1 treatment of anterior open bite in hyperdivergent...

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EARLY TOOTH EXTRACTION IN THETREATMENT OF ANTERIOR OPEN BITE INHYPERDIVERGENT PATIENTS

Aim: To describe the treatment of a 7-year-old patient with a hyperdiver-gent (dolichofacial) pattern, Class II Division 1 malocclusion, and anterioropen bite. Methods: Treatment was performed in 2 stages following theprinciples of the Ricketts bioprogressive technique and comprised earlyextraction of the maxillary permanent first molars and primary secondmolars. Results: The treatment plan established for correction of the initialmalocclusion reached the orthodontic goals, providing optimal estheticsand normal function. Conclusion: Posterior dentoalveolar height, which isfundamental in diagnosis and treatment planning, should be investigatedin cases with excessive vertical dimension. In addition, extraction of per-manent or primary maxillary posterior teeth at an early age may be a goodoption for hyperdivergent patients with excessive posterior dentoalveolarheight. World J Orthod 2007;8:249–260.

Márcio Antonio deFigueiredo, MSc1

Danilo Furquim Siqueira, PhD2

Silvana Bommarito, PhD3

Eduardo Kazuo Sannomiya, PhD4

Larry W. White, DDS, MSC5

According to Epker and Fish,1 the diag-nosis, treatment, and stability of

open-bite treatment has been confound-ing and frustrating clinicians more thanany other malocclusion. Schulz et al2

considered the treatment of patientswith increased vertical dimension asone of the greatest challenges of ortho-dontic/facial orthopedic treatment; diffi-culty also applies to maintenance ofresults achieved. Gavito-Lopes andLittle3 observed more than 35% relapsein anterior open bite cases. Huang,4 in2002, reviewing the literature on thetreatment stability of anterior open bitewith or without aid of or thognathicsurgery, found 20% relapse for bothmethods, yet the author reported thatthe current level of evidence is not con-clusive because many studies are char-acterized by small samples and selec-tion problems.

Schudy5 was one of the first to assignimportance to vertical facial relation-ships and their interrelation with antero-

posterior problems. The author classi-fied patients with imbalance betweencondylar growth and posterior den-toalveolar development as hyperdiver-gent; ie, these patients presented a den-toalveolar increase at the molar regionthat was not fol lowed by condylargrowth.

As mentioned by Schendel et al,6 thelong-face syndrome is the most ade-quate name to describe all aspectsinvolved in this dentofacial deformity.According to the authors, the commonaspect of this type of deformity is themaxillary vertical excess.

In the opinion of Proffit et al,7 themain cephalometric indicators of askeletal relationship predisposing toopen bite are short mandibular ramusand excessive maxi l lary ver t icalincrease. These alterations tend to pro-duce downward and backward mandibu-lar rotation, with consequent increase inlower anterior facial height and anterioropen bite.

1Postgraduate Resident, Program inDentistry, Area of Concentration inOrthodontics, Methodist University,São Paulo, Brazil.

2Professor, Postgraduate Program inDentistry, Area of Concentration inOrthodontics, and Professor, Disci-pline of Child Clinic (Undergraduate),Dental School, Methodist University,São Paulo, Brazil.

3Professor, Human CommunicationDisturbances by UNIFESP, andChairman and Professor, Postgradu-ate Program in Dentistry, Area ofConcentration in Orthodontics, Den-tal School, Methodist University, SãoPaulo, Brazil.

4Professor, Postgraduate Program inDentistry, Area of Concentration inOrthodontics, Dental School,Methodist University, São Paulo,Brazil.

5Private practice of Orthodontics,Dallas, Texas, USA.

CORRESPONDENCEDr Márcio Antonio De FigueiredoRua Capitão Nascimento Filho, 131 – VergueiroCep.18030-123Sorocaba, SPBrazilE-mail:[email protected]

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According to Proffit and Ackerman,8

anterior open bite might be related toinadequate eruption of anterior teethand normal eruption of posterior teeth,even though there is a higher frequencyof normal or even increased eruption ofanterior teeth and excessive eruption ofposterior teeth.

Other authors9,10 have agreed withProffit and Ackerman8 in that the ante-rior teeth (both maxillary and mandibu-lar) present extrusion in patients withopen bite, whereas the posterior teeth,especially the maxillary molars, presentincreased eruption.5,9

Ceylan and Eröz10 investigated theeffect of overbite on the morphology ofthe maxilla and mandible. The result oftheir study revealed that both maxillaryand mandibular dentoalveolar heightwere larger for the group with open biteand long and narrow symphysis. Themost significant change in mandibularmorphology was observed for the gonialangle, which was larger in the group withopen bite. The authors concluded thatevaluation of maxillary and mandibulardentoalveolar height, symphyseal shape,and gonial angle may be useful in thediagnosis and successful treatment ofopen bite.

