(n=11) andthetreatedgroupT(n=30)anda comparisonofthedifferencesbyanalysisofvariance andbythepairedttestandFisher-Behrenstest 7 ,ziLgfor------- Angles(degrees)NTD$erencesFvalueIper&Signijicuncx~ 1.SN-MP+2.32-5.471.192.923.54** 2.SN-PP-0.36+2.302.662.095.24*** 3.PP-MP+2.68-1.4210.101.543.95*** 4.Go+0.23-6.376.601.355.54*** 5.z+2.68-5.128.403.707-.-4** 6.AFH-PFHquotient(Jarabak)-0.32+5.405.722.726.96*** 7.RatioUFH-LFH(Nahoum)-0.018+0.0530.071I.094.67*** Significance: **p


Drug Class Review on Skeletal Muscle Relaxants · Skeletal muscle relaxants have been approved for either treatment of spasticity or for treatment of musculoskeletal conditions. Drugs

Versatility of Growth Modulation Appliances in Treatment ... 4.pdfVersatility of Growth Modulation Appliances in Treatment of Skeletal Class II Malocclusions Journal of Contemporary

Compensatory orthodontic treatment of skeletal Class III ... · Introduction: This case report describes the orthodontic treatment of an adult patient with skeletal Class III maloc-clusion

Class III Treatment with Skeletal and Dental Anchorage: A ...downloads.hindawi.com/journals/bmri/2018/7946019.pdf · ReviewArticle Class III Treatment with Skeletal and Dental Anchorage:

Surgical Orthodontic Treatment of Hyperdivergent Skeletal Class III Malocclusion … · 2019. 9. 27. · Surgical Orthodontic Treatment of Hyperdivergent Skeletal Class III Malocclusion

Camouflage Treatment of Skeletal Class III Malocclusion

treatment of Class III with skeletal anchorage by miniplates

Orthodontic Camouflage Treatment of Class II Malocclusion ... · PDF fileadults with severe skeletal malocclusion involving deficient ... moderate skeletal discrepancies, dental compensation

The effect of treatment of skeletal open bite with two ...doc.rero.ch/record/296791/files/14-6-489.pdf · for the treatment of a skeletal anterior open bite. This type of treatment

Heat Treatment Inhibits Skeletal Muscle Atrophy of ... · myopathy develop muscle weakness of proximal skeletal muscles that are severe enough to interfere with the activities of

Skeletal System Characteristics and Treatment of Common Skeletal Disorders

Surgical-Orthodontic Treatment of Two Skeletal Class III Patients

Skeletal and dental effects of Class III orthopaedic treatment: a systematic review ... · 2017-12-18 · Review Skeletal and dental effects of Class III orthopaedic treatment: a

TREATMENT OF SKELETAL UNILATERAL CROSSBITE WITH …

Surgical fracture treatment, fixation types - gordiosz-shop.hugordiosz-shop.hu/doclib/465/externalfixation.pdf · Surgical fracture treatment, fixation types III. External Skeletal

Surgical treatment of dental and skeletal Class III ... · 13 143 13 1811439 Surgical treatment of dental and skeletal Class III malocclusion » The author reports no commercial,

11 Treatment of Metastatic Bone Disease - Sarcoma.orgsarcoma.org/publications/mcs/ch11.pdf · 11 Treatment of Metastatic Bone Disease Martin Malawer OVERVIEW Few skeletal metastases

Camouflage treatment in adult skeletal Class III cases … … · tients with “borderline” skeletal Class III malocclusion were included in this study. The ages of the patients

NON-SURGICAL TREATMENT OF SKELETAL CLASS II HIGH …fac.ksu.edu.sa/sites/default/files/non-surgical... · NON-SURGICAL TREATMENT OF SKELETAL CLASS II HIGH ANGLE MALOCCLUSION – A

Insuficiencia Mitral Funcional: tratamiento · Insuficiencia Mitral Funcional: tratamiento quirúrgico o endovascular? Functional MR : Percutaneous or Surgical treatment ? Patrice

Assessment of the Skeletal Pattern and Its Relevance in Treatment Planning

Non‑extraction treatment of skeletal class II malocclusion

GROWTH MODIFICATION TREATMENT OF ... - …media.unpad.ac.id/files/publikasi/2017/rpm_20170208205950_7330.pdf · GROWTH MODIFICATION TREATMENT OF SKELETAL CLASS II MALOCCLUSION

Surgical Orthodontic treatment of Skeletal Class II … REPORT5.pdf · Journal of Scientific Dentistry, 3(1), 2013 CASE REPORT Surgical Orthodontic treatment of Skeletal Class II

Nonsurgical Treatment of a Case With Skeletal …...Nonsurgical Treatment of a Case With Skeletal Class III Malocclusion and Total Open – Bite: A Case Report Nihal HAMAMCI1*, Emin

COMPARISON OF GLYCEROL TREATMENT IN FROG SKELETAL …

TREATMENT OF SKELETAL CLASS II DIVISION II …

COMPLEX NON – SKELETAL PROBLEMS IN PREADOLESCENT CHILDREN: PREVENTIVE & INTERCEPTIVE TREATMENT (Orthodontics)

Treatment protocol for skeletal Class III malocclusion in ... · Skeletal class III malocclusion is characterized by mandibular prognathism, maxillary deficiency or some combination

Diagnosis and conservative treatment of skeletal

Skeletal muscle laminin and MDC1A: pathogenesis and ... · Skeletal muscle laminin and MDC1A: pathogenesis and treatment strategies ... the myotome during ... Skeletal muscle laminin

Treatment of Breast Cancer Lytic Skeletal Metastasis Using a

COMPARISON OF GLYCEROL TREATMENT IN FROG SKELETAL MUSCLE AND

TREATMENT OF SKELETAL CLASS II DIVISION II MALOCCLUSION

Surgical Orthodontic Treatment for a Skeletal Class III ... · finishing and detailing the occlusion. Total ... functional disability although ... Surgical Orthodontic Treatment for