open bite franchi def - aao annual session€¦ · comparisonof 2 earlytreatment protocolsfor...

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Lorenzo Franchi, DDS, PhD

Treatment Timing andRetention Considerations

for Openbite Patients

Department of Surgery amd Translational Medicine,The University of Florence, Italy,

and�T.M. Graber Visiting Scholar�

Department of Orthodontics and Pediatric DentistryThe University of Michigan

A SERIOUS CHALLENGE

IN ORTHODONTICS

OPENBITE

?What can the clinician do to best treat a

patient with dento-skeletal open bite?

Efficacy?

Treatment timing?

Efficiency?

Long-term stability?

Limitations?Orthopedics

Orthodontics

Surgery?

?Effic

acy?

Treatment timing?

Efficiency?

Long-term stability?

Limitations?Orthopedics

Orthodontics

Surgery?

What can the clinician do to best treat a patient with dento-skeletal open bite?

When is the best timing to start treatment

of an open-bite growing patient?

Openbite patients WITH persistingdigit sucking

habits

Patients with dentoskeletal

openbite WITHOUT sucking habits

When is the best timing to start treatment

of an open-bite growing patient?

Openbite patients WITH persistingdigit sucking

habits

Patients with dentoskeletal

openbite WITHOUT sucking habits

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Digital Sucking HabitsLittle long-term effect during the primary dentition years

The sucking habit should be terminated before the eruptionof the permanent teeth

(Warren and Bishara 2002, Singh 2008)

The more prolonged the duration of the habit, the more severe the developing malocclusion tends to be

Prolonged sucking habits can lead to malocclusionsDigital Sucking Habits

Larsson, 1987

dentoalveolar (anterior open bite)

constriction of the maxillary arch

maxillary protrusion and upward inclin. palatal pl.mandibular retrusion and backward inclin. mand. pl.

To evaluate sucking habits and hyperdivergency as risk factorsfor Anterior Open Bite (AOB) in mixed-dentition subjects

Large cross-sectionalsample (N=1710)

Am J Orthod Dentofacial Orthop 2005;128:517-9

The presence of Thumbsucking in absence of HyperdivergencyIS NOT ASSOCIATED with an increased risk of AOB

The presence of Hyperdivergency in absence of ThumbsuckingIS NOT ASSOCIATED with an increased risk AOB

The concurrent presence of both Thumbsucking and Hyperdivergency IS ASSOCIATED with an increased risk of AOB

Conclusions

… thumb and finger sucking, lip and tongue habits, airway obstruction, and true skeletal growth abnormalities

Ngan P, Fields HW. Open bite: a review of etiology and management. Pediatr Dent 19:91-98. 1997

Sucking habitsVertical malocclusions develops as a result of the interaction of many different etiologic factors …

Courtesy of Paola Cozza

AOB can self-correct after removal of the sucking habit, provided that no other secondary dysfunctions have set in

Subtelny and Sakuda, 1964; Artese et al., 2011

Anterior Open Bite (AOB) and Sucking Habits

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These secondary dysfunctions may develop from maxillary incisor protrusion, thereby hindering the lip seal required for swallowing, and causing an abnormaltongue posture at rest that maintains the AOB

Proffit, 1978; Justus, 2001; Shapiro, 2002; Artese et al., 2011

Anterior Open Bite (AOB) and Sucking Habits

Removable or Fixed Appliances??Comparison of 2 early treatment protocols for open-bitemalocclusions.Cozza P, Baccetti T, Franchi L, Mucedero M.Am J Orthod Dentofacial Orthop. 2007;132(6):743-7.

Dentoskeletal changes associated with fixed and removable appliances with a crib in open-bite patientsin the mixed dentition.Giuntini V, Franchi L, Baccetti T, Mucedero M, Cozza P.Am J Orthod Dentofacial Orthop. 2008;133(1):77-80.