Riolo et al,11 in their atlas on craniofa-cial growth, presented guidelines thatmight be used for the dentoalveolarheight of maxillary and mandibular firstmolars. Using the same methodology ofRiolo et al11 to measure the maxillary den-toalveolar height and a similar methodol-ogy for mandibular height, Langlade9 con-ducted a study on 65 cases with anteriorvertical excess and concluded that thevertical dysplasia was located at the max-illa, due to its increased dentoalveolarprocess, and that the mandibular den-toalveolar process was often reduced,indicating a natural attempt of verticalcompensation by mechanisms of growthand development.

In 1994, Janson et al12 demonstrateda correlation between dentoalveolarheight and the ratio between maxillaryanterior facial height and lower anteriorfacial height. The dentoalveolar height issignificantly different between patientswith excessive, normal, or reduced verti-

cal dimension; the dentoalveolar heightwas significantly larger in individuals withvertical excess compared to the normalpatterns. The difference in dentoalveolardevelopment, particularly on the maxilla,significantly influenced the anterior facialheight in orthodontic patients.

TREATMENT OF ANTERIOROPEN BITE

Many cases of anterior open bite charac-terized by a remarkable vertical imbal-ance between the bone bases (maxillaand mandible) are treated with orthog-nathic surgery. For more severe cases,compensatory orthodontic treatmentincluding extractions may not providepleasant facial esthetics,13 and orthog-nathic surgery with Le Fort I osteotomy ofthe maxilla in isolation or combined withsagittal surgery of the ramus is the mostindicated treatment.

Many methods are available in the lit-erature for cases with anterior open bitesubmitted to orthodontic treatment with-out orthognathic surgery, most of whichemphasize the need to reduce the verti-cal dimension of the maxillary posteriorsegments by intrusion of molars, or atleast attempting to prevent their extru-sion during orthodontic treatment.2,14–16

Extraction mechanics are also fre-quently used for patients with anterioropen bite. Freitas et al17 performed a ret-rospective study of 31 patients treatedwith extraction of first or second premo-lars and observed that 74.2% of caseswere clinically stable with respect to cor-rection of the open bite. Langlade9 haswritten that the best option for correctionof open bite is extraction of the mandibu-lar second molars and maxillary firstmolars; the author’s explanation for thiswas the reduced dentoalveolar height ofmandibular first molars and increaseddentoalveolar height of maxillary firstmolars.

For successful orthodontic treatment,it is fundamental to investigate possibleenvironmental influences present inpatients with anterior open bite, such asairway obstruction, oral habits, andaltered tongue posture and function.

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VOLUME 8, NUMBER 3, 2007 Figueiredo et al

Cases presenting some of these etiologicfactors should receive special attentionand a treatment protocol to removethese interferences.

CASE REPORT

The patient, MCC, a female 7 years ofage, had a dolichofacial pattern. Anam-

nesis revealed typical signs and symp-toms of mouth breathing, which was con-firmed after an ear-nose-throat (ENT)evaluation. The extraoral clinical exami-nation (Fig 1) demonstrated that thepatient had a long face with a convexfacial profile and excessive contractionof the mentalis muscle during lip sealing.

The intraoral clinical examination (Fig2) revealed that the patient was in the

Fig 1 Extraoral photographs taken at treatment onset of patient with long face (effort of the orbicularis oris muscle for lipsealing).

Fig 2 Intraoral photographstaken at treatment onset.


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Fig 3 (above) Initial lateral cephalogram.Fig 4 (right) Ricketts cephalometricanalysis.

Fig 5 Transpalatal distance according toSpillane and McNamara.18

Fig 6 Distance between mandibularteeth, according to Ricketts.

Table 1 Pretreatment cephalometric analysis

Normal Measurement Patient value

SNA (degrees) 85 82

SNB (degrees) 81 80ANB (degrees) 4 2Sella-Nasion to Gonion-Gnathion (degrees) 42 34Mandibular plane to Frankfort (degrees) 33 26Facial axis (degrees) 87 90Convexity (mm) 4 3Maxillary depth (degrees) 94 90Maxillary height (degrees) 55 53Facial depth (degrees) 89 86Lower facial height (degrees) 53 45Mandibular corpus length (mm) 62 62Interincisal angle (degrees) 124 132Maxillary incisor to Plane 1Apo (mm) 8 4Mandibular incisor to Plane 1Apo (mm) 2 1Dentoalveolar height; maxillary first molar (mm) 22 18Dentoalveolar height; mandibular first molar (mm) 28 28Growth pattern Dolichofacial

Table 2 Analysis of dental measurements

Mandible Measurement Normal value

Arch depth (mm) 24 26Intermolar distance (mm) 48 55IV/IV distance (mm) 33 38Intercanine distance (mm) 23 25


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mixed-dentition stage and had a Class IIDivision 1 malocclusion with anterioropen bite, reduced transverse dimension,and lack of space for eruption of the max-illary and mandibular lateral incisors.

