Biomechanical Consideration in Openbite-Ortho / Orthodontic Courses by Indian Dental Academy

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INDIAN DENTAL
ACADEMY
Leader in continuing dental education
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BIOMECHANICAL
CONSIDERATIONS IN
OEN BITE
CONTENTS
CONTENTS
Introduction.
De!inition.
Ty"e# O! $ertical Malocclu#ion.
O%er%iew O! O"en Bite.
Etiologic Con#ideration.
E#t&etic Con#ideration.
'unctional Con#ideration
Clinical Con#ideration
Ce"&alometric Critera
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E(amination o! Oro)'acial Dy#!unction
*
Swallowing
*
Tongue)t&ru#t
*
C&ee+ Dy#!unction
*
Mout& Breat&ing
E,uili-rium T&eory
In!luence O! Na#o)re#"iratory 'unction
Long 'ace Syndrome
T&e A##ociation Between Anterior O"en*Bite
and Amelogene#i# Im"er!ecta
Treatment In rimary Dentition
Treatment In Mi(ed Dentition
$ariou# 'unctional A""liance# 'or Treatment
O! O"en Bite
Treatment In ermanent Dentition
Conclu#ion.
Introduction
Introduction
.. /&at i# an o"en -ite0
1. T&e diagno#tic criteria o! o"en -ite re,uire
clari!ication0
2. /&at are we tal+ing a-out a# we loo#ely u#e t&e
de#cri"ti%e term o"en -ite0
3. I# it 4u#t a %ariation on anot&er t&eme)a %aria-le o! t&e
dental occlu#ion0
5. I# it a #e"arate clinical entity in w&ic& t&e o"enne##
-etween t&e u""er and lower teet& i# t&e only !actor
in%ol%ed0
Etiologic !actor# Etiologic !actor# related to o"en)-ite mu#t "recede any

di#cu##ion o! clinical treatment
Succe##!ul ort&odontic t&era"y u#ually re,uire# a a
care!ul a""rai#al o! etiological !actor#. care!ul a""rai#al o! etiological !actor#.
6n!ortunately7 it i# not alway# "o##i-le to remo%e it i# not alway# "o##i-le to remo%e
!actor# !actor# t&at &a%e cau#ed or contri-uted to e(i#ting
malocclu#ion.
6n!a%ora-le growt& 6n!a%ora-le growt& or genetic determinant# genetic determinant# o! a

malocclu#ion7 including o"en)-ite cannot -e altered or
remo%ed #ucce##!ully.
DEFINITION
DEFINITION
Description of open-bite differ among various
authors and investigators.
.. O"en)-ite to -e "re#ent w&en t&ere i# le## t&an an
a%erage o%er-ite.
1. O"en)-ite to -e "re#ent w&en t&ere i# edge)to edge
relation#&i".
2. O"en)-ite to -e "re#ent w&en t&ere i# de!inite degree
o! o"enne## mu#t -e "re#ent.
O"en)-ite mu#t -e con#idered a# a de%iation in t&e
%ertical relation#&i" o! t&e ma(illary and mandi-ular
dental arc&e#.
In an o"en)-ite t&ere #&ould -e a de!inite lac+ o!
contact7 in t&e %ertical direction7 -etween o""o#ing
#egment# o! teet&.
T&e degree o! o"enne## can %ary !rom "atient to
"atient7 -ut an edge)to)edge relation#&i" or #ome
degree o! o%er-ite cannot -e rig&t!ully categori8ed a#
an o"en)-ite.
T&e lo## o! contact7 in t&e %ertical direction7 o!
#egment# o! teet& can occur -etween t&e anterior t&e anterior
#egment# #egment# or -etween t&e -uccal #egment# -uccal #egment#.
T9ES O' $ERTICAL
T9ES O' $ERTICAL
MALOCCL6SION
MALOCCL6SION
TYPES OF VERTICAL MALOCCLUSION
TYPES OF VERTICAL MALOCCLUSION
ro-lem# in t&e %ertical dimen#ion include# o"en -ite
and dee" -ite malocclu#ion and al#o !acial
di#!iguration.
Some "ro-lem# can -e di%ided into t&o#e t&at are
limited to t&e dentoal%eolar area and t&o#e t&at
"redominantly are o! #+eletal nature.
Dentoal%eolar : O"en ; Dee" Bite
S+eletal : Hy"o ; Hy"er di%ergent
<S&ort ; Long !ace #yndrome=
I! only dentoal%eolar #tructure# dentoal%eolar #tructure# are in%ol%ed7 t&e term#
o"en -ite and dee" -ite are u#ed.
I! #+eletal #tructure# #+eletal #tructure# are in%ol%ed7 t&e ty"e# o! %ertical
!acial "attern# can -e de#cri-ed a# &y"erdi%ergent and
&y"odi%ergent.
T&e#e %ertical dy#"la#ia# clinically &a%e -een termed
long !ace #yndrome and #&ort !ace #yndrome.
>enerally7 !acial "attern# wit& a mandi-ular "lane angle
greater t&an 2? 2?
? ?
are con#idered &y"erdi%ergent7 and
le## t&an 1? 1?
? ?
&y"o di%ergent.
Skeletal open bite a# a re#ult o!
increa#ed downward and -ac+ward
inclination o! t&e mandi-le. T&e
mandi-ular angle i# increa#ed.
Open bite of dentoalveolar origin a# a
re#ult o! underde%elo"ment anteriorly o!
t&e ma(illary and mandi-ular al%eolar
"roce##e#.
Differentiation et!een Skeletal "
Differentiation et!een Skeletal "
Dentoalveolar #alocclusion
Dentoalveolar #alocclusion
O$ER$IE/ O' OEN BITE
O$ER$IE/ O' OEN BITE
Overview of Open Bite
Overview of Open Bite
Non)Occlu#ion
.. Traditionally o"en -ite : @o""o#ing teet& do not meetA.
