open bite and deep bite

Good AfternoonDR. KAPIL SAROHA

BDS, MDSORTHODONTICS AND DENTOFACIAL

ORTHOPAEDICS

www.drdentiste.comMonday, May 1, 2023 1

Overbite

Deep bite Open bite


CONTENTS Introduction Definition and Classification of open bite Development of normal over bite Etiology Epigenetic / hereditary factors Skeletal factors Environmental factors Thumb/finger sucking Mouth breathing Tongue dysfunction Role of Musculature Characteristics of Anterior open bite (Skeletal)

Anterior open bite


Treatment of open bite Early mixed dentition period Habit reminders Rx Tongue thrust swallow Rx Lip sucking Oral screen Mixed / early permanent dentition period Myofunctional appliances Activatior and its modifications Bionator Frankel regulator (FR IV) Twin block Orthopaedic appliance High Pull Head Gear Vertical Chincap


Molar intrusion Bite blocks Active Vertical Corrector (AVC) MAD IV (Magnetic Activator Device) Molar Intruder (MI) appliance Rapid molar intruder (RMI)Late permanent dentition Extractions Fixed appliance therapy MEAW (Multiloop Edgewise Archwire) Microscrew implant Titanium Miniplates Glossectomies Orthognathic surgery Conclusion


Esthetics primarily responsible for orthodontics

Appearance the most important factor for treatment

Physically attractive people achieve higher levels of success in life than unattractive people

Breece and Neilberg JCO 1986www.drdentiste.comMonday, May 1, 2023 6

Facial appearance is the most important characteristic in relation to self image and self esteem

People dissatisfied with facial appearance express more dissatisfaction with teeth than any other feature Herchan etal AJO 1980

WOULD YOU LIKE TO HAVE A SMILE LIKE THIS ?


Open bite

By Graber A condition where a space exists

between the occlusal or incisal surfaces of maxillary and mandibular teeth in buccal or anterior segments when the mandible is brought into habitual or centric occlusion


Moyer'sMoyer's Simple or DentoalveolarSimple or Dentoalveolar AnteriorAnterior PosteriorPosterior Complex or SkeletalComplex or Skeletal

LocationLocation Anterior Anterior PosteriorPosterior


Orthodontic equation

Causes

Times

Tissues

Results

Act at

on

producing

TREAT THE CAUSE

DOCKRELL R 1952


Etiology

Epigenetic / hereditary factors Skeletal growth pattern of maxilla

and mandible Vertical relationship of jaws Morphology and size of tongue Muscle dysfunction Neurological disturbances

Epigenetic / hereditary factors Environmental factors


Environmental factors Tongue dysfunction Thumb/finger sucking Mouth breathing Foreign body in mouth Trauma or pathology of condyles


Establishment of Normal Overbite


ENLOWS COUNTERPART PRINCIPLE

Growth of any given facial or

cranial part relates specifically to

other structural and geometric

"counterparts" in the face and

cranium.


Balanced growth


Upward and backward growth of condyleDownward and forward displacement

Expansion of Middle cranial fossa


Tongue Morphology,size Tongue thrust , posture

MACROGLOSSIA


TONGUE THRUST AND POSTURE

Swienheart(1942) Straub(1960) Tongue thrust primary cause Mouth seal difficult in open bite

Physiological adaptation tongue

Thrust swallow is always seen in open bite

but reverse is not truewww.drdentiste.comMonday, May 1, 2023 18

Respiratory pattern Primary determinant of posture of jaws and

tongue

Mouth breathing Nasal inflamation Nasal polyps Deviated nasal septum Mechanical obstruction Inflamed tonsils or adenoids


Postural changes Lowering of mandible Downward and forward positioning

of tongue Tipping back of head

Adenoid facies


Thumb sucking

29 week IU


Role of Musculature

Facial muscles affect jaw growth Formation of bone at point of muscle

attachment Growth of muscle carries jaws

downward and forward Loss of musculature can result in

underdevelopment of that part of face

Excessive muscle contraction can restrict growth


Characteristics of Anterior open bite (Skeletal)

Hyperdivergent face (long Face) Vertical growth pattern Discrepancy in vertical proportions > AFH restricted to lower third , < PFH No contact of teeth in anterior region Retruded Mandible Short ramus


> eruption of posterior teeth Clockwise rotation of mandible > gonial angle Antegonial notching Open mouth posture Proclination of upper incisors / retroclination of

lower incisors Lip incompetence Forward tongue posture Defective speech (s,f,z,l,r) (Munim 1966)


Treatment of open biteObservationSimple habit controlComplex surgical procedures

Vertical growth last dimension to be

TREAT THE CAUSEETIOLOGY

completed


Moyers Self correction of open bite can

occur if habit is corrected

Johson , Larson

Benefit should outweigh the risks

Treatment in early mixed dentition period


Treatment of sucking habitsSucking habit

Communication with patient

Meaningful Empty

Psychological approach Dental approach

Diagnose and resolve the problem

Habit reminderswww.drdentiste.comMonday, May 1, 2023 28

Habit remindersThumb sucking Extraoral Thumb guard (Allen 1991) Chemical method Intraoral ( removable / fixed ) To remind the patient To make the habit a non-pleasurable one.


