open bite and deep bite
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Good AfternoonDR. KAPIL SAROHA
BDS, MDSORTHODONTICS AND DENTOFACIAL
ORTHOPAEDICS
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Overbite
Deep bite Open bite
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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
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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
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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
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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 ?
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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
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Moyer'sMoyer's Simple or DentoalveolarSimple or Dentoalveolar AnteriorAnterior PosteriorPosterior Complex or SkeletalComplex or Skeletal
LocationLocation Anterior Anterior PosteriorPosterior
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Orthodontic equation
Causes
Times
Tissues
Results
Act at
on
producing
TREAT THE CAUSE
DOCKRELL R 1952
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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
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Environmental factors Tongue dysfunction Thumb/finger sucking Mouth breathing Foreign body in mouth Trauma or pathology of condyles
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Establishment of Normal Overbite
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ENLOWS COUNTERPART PRINCIPLE
Growth of any given facial or
cranial part relates specifically to
other structural and geometric
"counterparts" in the face and
cranium.
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Balanced growth
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Upward and backward growth of condyleDownward and forward displacement
Expansion of Middle cranial fossa
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Tongue Morphology,size Tongue thrust , posture
MACROGLOSSIA
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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
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Postural changes Lowering of mandible Downward and forward positioning
of tongue Tipping back of head
Adenoid facies
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Thumb sucking
29 week IU
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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
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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
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> 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)
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Treatment of open biteObservationSimple habit controlComplex surgical procedures
Vertical growth last dimension to be
TREAT THE CAUSEETIOLOGY
completed
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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
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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.
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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 )
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Oral screen
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Treatment in mixed / early permanent dentition period
Myofunctional appliances Orthopaedic appliance Combination Fixed appliance therapy
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Myofunctional appliances
Activatior and its modifications Bionator Frankel regulator (FR IV) Twin block
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Activator Palate free activator (Metzelder)
Elastic open activator (Klammt)
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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
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Twin block
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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
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Orthopaedic appliance
High Pull Head Gear Restrict maxillary sutural growth and vertical
dentoalveolar development Mandibular rotation
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12 –14 hrs/day force 10 –16 oz (400 –450 gms) per side
Head gear with Maxillary occlusal splint Bite blocks Functional appliances
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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.
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Treatment of late permanent dentition (adult)
Extractions Fixed appliance therapy MEAW (Multiloop Edgewise Archwire) Microscrew implant Titanium Miniplates Glossectomies Orthognathic surgery
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Premolar extractions
Mesial movement of the molar teeth. Retraction of incisors
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Fixed appliance therapy Leveling of arches (mild open bites) Elastics Incisor and canine brackets placed 0.5 mm
more gingival
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MEAW
Young H Kim Angle (1987) Multiloop Edgewise Archwire L shaped loops 0.016 ×0.022 inch SS wire
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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
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Advantages Simpler Hygienic Reduced chair side time Did not irritate soft tissues Results similar
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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
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Advantages Prevents mesial tipping of premolars Eliminate need of intermaxillary elastics
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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.
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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
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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.
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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
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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)
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Lefort I osteotomy
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Posterior Maxillary osteotomySchuchard , Kufner
High palatal vault > Curvature of maxillary plane
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Anterior Maxillary and Mandibular Subapical osteotomy
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Mandibular body V / Y osteotomy
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Sagittal split of Mandibular Body
Obwegesser,Dalport Preserves integrity of inferior aspect of body of
mandible No bone grafting
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Conclusion
Open Bite is one of the most challenging malocclusions to treat
Are we ready for this challenge ???
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DEEP OVER BITE
DR.KAPIL SAROHABDS, MDS
ORTHODONTICS AND DENTOFACIAL ORTHOPAEDICS
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Contents Introduction Definition Classification Diagnosis Clinical features Treatment in functional appliance
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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.
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Etiological Consideration According to etiological stand point over bite can
be differentiate into developmental deep bite and acquired deep bite.
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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.
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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.
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The wearing away of the occlusal surface or teeth abrasion can produce an acquired secondary deep over bite in some patients.
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Deep over bite can be localized in either
1. Dentoalveolar 2. skeletal.
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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.
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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.
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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
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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.
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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.
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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.
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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.
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ABSOLUTE INTRUSION
RELATIVE INTRUSION
EXTRUSION
THREE POSSIBLE WAYS FOR INTRUSION
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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.
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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.
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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.
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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.
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Correction of deep bite with activator
correction of deep bite with bionator
correction of deep bite with frankel
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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
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Thank you
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