1. $ander Linden7 &owe%er7 &a# indicated t&at t&e
o%erla" criterion i# ar-itrary and i# a##ociated wit& t&e
#agittal relation -etween t&e teet& in%ol%ed.
2. T&e a-#ence o! an Occlu#al #to" -etween t&e teet&
wit& t&eir antagoni#t# or o""o#ing gingi%a i# o! greater
#igni!icance.
3. A-#ence o! #uc& a #to" mean# t&at t&e eru"tion
"roce## &a# -een arre#ted -y one or more !actor#.
5. T&e #ame %iew wa# e("re##ed -y Moyer#7 w&o #tated
t&at it i# mo#t im"ortant to u#e t&e term @o"en -iteA !or
all condition# c&aracteri8ed -y t&e a-#ence o! an
Occlu#al #to".
B. In t&e international literature7 &owe%er7 t&i#
recommendation &a# not -een im"lemented7 and t&e
term Co"en -iteA #till i# u#ed only !or condition# wit&out
%ertical o%erla".
D. T&e recently "u-li#&ed >lo##ary o! ort&odontic Term#
de!ine# non)occlu#ion a# any #ituation in w&ic& t&e
teet& do not &a%e maximum contact wit& t&eir
antagoni#t# in &a-itual occlu#ion.
8. Anterior non-occlusion Occur# in t&e inci#or area and
u#ually i# a##ociated wit& #ome degree o! o%erla" o!
t&e inci#or#7 a# o-#er%ed o!ten in "atient# wit& Class II,
division 1 malocclusion.
9. Posterior non-occlusion can occur in t&e "remolar or
molar region7 wit& great %ariation occurring in t&e
num-er o! teet& and t&e Occlu#al #ur!ace# in%ol%ed.
10. Total non-occlusion7 t&e tongue i# "o#itioned -etween
t&e o""o#ing teet& mo#t o! t&e time.
11. Non-occlusions are more common t&an o"en -ite#.
T&at &old# true !or t&e anterior and "o#terior region#.
/&en a#+ed to
clo#e t&e teet&
toget&er.
Ha-itual
"o#itioning
o! Tongue
ESTHETIC CONSIDERATIONS
ESTHETIC CONSIDERATIONS
EST$ETI% %ONSIDE&'TIONS
EST$ETI% %ONSIDE&'TIONS
.. Balance -etween t&e no#e7 li"#7 and c&in "ro!ile i#
e##ential !or o"timal e#t&etic#.
1. T&e nasolabial angle al#o i# im"ortant.
2. T&e dentoalveolar open ite malocclu#ion i#
e#t&etically unattracti%e "articularly during #"eec&
w&en t&e tongue i# inter"o#ed -etween teet& and t&e tongue i# inter"o#ed -etween teet& and t&e
li"#. li"#.
3. T&e lower !acial t&ird lower !acial t&ird i# elongated in "atient# wit&
!"eletal open ite#
'6NCTIONAL
'6NCTIONAL
CONSIDERATION
CONSIDERATION
F(N%TION') %ONSIDE&'TION
F(N%TION') %ONSIDE&'TION
1. Tongue osture and !unction #&ould -e "rimary
con#ideration# in O"en)-ite "ro-lem#.
E Acc. To ro!!it @i! a "atient &a# a !orward t&ru#ting
"o#ture "o#ture o! t&e tongue t&e d$ration o! t&i# "re##ure
e%en i! %ery lig&t could a!!ect toot& "o#ition %ertically or
&ori8ontallyA.
1. Di!!erentiation -etween "rimary cau#al and #econdary
ada"ti%e or com"en#atory tongue dy#!unction i#
e##ential.
E Acc. to ro!!it @A tongue t&ru#t #wallow i# a u#e!ul
"&y#iologic ada"tation "&y#iologic ada"tation i! you &a%e an o"en -ite7 w&ic&
i# w&y an indi%idual wit& an o"en -ite al#o &a# a tongue
t&ru#t #wallowA <i.e. Secondary ada"ti%e tongue
dy#!unction=
'ccording to ahr and $olt* four varieties
'ccording to ahr and $olt* four varieties
of
of
tongue thrust
tongue thrust
ma+ be differentiated
ma+ be differentiated
F
F
1. Tongue t"rust wit&out de!ormation wit&out de!ormationF) F) De#"ite t&e
a-normal !unction7 no de!ormation# en#ue#.
#. Tongue t"rust cau#ing anterior cau#ing anterior de!ormationF) i.e
anterior o"en -ite7 #ometime# cou"led wit& -ilateral
narrowing o! t&e arc& and a "o#terior cro##-ite.
Moyer# <.GB3= term# t&i# a simple open bite.
$. Tongue t"rust cau#ing buccal segment de!ormation%-
wit& a osterior oen bite i# o!ten #een clinically.
Lateral tongue t&ru#t acti%ity al#o can -e re#"on#i-le
!or a !unctional dee" -ite7 a %ariation o! t&e "o#terior
o"en -ite. Some Cla## II7 di%i#ion 1 malocclu#ion !it
t&i# category. In%agination o! t&e c&ee+ into t&e
interocclu#al #"ace al#o may -e a !actor in t&i#
dy#!unction.
&. Combined tongue t"rust%- cau#ing -ot& an anterior
and a "o#terior o"en -ite7 i# anot&er common
dy#!unction. T&i# i# called a comple, open bite -y
Moyer# and i# more di!!icult to treat.
'ccording to &akosi* four varieties of
'ccording to &akosi* four varieties of
open bite
open bite

due to tongue posture ma+ be differentiated
due to tongue posture ma+ be differentiated
F
F
Anterior Open Bite Anterior Open Bite
O"en -ite in a deciduou#
dentition7 cau#ed -y a tongue
dy#!unction a# a re#iduum o!
a #uc+ing &a-it.