Palatal Cribs

Rakeswww.drdentiste.comMonday, May 1, 2023 30

Thumb sucking Tongue thrusting Lip sucking Mouth breathing Flaccid hypo tonic orofacial musculature Open bites

Oral screen ( Newell 1912 )


Oral screen


Treatment in mixed / early permanent dentition period

Myofunctional appliances Orthopaedic appliance Combination Fixed appliance therapy


Myofunctional appliances

Activatior and its modifications Bionator Frankel regulator (FR IV) Twin block


Activator Palate free activator (Metzelder)

Elastic open activator (Klammt)


Bionator

Open bite appliance Maxillary acrylic portion is modified with acrylic

extending up behind the maxillary incisors It does not contact the teeth or the alveolus Prevent tongue from thrusting between teeth Thin layer of acrylic between all posterior teeth to

exert a depressing forcewww.drdentiste.comMonday, May 1, 2023 36

FR IV

www.drdentiste.com

Twin block

Monday, May 1, 2023 37

Intra oral elastics - Dr Christine Mills

To maintain occlusal contact on the appliances Reinforcement of intrusive force on the bite

blocks to close the bite.

Repelling magnets

Intraoral traction


Orthopaedic appliance

High Pull Head Gear Restrict maxillary sutural growth and vertical

dentoalveolar development Mandibular rotation


12 –14 hrs/day force 10 –16 oz (400 –450 gms) per side

Head gear with Maxillary occlusal splint Bite blocks Functional appliances


http://www.dentistanbul.com.tr/rus/images/c_ortodonti6.jpg

Active Vertical Corrector (AVC)

Dellinger AJO-DO 1986 Removable or fixed

orthodontic appliance that intrudes the posterior teeth in both the maxilla and mandible by reciprocal forces.


Treatment of late permanent dentition (adult)

Extractions Fixed appliance therapy MEAW (Multiloop Edgewise Archwire) Microscrew implant Titanium Miniplates Glossectomies Orthognathic surgery


Premolar extractions

Mesial movement of the molar teeth. Retraction of incisors


Fixed appliance therapy Leveling of arches (mild open bites) Elastics Incisor and canine brackets placed 0.5 mm

more gingival


MEAW

Young H Kim Angle (1987) Multiloop Edgewise Archwire L shaped loops 0.016 ×0.022 inch SS wire


Objective Correction of occlusal plane Alignment of maxillary incisors Uprighting of axial inclinations of

posterior teethwww.drdentiste.comMonday, May 1, 2023 46

Enacar etal (JCO 1996) 0.016 ×0.022 inch upper accentuated Niti

lower reverse curve Niti


Advantages Simpler Hygienic Reduced chair side time Did not irritate soft tissues Results similar


Microscrew implant anchorage for intrusion

Hyo Sang Park etal AJO 2004

Maxillary II premolars and I molars Anchorage for anterior retraction Posterior intrusion

Mandibular I and II molars Anchorage for uprighting Counteract mesial tipping during space closure


Advantages Prevents mesial tipping of premolars Eliminate need of intermaxillary elastics


Titanium Miniplates as Skeletal anchorage for Intrusion .

Keith H AJO Dec 2002

L-, Y-, or T-shaped plates

Miniplate size and shape were based on Length of the roots of adjacent molars Contour and density of underlying bone.


Positioned so that only the last loop on the vertical (most occlusal) leg of the plate projected through the mucosal incision into the oral cavity

Several millimeters apical to the brackets on the molars and adjacent to the teeth requiring intrusion


A elastic thread passed through the exposed loop of the implanted miniplate and tied tightly to the bracket of the closest molar or molars to create a directly vertical intrusive force.


Orthognathic surgery Superior repositioning of maxilla as

a whole or as apart Mandibular surgery to bring lower

jaw forward and upward by tilting the body of mandible upward

Superior repositioning of chin by lower border osteotomy


Osteotomies Maxilla Lefort I osteotomy Posterior Maxillary osteotomy Anterior Maxillary subapical osteotomy

Mandible Anterior Mandibular subapical osteotomy Mandibular body V osteotomy Sagittal split of Mandibular body

Hullihen(1849)


Lefort I osteotomy


Posterior Maxillary osteotomySchuchard , Kufner

High palatal vault > Curvature of maxillary plane


Anterior Maxillary and Mandibular Subapical osteotomy


Mandibular body V / Y osteotomy


Sagittal split of Mandibular Body

Obwegesser,Dalport Preserves integrity of inferior aspect of body of

mandible No bone grafting


Conclusion

Open Bite is one of the most challenging malocclusions to treat

Are we ready for this challenge ???