Treatment timing of AOBin patients with prolonged thumb-suckingAOB (associated with prolonged sucking habits and/or abnormal

tongue posture) should be treated EARLY (in the early mixed dentition) to stop habits and/or correct tongue posture

To compare the efficacy of a Quad-Helix/Crib (QH-C) appliance versus the Open-Bite Bionator (OBB) and a Removable Plate

with Crib (RP-C) in growing patients who presented with prolonged thumb-sucking habits and dento-skeletal openbite

Objective

VSQH-C OBB RP-C

Inclusion Criteriaü PERSISTING DIGIT SUCKING

ü ANTERIOR OPEN BITE (NEGATIVE OVB)

ü FACIAL HYPERDIVERGENCY (FH to Mand.Pl.>25deg)

ü FULLY ERUPTED PERMANENT FIRST MOLARSand INCISORS

ü PRE-TX AND POST-TREATMENT LATERAL CEPHS

QH-C Treatment ProtocolQUAD-HELIX WITH BANDS ON E+/+E OR 6+/+6

Spurs for thumb-sucking prevention and to prevent interposition of the tongue in the anterior openbite were formed from 3 or 4 segments of .036�

stainless steel wires soldered on the anterior bridge of the Quad-Helix

OBB Treatment Protocol

The acrylic portion of the lower lingual part extended into the maxillary incisor region as a lingual shield, closing off the anterior space without touching the maxillary teeth

The OBB had posterior acrylic bite blocks to prevent extrusion of the posterior teeth

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RP-C Treatment ProtocolThe removable plate consisted of a modified Schwarz upper platewith Adams clasps on the maxillary first molars and a cribconsisting of loops modeled with 0.036-in stainless steel wire to prevent forward posturing of the tongue

ConclusionsQH-C is more effective than OBB and RP-C for the improvement of overbite with greater extrusion of the maxillary incisors (OVB correction 4.0-4.5 mm with QH-C and 2.5-3.0 mm with removable appliances)

The QH-C produces a greater reduction of intermaxillary divergence due to posterior rotation of the palatal plane(about 2 degrees)

Vertical skeletal changesproduced by the Q-H/C appliance

European Journal of Orthodontics 2017;39(1):31-42

In conclusion, this systematic review with a meta-analysis suggestedthat crib therapy could be considered as an effective treatmentfor the correction of AOB in growing patients, with the approximateincrease of 3 mm in overbite

Treatment Timing of Dentoskeletal Openbitein Growing Patients without Sucking Habits??


One of the main targets of orthopedic treatment is…

Skeletal Open-Bite

Pearson, 2000

and to control extrusion of molars… to increase mandibular ramus heightin order to induce an anterior mandibular autorotation

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Angle Orthod 1991;61:71-6

Treatment effects of the acrylic splint expander and the vertical-pull chin cup in openbite patients

1) RME with a bonded expander,left in place 8 wks after expansion.

2) Retention with occlusal-coveragemaxillary retainer to be wornfull-time until Phase 2 treatment.

3) VPCC was worn 12 h/day.Padded band that extendedcoronally, secured to the back of the head by a cloth strap. Forces of 16 oz per side with the vector at 90 deg to the occlusalplane.

Treatment effects+

Treatment timing


(Subjects with skeletal open bite – MPA>25 degreestreated with bonded RME and vertical-pull chin cup)

(ETG) * = Treatment was completed before the peak (CS 1 - 3)(LTG) ** = Treatment included the peak (CS 3 - 5)

• Early-Treated Group (ETG) *

21 subjectsT1 = 8 y 8 mo� 9 moT2 = 11 y 5 mo� 9 moT1-T2 = 2 y 7 mo� 11 mo

• Late-Treated Group (LTG) **

15 subjectsT1 = 9 y 4 mo� 1y 1 moT2 = 12 y 4 mo� 10 m T1-T2 = 3 y � 10 mo

36 subjects

Treated Sample(Untreated subjects with skeletal open bite – MPA >25 degrees)

(ETG) * = Observation period before the peak (CS 1 - 3)(LTG) ** = Observation period included the peak (CS 3 - 5)

• Early-Control Group (ECG) *

18 subjectsT1 = 8 y 5 mo� 1 yT2 = 11 y 2 mo� 11 moT1-T2 = 2 y 8 mo� 11 mo

• Late-Control Group (LCG) **

12 subjectsT1 = 9 y 9 mo� 1y 2 moT2 = 13 y 1 mo� 10 moT1-T2 = 3 y 4 mo� 11 mo

University of Michigan Growth Study

30 subjects

Control Sample

ETG:treatment

before the peak

net changes versus corresponding controls

LTG:treatment

including the peak

CondAx to MPdeg : -0.1 CondAx to MPdeg : -2.2*

Co-Go mm : +1.7 *Co-Go mm : -0.4

FH to MP deg : 0.1 FH to MP deg : -2.2 *

Treatment of moderately hyperdivergent patients with a bonded RME in conjunction with a VPCC at puberty induced more favorable verticalskeletal changes than prepubertal treatment

Conclusions

The sizes of these short-term favorable treatment effects were relativelymodest (about 2 mm or degrees)


Long-term stability???