%ait$al po!ition
T&e tongue "o#itioned !orward
during !unctioning7 t&u#
im"eding t&e %ertical
de%elo"ment o! t&e
dentoal%eolar #tructure# around
t&e u""er and lower anterior
teet&.
Lateral Openite
Occlu#ion7 In t&i# ty"e o! o"en -ite
t&e occlu#ion on -ot& #ide# i#
#u""orted only anteriorly and -y t&e
!ir#t "ermanent molar#.

%ait$al Po!ition
T&e tongue t&ru#t# -etween t&e
teet& laterally.
T&e tongue dy#!unction occur# in
con4unction wit& a di#tur-ance in
t&e "&y#iologic growt& "roce##ed
around t&e !ir#t and #econd
deciduou# molar#.
Co&ple' open ite(
Se%ere %ertical
malocclu#ion. T&e teet&
occlude only on t&e #econd
molar#.
%ait$al Po!ition
Tongue)t&ru#ting occur#
during !unction.

Ton)$e d*!f$n+tion and
&alo++l$!ion(
In mandi-ular "rognat&i#m7
t&e downward !orward
di#"lacement o! t&e tongue
o!ten cau#e# an anterior
tongue)t&ru#t &a-it.
CEHALOMETRIC CRITERIA
CEHALOMETRIC CRITERIA
Ce"&alometric Criteria
Ce"&alometric Criteria
A "ro"er ce"&alometric analy#i# ena-le# a cla##i!ication o!
o"en -ite malocclu#ion#F
.. Dento Al%eolar O"en Bite.
1. S+eletal O"en Bite.
.. o#itional De%iation#.
1. Dimen#ional De%iation#
2. S+eletal Cla## II O"en Bite
3. S+eletal Cla## III O"en Bite
Dento al%eolar o"en -ite
.. T&e e(tent o! t&e dentoal%eolar o"en -ite de"end# on
t&e e(tent o! t&e eru"tion o! t&e teet&.
1. Su"raocclu#ion o! t&e molar# and in!raocclu#ion o! t&e
inci#or# can -e "rimary etiologic !actor#.
2. In %ertical growt& "attern# t&e dentoal%eolar #ym"tom#
include a "rotru#ion in t&e u""er anterior teet& wit&
lingual inclination o! t&e lower inci#or#.
3. In &ori8ontal growt& "attern#7 tongue "o#ture and t&ru#t
may cau#e "roclination o! -ot& u""er and lower
inci#or#.
5. A lateral o"en -ite may -e con#idered dentoal%eolar in
com-ination wit& in!ra)occlu#ion o! molar teet&.
Verti+al )rowt, pattern a!!o+iated wit, anterior ton)$e
d*!f$n+tion
In $ertical growt& "attern7 tongue
t&ru#t tend# to ti" t&e u""er inci#or#
to t&e la-ial and t&e lower inci#or#
to t&e lingual.
E "rotru#ion in t&e u""er anterior
teet& wit& lingual inclination o!
t&e lower inci#or#.
E o%er eru"tion o! "o#terior teet&
and #tee"er t&an normal
mandi-ular "lane
%ori-ontal )rowt, pattern a!!o+iated wit, anterior ton)$e
d*!f$n+tion
Hori8ontal growt& "attern7
tongue t&ru#t cau#e#
-ima(illary dental "rotru#ion7
i.e. la-ial ti""ing o! u""er and
lower anterior teet&.
T&e inci#or relation#&i"# in a
ca#e wit& an anterior o"en
-ite7 tongue)t&ru#t7 and
&ori8ontal growt& "attern
S+eletal O"en Bite
S+eletal O"en Bite
.. Dy#gnat&ia wit& a %ertical growt&
"attern
1. T&e downward and -ac+ward
rotation o! t&e mandi-le i# t&e
cau#e o! t&e anterior o"en -ite.
T&e gonial angle and it# lower
#egment are mar+edly enlarged.
2. T&e clinical "icture o! t&e o"en -ite
i# "artly com"en#ated -y t&e
linguo)%er#ion o! t&e u""er anterior
teet&.
S"eletal Open.Bite
S"eletal Open.Bite

.. o#itional de%iation#.
1. Dimen#ional de%iation#.
Po!itional /eviation!
Po!itional /eviation!
Acc to Sa##ouniH
.. T&e !our -ony "lane# o! t&e !ace are #tee" to eac&
ot&er7 -ringing t&e center ? clo#e to t&e "ro!ile.
1. T&e anterior arc7 t&ere!ore !ollow# t&e con%e(ity o! t&e
"ro!ile.
diagram
2. T&e "o#terior %ertical c&ain o! mu#cle# i# arcuate7 and
t&e ma##eter mu#cle i# "o#terior to t&e -uccal teet&7
t&u# creating a me#ial com"onent o! !orce#
re#"on#i-le !or t&e dental "rotru#ion.
3. T&e cranial -a#e angle and t&e gonial angle are o-tu#e.
5. T&e long a(i# o! t&e inci#or# !orm# a #mall interinci#al
angle.
B. Alt&oug& t&e inci#or# are u#ually more e(truded in t&e
o"en)-ite ty"e7 t&i# e(tru#ion i# not #u!!icient to
e#ta-li#& t&eir %ertical contact.
Dimensional Deviations
Dimensional Deviations
.. T&e total "o#terior !acial &eig&t <S)>o= tend# to -e &al!
t&e #i8e o! t&e anterior total !acial &eig&t <N)Me=.
1. T&e lower anterior !acial &eig&t e(ceed# t&e u""er
anterior !acial &eig&t.
2. T&e !acial -readt&# tend to -e narrow7 gi%ing a long7
o%oid a""earance in t&e !rontal %iew.