Initial radiographic examinations (Fig3) and cephalometric analysis (Fig 4,Table 1) confirmed the presence of askeletal Class II malocclusion with ante-rior open bite and revealed excessiveposterior dentoalveolar height located onthe maxilla, according to Langlade.9

Analysis of the transpalatal dimen-sion, according to Spillane and McNa-mara18 (Fig 5), revealed a transpalataldistance of 29 mm, whereas the normalvalue of this distance during this stage ofmixed dentition is 36 mm.

According to the same authors,18

when a child in the stage of early mixeddentition presents a transpalatal dimen-sion smaller than 31 mm, achievementof adequate arch dimensions by normalgrowth mechanisms is not likely. Thus,dental arch expansion at an early age isfavorable for skeletal, dentoalveolar, andmuscular adaptation before eruption ofall permanent teeth.

Figure 6 illustrates the analysis ofdental measurements according to Rick-etts.19 All values observed are less thannormal values (Table 2).

Treatment plan

The treatment plan was discussed withthe patient and parents, and followedpre-established objectives to: (1) normal-ize the maxillary and mandibular trans-verse diameters, allowing more space fortongue function and posture; and (2) cor-rect the skeletal Class II malocclusionand anterior open bite. The permanentmaxillary first molars and primary maxil-lary second molars were extractedbecause of the excessive maxillary den-toalveolar height, thus removing posteriordental support and allowing upward andforward rotation of the mandible. Themandibular dentoalveolar height waswithin the normal pattern and without theneed for extraction of mandibular teeth.

Treatment

Treatment was performed in 2 stages,following the principles of the Rickettsbioprogressive technique.19

Stage 1. This stage comprised maxil-lary and mandibular dentoalveolar expan-sion with the quad-helix and bi-helix (Fig7) and extraction of the permanent maxil-lary first molars and primary maxillarysecond molars. Af ter maxil lary and

Fig 7 (a) Occlusal view of fittedquad-helix after placement. (b)Occlusal view of fitted bi-helix soonafter placement. (c) Dentoalveolarexpansion achieved by quad-helix. (d)Dentoalveolar expansion achieved bybi-helix.

a b

c d


mandibular dentoalveolar expansion, theprimary maxillary second molars and per-manent maxil lary f irst molars wereextracted (Fig 8). The immediate effectwas upward and forward rotation of themandible, which can be seen on theintraoral photographs (Fig 9).

The first stage of orthodontic treatmentachieved the desired goals: Correction of

Class II malocclusion and anterior openbite. The perioral and facial muscularfunction was also improved, demonstrat-ing better balance at onset of the secondstage (Figs 10 and 11), intermediate radi-ographic examinations (Fig 12), andcephalometric analysis (Fig 13, Table 3).

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Fig 8 (a) Maxillary occlusal view afterslow expansion. (b) Maxillary occlusalview after extraction of primary secondmolars and permanent first molars.

Fig 9 Intraoral photographs showing upward and forward rotation of the mandible.

Fig 10 Extraoral photographs at onset of the second stage of orthodontic treatment.

a b


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Fig 11 Intraoral photographs at onsetof the second stage of orthodontic treat-ment.

Fig 12 Intermediate lateral cephalo-gram.

Fig 13 Intermediate Ricketts cephalometricanalysis.


Stage 2. The second stage of treat-ment (fixed orthodontics) was performedfollowing the principles of the Rickettsbioprogressive technique, with utilizationof brackets with a 0.018-inch slot. Thefinal result achieved all orthodonticgoals: (1) ideal occlusion with satisfac-tory overjet and overbite; and (2) ade-quate perioral muscular function andfacial esthetics (Figs 14 and 15). Thetreatment results are observable on thefinal radiographs and final cephalometrictracing (Figs 16 and 17, Table 4).

