Anterior open bite treatment in the permanent dentition part 2-

Anterior Open Bite
Treatment in the Permanent
Dentition
Molars Intrusion
Dr.Marwan Mouakeh, Consultant Orthodontist
Academic Adviser, Al-Hokail Polyclinic – Khobar ( KSA)

Open Bite Correction With Posterior Teeth Intrusion
 Indications
 Severe skeletal open bite malocclusions with anterior face
height excess in growing and nongrowing patients.
 Vertical maxillary excess with overgrowth of the maxillary
posterior dentoalveolar heights.
 Anterior and posterior gummy smile.
 Increased posterior mandibular height.

 Skeletal Anterior Open Bite

 Main Cephalometric Characteristics of Skeletal
Open BiteMalocclusions
• Steep mandibular plane angle
• Short mandibular ramus
• Increased anterior facial height
• Decreased posterior facial height
• Increased lower anterior facial height
• Upward tipping of the anterior par
of the maxilla or palatal plane .

• Proportional discrepancy between anterior and
posterior facial heights
 Mechanism of Skeletal Open Bite (K.Yamaguchi )
•Any elongation of posterior
teeth will induce a clockwise
rotation of the mandible .
+
+

• Schudy , 1963
 Harmonious facial growth is characterized by a balance
between increment A and increments I,II,III, and IV .

Schudy , 1964
 Growth of the mandibular condyle
 Vertical growth of the corpus of
the maxilla (SN / PP) +
 Vertical growth of the maxillary
1st molar +
 Vertical growth of the mandibular
1st molar
Is less than the amount of
Clockwise Mandibular Rotation
 Hperdivergent Facial Type

 Growing patients :
Vertical growth modification
 Non-growing patients :
Intrude posterior teeth
Treatment of Skeletal Open Bites

 Nongrowing Patients
The goal is to intrude the molars instead of
holding them against growth .

• Traditional Orthodontic Methods :
 Modified transpalatal arch (TPA) with palatal button
 Low transpalatal arch (TPA)
 High pull headgear on the maxillary 1st molars
 Extraction of 3rd molars

• Traditional Orthodontic Methods :

 Modern Orthodontic Methods :
 Skeletal anchorage or use of temporary anchorage
devices TADs to actively intrude the maxillary and
mandibular posterior teeth .
Treatment – Skeletal Open Bites

 Surgical Approach
 Le Fort 1 osteotomy to reposition the maxilla
superiorly
 Posterior segmental maxillary osteotomy
 Vertical ramus osteotomy .

Open Bite Correction With
Posterior Teeth Intrusion
Skeletal Anchorage or
Temporary Anchorage Devices ( TADs)

 Challenges
• Avoiding extrusion of the upper labial segment.
• Preventing excessive buccal or palatal tipping of upper
molars during intrusion.
• Gaining access for TADs placement particularly on the
palatal aspect.
• Optimum siting of TADS to allow effective vertical
vectors of intrusion force.

 Types of Skeletal Anchorage
• Mini-implants
• Mini-plates

 Ideal Skeletal Anchorage ( Hernandez-Alfaro et al 2009)
• Simple to use
• Easy to insert and remove with minimal
trauma to surrounding tissues
• Small sized
• Biocompatible
• Resistant to immediate loading
• Inexpensive .

 Orthodontic Mini-plates
Main Indications :
• Narrow inter-radicular space
( especially between first and second
molars ).
• Narrow attached gingiva.
• Bone quality is poor.
• Amount of distal driving of posterior
teeth is › 3 mm.

Skeletal Anchorage Positioning for Molar Intrusion
• Buccally
 Near the mucogingival junction , between roots of
the adjacent teeth .
• Palatally
 Similar to buccally ,or
 Near the posterior midpalatal area.
• Zygomatic Buttress
 requires surgical procedures with special mini-implant
features ( 2.5mmdiameter, 14mm length ) ,or
a miniplate .

 Skeletal Anchorage Positioning for Molar Intrusion
• Buccally
 Near the mucogingival junction or further apically ,
between roots of the adjacent teeth .