DEEP OVER BITE

DR.KAPIL SAROHABDS, MDS

ORTHODONTICS AND DENTOFACIAL ORTHOPAEDICS


Contents Introduction Definition Classification Diagnosis Clinical features Treatment in functional appliance


Introduction Deep overbite presents an

orthodontist with challenge in any of its many forms.

Diagnosis ,treatment planning and appropriate mechanics form an backbone of successful orthodontic treatment.


Etiological Consideration According to etiological stand point over bite can

be differentiate into developmental deep bite and acquired deep bite.


Developmental ( Genetic) Deep Bite

Skeletal deep bite with a horizontal growth pattern is a common malocclusion.

Dentoalveolar deep bite caused by supra occlusion of the incisors, these cases the interocclusal clearance is usually small meaning the over bite is functionally a pseudodeep bite.


Acquired Deep Bite A lateral tongue thrust or postural

position frequently can produce acquired deep bite this type of function produce a infra-occlusion of the posterior teeth which intern leads to a deep over bite, the freeway space is large which is favorable for dentofacial orthopedics functional appliance treatment.

E.g. class II div. II.


The wearing away of the occlusal surface or teeth abrasion can produce an acquired secondary deep over bite in some patients.


Deep over bite can be localized in either

1. Dentoalveolar 2. skeletal.


Dentoalveolar deep over bite

Deep overbite caused by infraocclusion molars has the following symptoms.

1. Molars are partially erupted.2. Interocclusal space is large.3. A lateral tongue thrust and posture are

present.


Deep over bite caused by over eruption of the incisors has the following symptoms:

1. Molars are fully erupted. 2. Curve of spee is excessive(compensating

curve).3. Interocclusal space is small.


Skeletal Deep Over Bite

Is characterized by a horizontal type of growth pattern.

Anterior facial height is short, particularly the lower facial third, where as posterior facial height is long.

Interocclusal clearance is usually small


Vertical Malocclusion – Deep Bite

Excessive over bite – deciduous dentition. Over bite is the considered to be excessive when the

incisors overlap by more than half. Genuine deep bite in a deciduous dentition where

the lower anterior teeth are covered completely as result of an increased in the height of the upper anterior alveolar process.

An excessive overbite may be encountered during any developmental period of dentition.


Deep bite with class III malocclusion Deep bite conjunction with mandibular

prognathism and inverted over bite. This vertical deviation can be related with any

anteroposterior or transverse malocclusion.


Closed bite caused by loss of posterior teeth Gingivally supported closed bite resulting from

premature extraction of teeth in the mixed dentition.

Pathologically the closed bite is caused by an increased forward and upward rotation of the mandible, resulting form lack of posterior dental support.


Functional classificationTrue deep over bite

1. Infraocclusion of molars.2. Large freeway space. The prognosis for

successful therapy with functional method is favorable.

Pseudo deep over bite

1. Molars are fully erupted.

2. Over eruption of the incisors.

The prognosis for successfully therapy with functional method is unfavorable.


ABSOLUTE INTRUSION

RELATIVE INTRUSION

EXTRUSION

THREE POSSIBLE WAYS FOR INTRUSION


Dentoalveolar Deep Over Bite True Deep Over Bite 1. In true deep bite the choice of

treatment is extrusion of posterior teeth.

2. If a lateral tongue thrust is present, a lateral tongue crib is added to the palatal plate.


Treatment of acquired deep bite Treatment being carried out during

eruption levelling of the curve of spee can be carried out by the use of an activator.

Anterior bite plane can be used.


Anterior bite plane In growing patients anterior bite

plane inhibits the vertical development of the lower incisors and allows differential eruption of the posterior teeth to take place.

The posterior teeth will be occlusion and the over bite will reduced with in about 2 months.


Tip back springs Indicated:Deep over bitedeep curve of spee Growing patients with forward growth

rotation. the anchor molars are

reinforced with TPAIn the upper and lingual holding arch in

the lower arch.


Correction of deep bite with activator

correction of deep bite with bionator

correction of deep bite with frankel


Conclusion All these various modalities

described for the correction of the deep overbite have been time proven to be successful provided the right method of treatment is selected as per the demands if a particular case


Thank you


open bite and deep bite

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