DISCUSSION

Analysis of the initial, intermediate, andfinal radiographs and cephalometric trac-ings reveal that the upward and forwardmandibular rotation achieved soon aftertooth extraction was not maintained attreatment completion. The facial axis was87 degrees at treatment onset and 84degrees at treatment completion. Thisdemonstrates that the dolichofacial pat-tern was not affected by extractions andthe orthodontic mechanics applied, even

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Fig 14 Extraoral photographs taken at completion of the second stage of facial orthodontic-orthopedic treatment.

Table 3 Cephalometric analysis at the start of stage 2 treatment

Measurement Patient Normal value

SNA (degrees) 80 82SNB (degrees) 80 80ANB (degrees) 0 2Sella-Nasion to Gonion-Gnathion (degrees) 40 33Mandibular plane to Frankfort (degrees) 29 26Facial axis (degrees) 89 90Convexity (mm) 0 2Maxillary depth (degrees) 91 90Maxillary height (degrees) 58 54Facial depth (degrees) 91 87Lower facial height (degrees) 50 45Mandibular corpus length (mm) 66 67Interincisal angle (degrees) 118 130Maxillary incisor to Plane 1Apo (mm) 10 4Mandibular incisor to Plane 1Apo (mm) 4 1Dentoalveolar height; maxillary first molar (mm) 18 20Dentoalveolar height; mandibular first molar (mm) 30 30Growth pattern Dolichofacial


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Fig 15 Intraoral photographs taken atcompletion of facial orthodontic-orthope-dic treatment.

Fig 16 (a) Panoramic radiograph taken at treatment com-pletion. (b) Final cephalogram.

Fig 17 Final Ricketts cephalometric analysis.

a

b


though the extraoral and intraoral pho-tographs (Figs 18 and 19) obtained 3years after treatment completion revealstability of the permanent teeth, demon-strating that the pre-established treat-ment plan was adequate.

The panoramic radiograph obtained 3years posttreatment (Fig 20) shows allpermanent teeth, except the permanentmaxillary first molars that had beenextracted at an early stage. The maxillaryright third molar occupied the position ofthe second molar, providing normalocclusion, and the left maxillary thirdmolar is currently erupting and presentsa normal aspect.

Oral habits are etiologic factors fre-quently related with anterior open bite,since they can affect tongue posture andfunction. These habits should be elimi-nated during the period of mixed denti-tion, to avoid establishment of severedentoskeletal alterations. Removableappliances with tongue crib, as well asspeech therapy, should be used for treat-ment and should be presented to thechild as an aid rather than a punishment.According to Gugino and Ivan,20 there isa close relationship between shape andfunction in the oral cavity and any otherarea of the human body, which leads tothe assumption that normal oral function

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Table 4 Posttreatment cephalometric analysis

Measurement Patient Normal value

SNA (degrees) 77 82SNB (degrees) 74 80ANB (degrees) 3 2Sella-Nasion to Gonion-Gnathion (degrees) 46 33Mandibular plane to Frankfort (degrees) 31 25Facial axis (degrees) 84 88Convexity (mm) 2 2Maxillary depth (degrees) 92 90Maxillary height (degrees) 59 54Facial depth (degrees) 89 88Lower facial height (degrees) 54 45Mandibular corpus length (mm) 70 71Interincisal angle (degrees) 123 130Maxillary incisor to Plane 1Apo (mm) 9 4Mandibular incisor to Plane 1Apo (mm) 5 1Dentoalveolar height; maxillary first molar (mm) 21 22Dentoalveolar height; mandibular first molar (mm) 33 32Growth pattern Dolichofacial

Fig 18 Extraoral photographs taken 3 years posttreatment.


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is easier to achieve if oral anatomy iswithin the normal limits. On this basis,expansion of the atresic dental archesrestored functional orthodontic occlusionand yielded a wider smile with balancewith the remaining parts of the face,which may provide spontaneous correc-tion of the inadequate tongue posture.

Some options for nonsurgical correc-tion of anterior open bite in the period ofmixed dentition include high-pull head-gear, high-pull chin cap, and posteriorbite block. The main objective of thesemechanics is to avoid extrusion or evenachieve intrusion of posterior teeth. Earlyextraction of the permanent maxillaryfirst molars in well-indicated cases with

increased dentoalveolar height and pres-ence of the third molars may effectivelyachieve the same objectives, with noneed for patient compliance.

CONCLUSION

The treatment plan established allowedcorrection of a Class II malocclusion withanterior open bite, promoting optimalfunction and facial esthetics. In caseswith vertical excess, the posterior den-toalveolar height should be investigatedand extraction may be a good option forhyperdivergent patients with dentoalveo-lar height above the normal values.

Fig 19 Intraoral photographs taken 3years posttreatment.

Fig 20 Panoramic radiograph taken 3 years posttreatment.


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