• Palatally
 Similar to buccally , or near the posterior midpalatal area .

• The Most Frequent Mini-implants Characteristics
 Self-drilling thread
 Small diameter (1.5 mm)
 Moderate length ( 8 mm)
 Button head screw
 1mm or 3mm transgingival collar.

 requires surgical procedures with special mini-implant
features ( 2.5mm diameter, 14mm length ) or a miniplate .

Molar Intrusion Mechanics With
Skeletal Anchorage

Various Methods of Molar Intrusion
with TADs
Tae-Woo Kim ,
Clinical Application of Orthodontic Mini-implant . 2008

Various Methods of Molar Intrusion with TADs
Method 1
• 2 mini-implants from the buccal and palatal sides on
one tooth will exert intruding force without tipping.
Tae-Woo Kim , Clinical Application of Orthodontic Mini-implant

Method 1

Method 2
• 1 Midpalatal and 2 buccal mini-implants with TPA to
intrude molars.

Method 2

Method 3
• 2 Midpalatal mini-implants connected to each other
through a bar.

Method 4
• TPA with crown lingual torque and 2 buccal mini-implants
to intrude the molars .

Method 5
• TPA with buccal crown torque and a midpalatal mini-implant to
intrude the molars ( the preferred method ) .

Method 6
• Intruding lower molars using Buccal mini-implants
combined to Burstone lingual arch with lingual
crown torque .

• Intrusion force passing buccally to the center of resistance
of the maxillary molar
• A rotational moment (tipping) is created unless a
mechanical resource is applied to control this side effect.
CR
Molar Intrusion Mechanics With Skeletal Anchorage

 How to avoid buccal tipping during the
use of buccal intrusion?
• TADs placed on each side of the maxillary or
mandibular arch
• Use of TPA or lingual arch
• Insertion of lingual or palatal crown torque into the
main archwire
• Use of constriction secondary archwire in the
auxiliary tubes of the molars
• Keep the Hyrax expander as a palatal splint after
expansion .

• Mini-implant anchorage placed on each
side of the maxillary arch to obtain a
vertical tooth movement with minimal
undesirable buccolingual tipping .
S Brros & D.Garib , 2014
 How to avoid buccal tipping during the
use of buccal intrusion?

• TPA (3-4 mm distant from the palatal mucosa) used to prevent
molar tipping during intrusion mechanics with mini-
implant placed on the buccal side .
S Brros & D.Garib , 2014
 How to avoid buccal tipping during the use of
buccal intrusion?

 Magnitude of the intrusion force
• Maxillary Molars :
 Varies from 100 and 300 g for each side
 Always start with a small force magnitude
• Mandibular Molars :
 Varies between 300 to 450 g for each side.

 Each 1 mm of intrusion vertical movement of the molars
results in approximately 3mm of bite closure by mandibular
counterclockwise rotation .
 The AOB closure will be more effective the closer the
intruded teeth are to the TMJ ( mandibular hinge axis ).
 Clinical Tips

 In severe open bite cases , intrusion of both the maxillary
and mandibular molars may be necessary.
 Intrusion time : between 5 to 10 months .
 Clinical Tips

Tae-Woo Kim , 2013
The Use of Palatal Mini-implant
Method to Correct Anterior Open Bite
of Skeletal Origin

Palatal mini-implant method to correct
AOB of skeletal origin
• A Single midpalatal mini-implant associated to TPA with
crown buccal torque .
Tae-Woo Kim , 2013

• In open bite cases ,the buccal screws between the
1st and 2d molar fail very frequently .
•The stability is compromised when the implants are
placed near the alveolar crest .
Tae-Woo Kim , 2013

• The inter-radicular space between 1st and 2d molars is very
small.
• In open bite cases ,as the posterior teeth being intruded ,the
screw becomes closer to the alveolar crest and the periodontal
membrane .
 Disadvantages of the Buccal Min-implants in
open bite cases
Tae-Woo Kim , 2013

• More stability
• Possibility of placement more distally
(better biomechanically)
• Only 1 palatal mini-implant will be
required.
Advantages
Tae-Woo Kim , 2013