3. T&e na#al a"erture# are narrow.
5. T&e ramu# i# #&ort wit& an antegonial notc& at it# lower
-order.
B. T&e mandi-le #eem# to &a%e retained it# in!antile
c&aracteri#tic#7 wit& all it# "roce##e# underde%elo"ed.
D. T&e tem"oral !o##a i# #mall7 #ugge#ti%e o! wea+
mu#culature.
I. T&e mandi-ular #ym"&y#i# i# narrow antero "o#teriorly
and long %ertically.
G. T&ere i# a lac+ o! c&in mental "rotu-erance
de%elo"ment.
.?.T&e cranium i# #ometime# dolic&oce"&alic.
... According to t&e S&eldonian #omatoty"ing7 t&e o"en)
-ite ty"e rate# &ig& in ecto)mor"&#.
.1. ro"ortionally large teet& c&aracteri8e t&e dentition.
.2. Crowding and -i)dental "rotru#ion are o!ten "re#ent.
.3. Im"action or ecto"ic eru"tion o! t&ird molar# i#
!re,uent.
.5. T&e "alatal %ault i# &ig& and narrow.
.B. T&e mout& i# wide. T&e -road li"#7 #&ort %ertically
relati%e to t&eir #+eletal #u""ort7 are +e"t a"art at re#t7
leading to mout& -reat&ing.
.D. /&en t&e li"# are !orci-ly clo#ed7 t&e mentali# mu#cle
i# di#"laced u"ward. T&i# !urt&er increa#e# t&e
@c&inle##A a""earance o! t&e#e "er#on#.
S-E)ET')
S-E)ET')
%)'SS II
%)'SS II
O.EN ITE
O.EN ITE
.. T&i# com-ination i# "rimarily an o"en)-ite ty"e7
"o#itionally and dimen#ionally.
1. T&e ma4or %ariant &ere i# in t&e antero)"o#terior
dimen#ion# o! t&e 4aw#. T&e "alate may -e longer7 and
t&e mandi-le #&orter.
2. T&e di!!erential e%aluation o! t&e#e two "o##i-ilitie# i#
im"ortant7 a# t&e "rogno#i# and t&e treatment a""roac&
may -e di!!erent.
3. In t&i# re#"ect7 it "oint# out t&at a gi%en dental Cla## II
malocclu#ion may -e "re#ent in o""o#ite !acial ty"e#.
5. In t&i# ty"e7 in #ome in#tance#7 t&e rotation o! t&e
mandi-le may -e "urely "o#itional. O!ten t&i# i# due to a
downward and -ac+ward rotation o! t&e mandi-le.
B. T&i# rotation i# a##ociated wit& e(ce##i%e e(tru#ion o!
t&e molar#. I! t&e#e inter!erence# were remo%ed7 t&e
mandi-le could -e "ermitted to rotate in a clo#ing
direction7 im"ro%ing t&e Cla## II and t&e o"en)-ite
"attern# #imultaneou#ly.
S-E)ET')
S-E)ET')
%)'SS III
%)'SS III
O.EN ITE
O.EN ITE
.. T&i# com-ination con#i#t# "rimarily o! an o"en)-ite wit&
a "alatal de!iciency or a large mandi-le.
1. Among t&e !acial de!ormitie#7 t&e#e &a%e "ro-a-ly t&e
wor#t "rogno#i# in term# o! dento!acial ort&o"edic#.
2. I! correction o! t&i# o"en)-ite i# attem"ted -y rotating
t&e mandi-le in a clo#ing direction7 t&e "rotru#ion o! t&e
c&in i# increa#ed.
3. On t&e ot&er &and7 t&e reduction o! t&e mandi-ular
"rotru#ion i# attem"ted -y rotating t&e mandi-le
downward and -ac+ward7 t&e o"en)-ite i# increa#ed.
5. E%en #urgical correction o! t&e mandi-le i# o! limited
-ene!it &ere7 a# t&e teet& inter!ere in t&e clo#ing o! t&e
lower !ace &eig&t.
S-E)ET') O.EN ITE
S-E)ET') O.EN ITE
S0ELETAL FACTORS IN T%E /EVELOPMENT
S0ELETAL FACTORS IN T%E /EVELOPMENT
OF AN OPEN BITE TYPE(
OF AN OPEN BITE TYPE(
.. T&e "o#terior &al! o! t&e "alate i# ti""ed downward7
carrying t&e molar# !urt&er downward. T&i# gi%e# ri#e to
a large "alatomandi-ular "lane angle.
1. T&e com-ination o! an e(ce##i%e de%elo"ment o! t&e
u""er mid)!ace &eig&t# <cranial -a#e to molar#= and a
lac+ o! de%elo"ment o! "o#terior !acial &eig&t# <S)>o=
re#ult# in t&e downward and -ac+ward rotation o! t&e
mandi-le.
2. Becau#e o! t&e #&ort ramu# and t&e lower "alate7 t&e
"&aryngeal #"ace i# con#tricted. In order to -reat&e7
t&e#e "er#on# +ee" t&eir tongue# !orward. 'urt&er
en&anced -y t&e dental o"en)-ite7 t&ere i# a tongue)
t&ru#ting tendencie#.
3. /&en enlarged ton#il# are "re#ent7 t&e tongue i# !urt&er
con!ined anteriorly. A# t&e narrow "alatal %ault reduce#
t&e nece##ary #"ace7 t&ere i# a tendency toward
tongue "rotru#ion. T&i#7 in turn7 may -e a !actor in t&e
creation o! -i)dental "rotru#ion.
Vario$! For&! Of Anterior Open Bite
Vario$! For&! Of Anterior Open Bite
.. An o%er4et com-ined wit& an o"en -ite o! le## t&an .mm le## t&an .mm
can -e de#ignated a# p!e$do.open ite prole&!.