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2 factors can affect long-term stability of treatment outcomes

in openbite patients

1) Unfavorable vertical growth pattern

2) Abnormal tongue posture (forward and downward)



1) Unfavorable vertical growth pattern


Patterns of Mandibular Development

Open Bite Björk, 1963



1) Unfavorable growth pattern


Role of the soft tissue in AOB relapse

Anterior tongue rest posture IS clinically significant due to its long duration

Proffit, 1978

Anterior tongue thrust IS NOT as significant clinically because of its short duration (1- to 3-second maximum during swallowing)

The aim of a myofunctional program is to establish a new neuromuscular pattern and to correct abnormal functional and resting posture

myofunctional treatment

Neuromuscolar re-educationof abnormal tongue posture


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Other treatment objectives are strengthening of the orofacial muscles to pave the way for mouth closure, establish nasal breathing, and learn a physiological swallowing pattern

Therapist should train the patient to lift the body of the tongue in order to learn a normal resting position of the tongue


It is believed that voluntary activities such asswallowing and speech are easier to correctusing myofunctional exercises

Involuntary activities such as tongue posture habits are harder to automate Artese et al., 2011

Role of the soft tissue in AOB relapse

OMT with orthodontic treatment was effective in closing and maintainingclosure of dental open bites in Angle Class I and Class II malocclusions,and it dramatically reduced the relapse of open bites in patients who hadforward tongue posture and tongue thrust

Correcting low forward tongue posture and tongue thrust swallowsminimized the risk of orthodontic relapse

Am J Orthod Dentofacial Orthop 2010;137:605-14 ?Is treatment of openbite patients

stable in the long term?

A Critical Question:


1) human subjects, 2) stability of outcome assessed at the posttreatment

follow-up > 1 year, 3) negative overbite (OB) or open-bite preintervention

as defined by vertical measures, 4) corrective therapy for open-bite malocclusion adequately

described.

Inclusion criteria

Evidence for stability of surgical and nonsurgical

therapies for AOB malocclusion.

No study with a long-term follow-up

had a control group to demonstrate

the efficacy of the intervention

Non-surgical Studies

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Surgical Studies

Overbite in mmPost-treatment Overbite in Non-Surgical Studies

+1.40

-2.53

Overbite in mmPretreatment Overbite in Non-Surgical Studies

Post-treatment OB correction+3.9 mm

Overbite in mmLong-term Overbite in Non-Surgical Studies (Ys of Follow up)

+0.76

Long-term OB relapse(3.2 ys follow up) -0.6 mm

Long-termOB correction

+3.3 mm

Non-surgical Studies

Overbite in mmPost-treatment Overbite in Non-Surgical Studies

+1.55

-2.79

Overbite in mmPretreatment Overbite in Surgical Studies

Overbite in mmLong-term Overbite in Non-Surgical Studies (Ys of Follow up)

+1.27

Long-term OB relapse(3.5 ys follow up) -0.3 mm

Long-termOB correction

+4.0 mm

Post-treatment OB correction+4.3 mm

Surgical Studies Long-term stability in non-surgical studies

Long-term stability in surgical studies75%

82%

Orthognathic surgery is often indicated for many nongrowingpatients, particularly for esthetic need, severe open bite, or skeletal problems in multiple planes of space

The results of this study indicate that there is some verticalrelapse associated with surgical treatment, possibly becauseof increased facial height and extrusion of the maxillary molars


Considerations on surgical studies

However, many patients with mild to moderate open bites can be successfully treated with less invasive and less costly nonsurgicalorthodontics without notable compromises in long-term stability

For the adolescent subjects treated nonsurgically, it was difficult to determine whether the openbite relapse was due to poor growth patterns, residual habits, or rebound of tooth positions


Considerations on non-surgical studies

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To evaluate the LONG-TERM STABILITY of QH-C treatment in patientswith thumb-sucking habits, AOB, and skeletal open bite tendency

Aim

SubjectsQH-C Group

University of Rome Tor Vergata

28 subjects

T1 = 8 y 2 m � 1 y 3 m

T2 = 9 y 7 m � 1 y 6 m

T3 = 14 y 6 m � 1y 9 m

Control GroupUniversity of Michigan Growth StudyUniversity of Denver Growth Study