• Place a mid-palatal mini-implant
(1.6mm x 6mm ) , between 6 and 7
• Use TPA with (distal) hooks
• Insert an 019x025” SS archwire
• Apply a power chain tightly.
 Clinical Arrangement
Tae-Woo Kim , 2013

 Clinical Tips for Mid-palatal Mini-implant
1- There should be some space between the TPA and
palatal tissue to prevent impingement of palatal tissue as
the molars are being intruded.
Tae-Woo Kim , 2013

2- How to ligate the power chain
Tae-Woo Kim , 2013

3- Measure the mid-palatal bone thickness .
Use a 1.6x6mm mini-implant
Tae-Woo Kim , 2013

4- Place mini-implant more distally
•The upper posterior teeth will be intruded more efficiently .
Tae-Woo Kim , 2013

4- Place mini-implant more distally
Tae-Woo Kim , 2013

5- Attach hooks distally and ginivally
•Greater vertical intruding vector
•More efficient for intruding second molars
Tae-Woo Kim , 2013

6- Extract upper 3rd or 2d molars to remove the wedging
effect and provide the space for intrusion.
Tae-Woo Kim , 2013

7 - Manage upper arch constriction :
- Expand TPA
- Expand main archwire (0.019x0.025” SS ) with slight
crown buccal torque
Tae-Woo Kim , 2013

8 - To control intrusion of the upper 2d molar
- Add soldered hook palatally and / or
Clinical Tips for Mid-palatal Mini-implant
Tae-Woo Kim , 2013

8 - To control intrusion of the upper 2d molar
- Add buccal L loop with an intrusion step between 1st and
2d molars .
Tae-Woo Kim , 2013

9 - Monitor eruption of lower molars :
•Lower molar extrusion prevents mandible from rotating
counterclockwise
Tae-Woo Kim , 2013

• Active intrusion of lower molars if they extrude
 Burstone lingual arch with lingual crown torque + buccal
mini-implants .
Tae-Woo Kim , 2013

• Active intrusion of lower molars if they extrude
Tae-Woo Kim , 2013

- Passive lingual arch with posterior bite raiser
Tae-Woo Kim , 2013

10 – Intruding force should be strong enough
Tae-Woo Kim , 2013

11 - Retain the TPA and mid-palatal mini-implant during
finishing stage :
- To avoid any relapse related to extrusion of the
intruded upper molars .
Tae-Woo Kim , 2013

Tae-Woo Kim , 2013

 Segmented or Continuous Archwires ?
• Indications
 Upper incisor display at rest and
smile is normal or excessive
 Lip incompetency
 Lower anterior face height is large
 Evident compensating curve in the
upper dental arch .
 Segmented Archwire

 Segmented or Continuous Archwires ?
 Continuous Archwire
• Indications
 Upper incisor display during rest or smile lacking
and some incisor extrusion will be esthetically
favorable
 Mild lip incompetency
 Lower anterior face height is slightly large
 Mild compensating curve in the upper dental arch.

Dr . Colin Melrose
• Correction of Anterior Open Bite
& Class II Malocclusion Using
TADS & Segmented Archewires
Mechanics .

• Correction of Anterior Open Bite & Class II Malocclusion
Using TADS & Segmented Archewires Mechanics .
Dr . Colin Melrose

• Correction of Anterior Open Bite
& Class II Malocclusion Using
TADS & Segmented Archewires
Mechanics .
Dr . Colin Melrose

• Correction of Anterior Open Bite & Class II Malocclusion
Using TADS & Segmented Archewires Mechanics .
Dr . Colin Melrose

• Correction of Anterior Open Bite & Class II Malocclusion Using
TADS & Segmented Archewires Mechanics .
Dr . Colin Melrose

• Initial Photos
L. Piedade . Anterior Open Bite , Invisalign Cases Gallery
 Correction of skeletal anterior open bite using TADs
with Invisalign orthodontics.