1. A simple open bite e(i#t# in ca#e# in w&ic& more t&an
. mm o! #"ace may -e o-#er%ed -etween t&e inci#or#7
-ut t&e "o#terior teet& are in occlu#ion.
2. A comple, open bite de#ignate# t&o#e ca#e# in w&ic&
t&e o"en -ite e(tend# !rom t&e "remolar# or deciduou#
molar# on one #ide to t&e corre#"onding teet& on t&e
ot&er #ide.
3. T&e compound or infantile open bite i# com"letely
o"en7 including t&e molar#.
5. T&e iatrogenic open bite i# t&e con#e,uence o!
ort&odontic t&era"y7 w&ic& "roduce# aty"ical
con!iguration# -ecau#e o! a""liance mani"ulation or
ada"ti%e neuromu#cular re#"on#e.
.. T&e >lo##ary o! Ort&odontic Term# de!ine# o"en -ite a#
a de%elo"mental or ac,uired malocclu#ion w&ere-y no
%ertical o%erla" e(i#t# -etween ma(illary and
mandi-ular anterior or "o#terior teet&.
1. t&e latter are cau#ed -y tongue inter"o#ition or -y
di#tur-ance# in eru"tion <e.g an+ylo#i#=.
2. o#terior o"en -ite# rarely are due to "rimary !ailure o!
eru"tion. De!ect# in eru"tion o!ten are a##ociated wit&
%ariou# cranio!acial #yndrome#7 including cleidocranial
dy#"la#ia and Car"enterJ# #yndrome.
Clinical a##e##ment o! dental o"en -ite
3. An o"en -ite wit&out !acial di#!iguration i# cla##i!ied a#
a dental o"en -ite and !re,uently i# cla##i!ied a# dental
o"en -ite and !re,uently i# a##ociated wit& a digital
#uc+ing &a-it and ; or tongue inter"o#ition.
5. T&e c&aracteri#tic# o! a dental o"en -ite include
"ro-lem# ty"ically re#tricted to t&e anterior teet& and
immediately a##ociated &ard and #o!t ti##ue #tructure#
wit&out remar+a-le ce"&alometric !inding#.
/ertical #alposition
/ertical #alposition
$ertical mal"o#itioning o! grou"# o! teet& i# 4udged in
relation to t&e occlu#al "lane.
@In!ra%er#ionA or @in!raocclu#ionA indicate# t&at teet&
&a%e not yet reac&ed t&e le%el o! t&e occlu#al "lane.
T&i# mal"o#itioning u#ually occur# in con4unction wit&
irregularitie# in t&e %ertical de%elo"ment o! t&e al%eolar
"roce##.
Correct %ertical relation o! t&e anterior and "o#terior
teet& to t&e occlu#al "lane <t&e imaginary "lane "a##e#
t&roug& t&e ti"# o! t&e "remolar cu#"# and i#
"er"endicular to t&e tu-ero#ity "lane=.
In!ra%er#ion o! t&e u""er anterior teet& in con4unction wit& an
underde%elo"ed anterior al%eolar "roce## <Kor+&au#7 .G2G=.
Infraocclusion Of The 'nterior Teeth
Infraocclusion Of The 'nterior Teeth
O"en -ite malocclu#ionL t&e u""er inci#or# do not reac&
t&e occlu#al "lane. T&e al%eolar "roce## i# noticea-ly
unde%elo"ed in t&e anterior region.
.. An o"en -ite a##ociated wit& di%ergence o! t&e #+eletal
"lane# i# term a# #+eletal o"en -ite or a"ertognat&ia.
1. c&aracteri#tic# o! a #+eletal o"en -ite include
a= increa#ed lower anterior !acial &eig&t7
-= increa#ed total anterior !acial &eig&t7
c= increa#ed gonial7 mandi-ular "lane and Occlu#al
"lane angle#7
d= decrea#ed "alatal "lane angle7
e= occa#ional ma(illary retrognat&ia7 and
!= increa#ed %ertical ma(illary and mandi-ular
dentoal%eolar dimen#ion#.
Clinical a##e##ment o! #+eletal o"en -ite
2. E(treme #+eletal o"en -ite o!ten are a##ociated wit&
cranio!acial mal!ormation#7 #uc& a# t&e Crou8onJ#
#yndrome "atient7 in w&om t&ere are gro## im-alance#
in #+eletal #tructure# in all t&ree dimen#ion# o! t&e !ace.
3. T&e#e ty"e# o! "ro-lem# are addre##ed only wit&
cranio!acial #urgery7 including di#traction o#teogene#i#.
5. ro!!it and colleague# note t&at7 alt&oug& increa#ed
lower anterior !acial &eig&t e(acer-ate# t&e "ro-lem -y
adding a #+eletal element7 a-out one)t&ird o! "atient#
#ee+ing #urgical correction o! long)!ace #yndrome &a%e
a normal or e(ce##i%e o%er-ite7 rat&er t&an an o"en
-ite7 t&i# ty"e o! occlu#ion i# an indication o! t&e
com"en#atory dental eru"tion t&at can occur in t&e#e
"atient#.
B. T&i# illu#trate# t&at t&e long !ace #yndrome and t&e
dental o"en -ite are di!!erent entitie#.
D. Indeed7 t&e !acial di#!iguration #een in #+eletal o"en
-ite# can -e !ound wit&out t&e "re#ence o! dental o"en
-ite#L &owe%er7 mo#t in#tance#7 #+eletal o"en -ite i#
com-ined wit& dental o"en -ite.
T&e mor"&ology o! t&e !acial #+eleton and
t&e e!!ect# o! tongue)t&ru#ting are correlated
to a certain degree. In a %ertical growt&
"attern wit& tongue)t&ru#t t&e lower inci#or#
are o!ten in lingual inclination.
'rom t&e di!!erential diagno#tic "oint o!