20 subjects

T1 = 8 y 1 m � 4 m

T2 = 9 y 8 m � 4 m

T3 = 14 y 5 m � 7 m

Inclusion Criteria- Thumb-sucking habit before treatment- Negative overbite- Constricted maxillary arch- Full eruption of first permanent molars and permanent incisors

- T1 prepeak (CS 1-2); T3 postpeak (CS 4-6)

T1-T2 1.5 y

T1-T3 6.4 yAll patients receivedfixed appliances with no auxiliaries (verticalor sagittal elastics)

no significant changes in Mandibular Plane Angle

increase in Overbite (+2.2 mm)

downward rotation (+1.9°) of the Palatal Plane to FH

reduction in the Palatal Plane-Mandibular Plane angle (-1.9°)

5.7�of lingual tippingof the mandibular incisors

T1-T2 Changes


no significant changes in Mandibular Plane Angle

increase in Overbite (+2.1 mm)decrease in Overjet (-1.5 mm)

downward rotation (+1.8°) of the Palatal Plane to FH

reduction in the Palatal Plane-Mandibular Plane angle (-2.2°)

T1-T3 Changes

In the long term, the use of the Q-H/C appliance led to successful outcomes in about 93% of the patients and a mean closure of the anterior open bite of about 5 mm

The Q-H/C protocol produced a clinically significant downward rotation of palatal plane (1.8°). This favorable outcome contributed significantly to the overall correction of the anterior openbite with an improvement in the vertical skeletal relationships


ConclusionsProlonged sucking habits and hyperdivergencyin the mixed dentition are associated with narrow maxillary intermolar and intercaninewidths, increased posterior transversediscrepancies, and increased prevalence of posterior crossbites.

Am J Orthod Dentofacial Orthop 2007

42.85

44.08

28.94

28.42

Courtesy of Prof. P. Cozza

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The aim of the present study was to evaluate the dentoskeletal features of subjects with anterior open bite in the mixed dentitionusing both conventional cephalometric analysis and morphometric analysis (TPS analysis) applied to posteroanterior (PA) films

Angle Orthod. 2009;79:615–620

OPEN BITE PATIENTS showed a significant reduction in:


Thin-plate Spline Analysis

✗ Zygomatic width

✗ Maxillary width (skeletal and dentoalveolar levels)✗ Mandibular width (condylar

lateral width, gonial width)

Subjects with anterior open bite malocclusion show indicationsfor rapid maxillary expansion

ManagementDento-keletal Open Bite


AimAJO-DO 2012;142:60-69

To evaluate the skeletal and dental changes in the short and long terms in hyperdivergent patients treated with rapid maxillary expansion and fixed appliances.

TREATMENT PROTOCOL

1. Haas expander activated for 3 weeks

3. 2+ months post-activation period

4. RME followed by fixed appliances

Dr. Tom Herberger

2. Expansion 10.0 - 10.5 mm

Sample Size (N = 143)T1 (preTx)143 patients

11.4 � 1.2 y(CS 1-3)

T2 (post RME+Fixed App.)143 patients

14.3 � 1.1 y(CS 3-6)

T3 (long-term) 49 patients

20.1 � 1.6 y (CS 6)

Baccetti T, Franchi L, McNamara JA Jr Semin Orthod 2005;11:119-129

CS 1 CS 3 CS 4 CS 5 CS 6CS 2

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Sample Size (N = 143)Subjects were divided into 3 groups according to

the pre-treatment value of the mandibular plane angle (MPA):

Normal (N=52): 20 deg < MPA < 27 deg

27 deg < MPA < 32 degModerately Hyperdivergent (N=62):

Very Hyperdivergent (N=29): MPA > 32 deg

Comparison of Treatment Effects

Normal Group Mod Hyper Group

T1T2

T1T2

Very Hyper Group Mod Hyper Group


T1T2

T1T2

Long Term Treatment Effects (T3-T2)

Subjects were stratified based on magnitude of change

in MPA from T1 to T2

Opening Group (N=26): increase of 1.5 degrees or more

Closing Group (N=23): decrease of 1.5 degrees or more

No significant differences were found between the opening and closing groups for any cephalometric variables.

Opening vs Closing Groups

Long Term Treatment Effects (T3-T2)

MPA T2-T3 change in the opening group: – 1.1 � 2.3 deg.MPA T2-T3 change in the closing group: – 1.2 � 2.3 deg.