• Initial Photos
 Anterior open bite
 Moderate anterior
crowding

• Initial Photos

• Panoramic X-Ray • Cephalometric X-Ray

 Treatment Plan and Mechanics
• Intrusion of maxillary posterior teeth using TADs
with Invisalign orthodontics
• Interproximal stripping to relieve moderate crowding
• Sequential use of vertical intermaxillary and Class III
elastics

• Placement of 2 palatal posterior mini-implants “Vector, 8mm”

• Placement of 2 buccal posterior mini-implants “Vector 8mm”

• 13 months through active
treatment

treatment

• Finishing

• Anterior Open Correction with Invisalign Orthodontics
and Skeletal Maxillar Anchorage

• Anterior Open Correction with Invisalign Orthodontics and Skeletal
Maxillary Anchorage.

• Anterior Open Correction with Invisalign Orthodontics and Skeletal
Maxillary Anchorage

 Different Clinical Protocol
 Corticotomy and Skeletal Anchorage
to enhance the intrusion movement of the maxillary
molars (Moon 2007 ).
• Intrusion will be twice greater
than that obtained without
corticotomy in less than 2
months ( Akay 2009 ).

 Corticotomy and Skeletal Anchorage
• Schematic illustration of maxillary
corticotomy and skeletal
anchorage with miniplate .

Two Types of Vertical Excess :
 V.E with anterior open bite
 V.E with normal overbite
 Treatment of choice for vertical excess with anterior open
bite is Molar Intrusion which will automatically close the
anterior open bite.
C . H Paik , AAO Annual Session 2013

 Treatment of choice for vertical excess with anterior open
bite is Molar Intrusion which will automatically close the
anterior open bite.

• Molar intrusion induces traumatic anterior bite.
• To solve this problem ,intrusion of both the molars and anterior
teeth is necessary , eventually resulting total intrusion of the
whole dentition.
 Slow Impaction of the
whole dentition
 Treatment of choice V.E with normal overbite

• Total intrusion of the whole dentition
 Molar intrusion by TADs
 Anterior intrusion by Accentuated Curve of Spee
or Gable bend .
 Treatment of choice V.E with normal overbite

• Total intrusion of the whole dentition
 Molar intrusion by TAD
 Anterior intrusion by ACOS or Gable bend
• Treatment of choice V.E with normal overbite

 Usually, Maxilla
 Because of the stability & convenience
of the mini-implant fixation .
 Which side should we intrude ? Upper , lower or both?
Total Intrusion of the Whole Dentition

• Upper molar intrusion using midpalatal mini-implant and TPA
formed with thicker wire to resist lingual dumping of the
upper molars .

 Occasionally , Mandible
 Steep occlusal plane angle
 Lack of incisor showing
 Lack of sufficient overjet
To preserve upper incisor display in patients with insufficient amount of
upper incisor showing .
For the simultaneous retraction of the lower dentition and intrusion of
lower molars subsequent to counterclockwise mandibular rotation.
To avoid further steepening of the occlusal plane.
 Total Intrusion of the Whole Dentition

• Lower molars intrusion ( associated with anterior teeth
retraction ) using a single buccal mini-implant .

 In Severe Open Bite Cases where maximal
closure of the mandibular plane angle is
needed , double intrusion ( upper and lower
molars ) is recommended .
 Total Intrusion of the Whole Dentition

Extraction Options in Class II Open Bite Cases
Tae-Woo Kim, 2013

 Extraction of upper & lower second molars
• Indications
 3rd molars are good in shape
 3rd molars have erupting.
potential . Adolescent patients
are good .
 The angle between 7 & 8 is
between 20⁰-30⁰ .
 Posterior crowding .

 Effects of second molars
extraction:
 Center of rotation moves forward
 Wedge is removed
 Number of teeth to be intruded is
reduced .
 Regional Acceleratory Phenomenon (RAP)
can be utilized to maximize the intrusion rate
, provided that extraction is performed when
starting bite closure .

 Extraction of upper 2d molars & lower 3rd molars
• Indications
 Upper 3rd molars are good in
shape, but lower ones are
abnormal in shape or impacted.
 3rd molars have erupting
potential. Adolescents patient
are good.
 The angle between upper 7 & 8 is
between 20⁰-30⁰.