%iew7 it i# im"ortant to clari!y -ot& t&e
#+eletal relation#&i"# and t&e tongue
dy#!unction in order to locali8e t&e re#ult# o!
t&e a-normal tongue !unctioning.
E,uili-rium e(i#t# w&en a -ody at re#t i# #u-4ected to
!orce# in %ariou# direction#7 -ut i# not accelerated.
Malocclu#ion o! t&e teet& and t&e -roader #"ectrum o!
dento!acial de!ormity i# due7 to an inter"lay -etween
innate genetic !actor# and e(ternal en%ironmental
!actor#.
T&e en%ironment o! t&e teet& and al%eolar -one include#
con!licting !orce# and "re##ure#7 "rimarily !rom
mu#cular !unction7 w&ic& in "art determine toot&
"o#ition.
T&e more im"ortant t&e#e !orce# on t&e teet& are
concei%ed to -e7 t&e more one ta+e# an
en%ironmentali#t %iew a# !ar a# t&e cau#e o!
malocclu#ion i# concerned.
T&e more one -elie%e# in in&erited cau#e# !or
malocclu#ion7 t&e le## attention &e i# li+ely to "ay to
t&e en%ironment o! t&e dentition.
During ma#ticationJ# not only do t&e teet& mo%e #lig&tly
-ut t&e al%eolar -one and t&e -a#al -one o! ma(illa
and mandi-le -end and !le(. T&e#e c&ange# occur in
a matter o! #econd#7 and t&e teet& and 4aw# are
re#tored to t&eir original "o#ition# a# ,uic+ly a# t&ey
were di#"laced.
Natural dentition# are #ta-le o%er a time #"an o! year#
a!ter growt& i# com"leted.
Angle !elt t&at rela"#e a!ter ort&odontic treatment wa#
due to !orce# on t&e teet& re#ulting !rom an im"ro"er
en%ironment. It i# di!!icult e%en today to di#agree wit&
t&at %iew.
T&e 'renc& molecular -iologi#t @Maco-A ,uote# an
earlier "&y#ici#t7
'"o(ever, t"ere is al(a)s a desire in science to *exlain
t"e comlicated visible b) some simle invisible+.
Tongue "re##ure7 li" "re##ure7 "re##ure !rom eru"ting
t&ird molar# all ma+e nice @#im"le %i#i-leA cau#e# !or
ort&odontic rela"#e.
Fo$r Ma1or Fa+tor! In T,e /ental
Fo$r Ma1or Fa+tor! In T,e /ental
E2$iliri$&
E2$iliri$&
.. Intrin#ic !orce# -y tongue and li"#.
1. E(trin#ic !orce#F &a-it# <t&um-)#uc+ing7 etc=7 ort&odontic
a""liance#.
2. 'orce# !rom dental occlu#ion.
3. 'orce# !rom t&e "eriodontal mem-rane.
Intrin#ic 'orce# By Tongue And Li"#
Intrin#ic 'orce# By Tongue And Li"#
.. T&e teet& are "o#itioned -etween t&e li"# and c&ee+#
on one #ide and t&e tongue on t&e ot&er7 t&e o""o#ing
!orce or "re##ure# !rom t&e#e organ# #&ould -e ma4or
determinant# o! t&e dental e,uili-rium.
1. A #u"er!icial con#ideration o! t&e dental e,uili-rium
re,uire# t&at a di#tinction -e made -etween t&e amount
o! !orce generated again#t a toot& and t&e duration o!
!orce a""lication.
2. /a%e o! ent&u#ia#m wa# triggered -y /alter Strau- in
t&e .G5?J# a!ter &e &ad decided !rom clinical
o-#er%ation t&at incorrect #wallowing wa# a ma4or
cau#e o! anterior o"en -ite and inci#or "rotru#ion.
3. Tongue and li" "re##ure# during #wallowing ne%er
-alanced.
5. It #eemed logical t&at "atient# w&o #wallowed
incorrectly #&ould &a%e "rotruding inci#or# or o"en -ite
-ecau#e o! di!!erent tongue and li" "re##ure#.
B. In%e#tigator# ,uic+ly noted t&at tongue "re##ure#
during #wallowing alway# are #e%eral time# &ig&er t&an
t&e li" or c&ee+ "re##ure w&ic& #&ould -alance t&em.
D. /&en time*"re##ure integral# are com"ared7 tongue
and li"# come clo#er to -alance7 -ut tongue "re##ure i#
#till con#idera-ly greater t&an li" "re##ure.
I. T&ere i# no -alance o! "re##ure# !or #wallowing.
I. T&e dental a""aratu# i# well)ada"ted to re#i#t #&ort)
acting !orce# #uc& a# t&o#e generated during c&ewing7
#"ea+ing and #wallowing7 w&ere t&e duration o! !orce
a""lication i# ty"ically one #econd or le##.
G. Only re#ting "re##ure# o! tongue and li"# #&ould -e
con#idered a# !actor# in t&e e,uili-rium.
.?.T&i# wa# and i# a mo#t rea#ona-le #ugge#tion7 yet
re#ting "re##ure# do not -alance.
E3TRINSIC FORCES
E3TRINSIC FORCES
<E(ternal re##ure Ha-it# and Ort&odontic <E(ternal re##ure Ha-it# and Ort&odontic A""liance#= A""liance#=

.. All clinical ort&odontic# i# -a#ed on mo%ing teet& -y
deli-erately altering t&e !orce e,uili-rium on t&e
dentition.
1. Teet& can -e mo%ed e!!ecti%ely -y a !orce o! only a !ew
gram# "ro%ided t&at t&e !orce i# maintained
continuou#ly.
2. T&e duration o! !orce i# a more critical %aria-le in
ort&odontic treatment t&an !orce magnitude.