Opening Group Closing Group

T1T2T3

T1T2T3

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Conclusions1. RME combined with full fixed appliances had no significant long-

term skeletal effects in the vertical dimension in hyperdivergentsubjects compared to patients with normal vertical relationships

2. Rapid maxillary expansion can be used effectively in patients with increased vertical dimension without detrimental effects to the dental and skeletal structures

An increased mandibular plane angle IS NOT a contraindication to RME therapy in growing patients

Aimto evaluate the long-term stability of Rapid Maxillary Expansion (RME) and posterior Bite-block (BB) therapy in growing subjects with anterior dentoskeletalopen bite when compared to a control group with untreated open bite

The Angle Orthodontist, in press


Treatment protocolRME soldered to bands on the second deciduous molars or on the first permanentmolars. The RME was left in place for at least 8 months as a passive retainer. No removable appliance was applied after RME removal.

The Angle Orthodontist, in press

The removable mandibular bite block (RMBB) appliance consisted of a lowerSchwartz plate with 5-mm-thick posterior occlusal resin splints. The RMBB wasprescribed for 12 months to control the vertical dimension. The patients wereinstructed to wear the BB 24 hours a day.

SubjectsTreated Group

University of Rome Tor Vergata

16 subjects (14 f 2 m)T1 = 8.1 y � 1.1 yT2 = 9.6 y � 1.2 yT3 = 13.5 y � 1.4 y

Control GroupAAOF Legacy Collection

16 subjects (14 f 2 m)T1 = 8.3 y � 1.2 yT2 = 9.6 y � 1.4 yT3 = 13.3 y �1.2 y

3 consecutive lateral cephalograms were taken before treatment (T1), at the end of the active treatment with the RME and RMBB (T2), and at a follow-up observation (T3) at least 4 years after the completion of treatment (CS 4-6)

Inclusion Criteria- No sucking habit- Negative overbite- MPA > 26 deg- Full eruption of first permanent molars and permanent incisors

Significant changes in facial divergence

increase in Overbite (+1.8 mm)

T1-T3 Changes

smaller extrusion of U6^PP (-1.9 mm) and L6^MP (-1.3 mm)

decrease of the verticalskeletal relationship(FH^Mand. Pl. -2.8°)


ConclusionsThe Angle Orthodontist, in press

The Treated Group exhibited reduced extrusion of maxillary and mandibularmolars and, consequently, a significant improvement in vertical skeletaldimension when compared with untreated open bite subjects

The effects of early treatment with RME and RMBB resulted stable ata long-term follow-up

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Anterior open bite (associated with sucking habits and/or abnormal tongue posture) can be treated effectively EARLY (in the early mixed dentition) either with removable or fixed cribs

Take home messages

Since removable cribs are not more effective than fixed ones, it is recommended to use fixed designs rather than removable ones(unless patients have poor oral hygiene or are at high risk for caries)

A modest control of skeletal open bite can be achieved AT PUBERTY with posterior bite blocks associated with VPCC that produces an elongation of the mandibular ramus and controls extrusion of the molars

Pearson, 2000

Take home messages

Pearson, 2000

Take home messagesAdolescent patients with mild to moderate skeletal open bitecan be successfully treated with less invasive and less costlynonsurgical orthodontics without notable compromises in long-term stability with respect to surgical treatment

Long-term stability of both orthodontic and surgical openbite treatments can be compromised by an anterior and/low tongue posture

Orthodontic treatment of OB relapse can be attempted only if combined with neuromuscolar re-education of abnormal tongue posture

Take home messages

Take home messagesIn patients with sucking habits, AOB, and skeletal open bite tendency, the QH-C appliance produces favorable long-term changes in overbite and intermaxillary divergence

Rapid maxillary expansion is not contraindicated in patientswith skeletal openbiteIn patients without sucking habits, AOB, and skeletal open bite tendency the RME and RMBB produce favorable long-term changes in overbite and facial divergence

The Michigan Team

Acknowledgments

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The Rome Team

Paola Cozza Roberta Lione

Acknowledgments

Chiara PavoniManuela Mucedero

“My Lord, give me the force to change the things thatI can change. Give me the courageto accept the things thatI cannot change. Give me, above all, the good senseto distinguish the first onesfrom the second ones”

Thomas More

[email protected] you!!

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