• Indications
 In adolescent or adult patients
where 3rd molars are not good
in shape or impacted .
 Extraction of upper & lower 3rd molars
 Bite closing is slower than in
2d molars extraction cases .

 Extraction of 3rd molars
provides spaces for necessary
to intrude 2d molars.
 By extracting 3rd molars ,
bite closing is facilitated .

• Indications
 Class II canine and molar
relationship
 Severe upper anterior protrusion
and labial inclination
 Upper anterior crowding.
 Extraction of upper 1st & lower 2d bicuspids

• Indications
 Class II canine and molar
relationship
 Mild to moderate upper anterior
protrusion and normal labial
inclination
 Slight upper anterior crowding.
 Extraction of upper & lower 2d bicuspids
 Bite closing is facilitated by this type of extraction .

 Extraction of bicuspids also helps bite closing , because
 Wedging molars are moved forward .

 Extraction of bicuspids also helps bite closing , because
 Mesial movement of wedging molars is good to correct
the open bite

 Extraction of bicuspids also
helps bite closing , because :
 Number of teeth to be
intruded is reduced .

 In Non-extraction cases , it is
strongly recommended to
extract 3rd molars before
starting open bite closure .
 Bite closing is much slower than
in 2d molar extraction cases.

 Dentoskeletal Effects of Molar Intrusion
 The Primary effect is:
True molar intrusion with significant reduction of
posterior dentoalveolar height.

 A Counterclockwise mandibular rotation with significant
reduction of the total and lower anterior face height
 Increase in overbite without incisor extrusion
 Anterior mandibular repositioning ,in growing patients
,which decreases ANB angle and improves facial convexity
 Reduction of the interlabial gap and correction of lip
incompetency .
• Secondary Effects

• Maxillary molar intrusion is followed by a counterclockwise
mandibular autorotation and decrease in lower anterior face
height.
S. Barros & D.Garib in Janson Open-bite malocclusion. 2014

 Main Dentoskeletal Effects and Esthetics Effects
• Occlusal plane leveling at the expense of molar intrusion
• Overbite increase
• Lower anterior face height decrease
• Mandibular plane angle reduction
• Counterclockwise mandibular rotation
• Class II skeletal discrepancy decrease
• Posterior gummy smile correction
• Prevention of anterior teeth extrusion
• Lip seal improvement
• Unchanged anterior gingival exposure upon smiling
• Facial convexity angle reduction

Skeletal Anchorage for Molar Intrusion
• Indications - Summary - :
 Open bite malocclusions that need actual
intrusion of posterior teeth
 Skeletal open bite malocclusions with posterior
dentoalveolar and anterior face height excess
 Control of the vertical position of the posterior
teeth during anterior teeth extrusion
 Relative molar intrusion in growing patients
( restriction of the posterior alveolar growth).

1 – Monitor the possible causes ( tongue thrust , mouth
breathing, TMJ derangements …. ).
2- Use a fixed retainer ( 4 - 4 )
 Retention and Stability
3- Instruct patient to perform
chewing exercises many times
during the day.

4- When a relapse tendency found , apply labial buttons
( U2-2/ L 3-3 ) with vertical elastics.
 Retention and Stability

113th Annual Session
American Association of Orthodontists
Treatment and Stability of Anterior Open Bite
Guilherme JANSON

Anterior Open Bite - Treatment Stability
 In the Deciduous and Mixed Dentitions
- Close to 100% ( tongue crib & spurs )

 In the Permanent Dentition
- Non –extraction treatment : 62%
- Extraction treatment : 74%

 In the Permanent Dentition
- Non –extraction treatment : 62%
- Extraction treatment : 74%
Extraction treatment is more stable than non-extraction
treatment.

 Treatment by posterior teeth intrusion :
- Molar intrusion rate is around 20% -3o%

 Treatment with occlusal adjustment :
- Around 67%

 Orthodontic- Surgical Treatment
- Over 75%

Anterior open bite treatment in the permanent dentition part 2-

Anterior open bite treatment in the permanent dentition part 2-

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Anterior open bite treatment in the permanent dentition part 2-