3. T&e #ame i# true !or e(ternal "re##ure &a-it#7 #uc& a#
t&um- #uc+ing.
T,$& S$+"in)
T,$& S$+"in)
5. T&e greater t&e duration o! t&e &a-it7 t&e greater it#
im"act on t&e teet& i# li+ely to -e. 'or -ot& ort&odontic
a""liance# and &a-it#7 duration# mu#t -e mea#ured in
&our# "er day to "roduce #igni!icant c&ange# in toot&
"o#ition.
B. E(trin#ic !orce# can -e ,uit e!!ecti%e w&en t&eir
duration a""roac&e# !i!ty "ercent o! t&e time7 and #ome
im"act a""arently can -e "roduced -y duration# o! only
a !ew &our#.
D. T&e di#cu##ion &a# related largely to toot& "o#ition in
t&e anterior7 "o#terior and tran#%er#e "lane# o! #"ace.
/&at a-out t&e %ertical "lane o! #"ace7 %ertical toot&
"o#ition certainly can -e in!luenced -y en%ironmental
!actor#.
I. /allen indicate t&at %ertically directed "re##ure# during
#wallowing actually are le## in "atient# wit& anterior
o"en -ite t&an in "atient# wit& normal %ertical
relation#&i"#.
G. T&e tongue "re##ure# were greater in t&e o"en -ite
"atient# t&an in t&e normal occlu#ion "atient#7 it would
-e ea#y to under#tand &ow t&e tongue wa# "re%enting
eru"tion.
.?.I! t&e "re##ure# were t&e #ame in o"en -ite or normal
occlu#ion7 one could #ay t&at t&e teet& were -eing
im"eded -y t&i# "re##ure and &eld at a &ig&er le%el.
...It a""ear# t&at t&e relati%ely &ig& "o#ition o! t&e inci#or#
+ee"# t&e tongue !rom contacting t&em ,uite #o muc&
during #wallowing. T&i# doe# not #u""ort t&e idea t&at
tongue "lacement during #wallowing cau#e# o"en -ite.
Certainly !orward tongue "o#ition during #wallowing7
w&ic& u#ually i# called tongue t&ru#t7 i# a##ociated wit&
o"en -ite -ut it #eem# more li+ely to -e e!!ect t&an
cau#e.
.1.Maw "o#ture7 occlu#al !orce7 and eru"tion !orce !rom t&e
"eriodontal mem-rane mu#t -e con#idered.
.2.Ot&er !actor# w&ic& come to mind immediately are
!orce# o! occlu#ion and !orce# o! eru"tion.
FORCES FROM /ENTAL OCCLUSION
FORCES FROM /ENTAL OCCLUSION
.. T&e attac&ment a""aratu# o! all teet& i# an e!!ecti%e
&ydrodynamic dam"ing #y#tem7 li+e an automo-ile
#&oc+ a-#or-er and i# well de#igned to wit&#tand
occlu#al !orce#.
1. T&e teet& would ma+e minor correction# o! t&em#el%e#.
T&i# doe# &a""en 4u#t a!ter t&e com"letion o!
ort&odontic treatment7 w&en t&e teet& are &y"er mo-ile
and t&e attac&ment a""aratu# i# reorgani8ing.
2. It i# common e("erience t&at teet& remain in "o#ition#
o! traumatic occlu#ion rat&er t&an mo%ing away !rom t&e
o!!ending occlu#al contact#.
3. T&e mec&ani#m to di##i"ate #&ort) duration Occlu#al
!orce# #o t&at teet& do not "ermanently intrude or mo%e
-uccally or lingually -ecau#e o! occlu#al !orce#7
occlu#al !orce# can -e im"ortant in e,uili-rium related
to %ertical toot& "o#ition.
5. T&e %ertical "o#ition o! t&e teet& i# determined -y a
-alance -etween t&e !orce# w&ic& o""o#e eru"tion and
t&o#e w&ic& "romote it. Occlu#al !orce# &a%e an
in!luence related to t&i#.
B. Numerou# #tudie# o! occlu#al !orce# it i# +nown t&at a
ma(imum !orce o! one &undred +ilogram# or more
#u#tained !or only a !raction o! a #econd can -e e(erted
again#t a #ingle toot& during occlu#ion.
D. I! t&e molar teet& are e(truded -y ort&odontic !orce#7
t&e mandi-le will rotate downward and -ac+ward a# t&e
Occlu#al contact and re#t "o#ition# c&ange. Once a
natural toot& &a# eru"ted or -een e(truded7 t&e
mu#culature ada"t# to it# "o#ition.
I. Mandi-ular "o#itioning during growt& in!luence#
eru"tion and t&e !inal %ertical "o#ition o! t&e teet&
remain# entirely un+nown. Occlu#al !orce# during
growt& "ro-a-ly "lay a #igni!icant role.
FO&%ES F&O# T$E .E&IODONT')
FO&%ES F&O# T$E .E&IODONT')
#E#&'NE0- E&(.TION FO&%ES
#E#&'NE0- E&(.TION FO&%ES
.. An eru"tion !orce i# generated w&ic& mo%e# a toot&
t&roug& -one and continue# to mo%e it a!ter it &a#
-ro+en into t&e oral ca%ity. T&e eru"ti%e !orce remain#
acti%e a!ter a toot& &a# come into occlu#ion and
!unction &a# -een e#ta-li#&ed.
1. Eru"tion continue# along wit& %ertical growt& o! t&e !ace
e.g. a ma(illary !ir#t molar ty"ically eru"t# !or a
centimeter or -etween age #i( w&en it !ir#t come# into
occlu#ion and t&e time in t&e late teen# w&en %ertical
4aw growt& end#.
2. I! it# antagoni#t i# e(tracted7 any toot& may eru"t again
year# a!ter it# %ertical "o#ition a""arently wa# #ta-le7
indicating t&at t&e eru"ti%e mec&ani#m remain# intact
and ca"a-le o! generating !orce# w&ic& can mo%e a
toot&.
Toot& eru"tion t&eorie# can -e di%ided into
Toot& eru"tion t&eorie# can -e di%ided into
t&ree ma4or grou"#F
t&ree ma4or grou"#F
.. T&eorie# -a#ed on cell "roli!eration at t&e root a"e(
1. T&eorie# -a#ed on -lood "re##ure) -lood !low
di!!erential# in t&e "eriodontal mem-rane
2. T&eorie# -a#ed on meta-olic c&ange #in t&e "eriodontal
mem-rane7 u#ually in%ol%ing collagen "olymeri8ation.
T&e weig&t o! "re#ent e%idence indicate# t&at eru"ti%e
!orce# are generated in t&e "eriodontal mem-rane
rat&er t&an at t&e root a"e(7 -ut e(actly &ow remain#
unclear.
Tongue and li" "re##ure# to "roduce a %ery #en#iti%e
and &ig&ly #ta-le tran#ducer7 w&ic& can -e "laced
again#t t&e ti" o! an eru"ting inci#or.
IN'L6ENCE O'
IN'L6ENCE O'
NASORESIRATOR9 '6NCTION
NASORESIRATOR9 '6NCTION
INF)(EN%E OF N'SO&ES.I&'TO&1 F(N%TION INF)(EN%E OF N'SO&ES.I&'TO&1 F(N%TION
.. Cau#e o! %ertical dy#"la#ia i# de%iating neuromu#cular
!unction a##ociated wit& an a-normal -reat&ing "attern.
1. &y#iologic ada"tation# to %ariou# ty"e# o! u""er
re#"iratory o-#truction <eg con#tricted e(ternal nare#7
de%iation #e"tum7 na#al "oly"# enlarged adenoid#7
enlarged ton#il#= initially may lead to altered !unctional
acti%ity o! t&e mu#cle# a##ociated wit& re#"iration.
2. It i# &y"ot&e#i8ed t&at t&i# c&ange in t&e le%el o!
"o#tural acti%ity o! certain cranio!acial mu#cle#
ultimately may lead to a c&ange in cranio!acial
mor"&ology7 "articularly in t&e %ertical dimen#ion.
3. C&ange# in t&e le%el o! le%el o! acti%ity o! certain
cranio!acial mu#cle# lead# to an e(ten#ion o! t&e &ead
and airway maintenance.
5. T&i# alteration cau#e# a #tretc&ing o! t&e ma#ticatory
and !acial mu#cle# a# well a# t&e a##ociated #o!t ti##ue.
B. A "rolonged o-#truction o! t&e airway can lead to
#+eletal remodeling and ultimately a c&ange in
cranio!acial mor"&ology.
D. T&e "o##i-le relation#&i" -etween airway o-#truction
and a-errant cranio!acial growt& i# t&e ty"e o! "atient#
de#cried a# &a%ing Cadenoid !acie#.J
I. T&e#e "atient# ty"ically "re#ent a mout&) o"en "o#ture7
a #mall no#e wit& -utton li+e ti"7 no#tril# t&at are #mall
and "oorly de%elo"ed7 a #&ort u""er li"7 "rominent
ma(illary inci#or#7 a "utting lower li"7 and a %acant
!acial e("re##ion.
G. CMout&)-reat&ingA indi%idual# cla##ically &a%e -een
de#cri-ed a# "o##e##ing a narrow7 $)S&a"ed ma(illary
arc&7 a &ig& "alatal %ault7 "roclined ma(illary inci#or#7
and a Cla## II occlu#ion.
.?.atient# w&o &a%e #e%ere allergie# o!ten "re#ent# wit&
#imilar !acial mani!e#tation#. In addition7 t&ey may &a%e
w&at are termed allergic #&iner#J w&ic& re"re#ent a
"ooling o! -lood under t&e eye#7 a #ign o! t&e allergic
re#"on#e.
E(amination o! Oro!acial
E(amination o! Oro!acial
Dy#!unction#
Dy#!unction#
E,amination of Orofacial D+sfunctions
E,amination of Orofacial D+sfunctions
Swallowing
Tongue
S"eec&
Li"#
Re#"iration
Swallowin)
Swallowin)
Normal mature #wallowing ta+e# "lace wit&out contracting t&e
mu#cle# o! !acial e("re##ion. T&e teet& are momentarily in
contact and t&e tongue remain# in#ide t&e mout&.
A-normal #wallowing i# cau#ed -y tongue)t&ru#t7 eit&er a#
#im"le t&ru#ting
action
Tongue)t&ru#t #yndrome
T&e !ollowing #ym"tom# di#tingui#& Tongue T&ru#t
SyndromeF
.= rotru#ion o! t&e ti" o! t&e tongue .
1= No contact o! t&e molar#.
2= Contraction o! t&e "erioral mu#cle# during t&e
deglutition cycle.
During t&eir !ir#t !ew year#7 in!ant# #wallow %i#cerally7
i.e. wit& t&e tongue -etween t&e teet&
A# t&e deciduou# dentition i# com"leted7 t&e %i#ceral
#wallowing i# gradually re"laced -y #omatic #wallowing.
Tongue "eri#tal#i# during #omatic #wallowingF
Tongue "eri#tal#i# during #omatic #wallowingF

I Collecting #tage
II Tran#"orting #tage ) I#t "art o! mo%ement
1nd "art o! mo%ement
2rd "art o! mo%ement
III T&ird #wallowing #tage
I$ 'ourt& #wallowing #tage
$ 'inal #tage
Colle+tin) Sta)e Colle+tin) Sta)e 4 4
T&e !ood i# collected in t&e !oremo#t "art o! t&e mout&7 in !ront
o! t&e retracted tongue. T&e "o#terior arc&ed "art o! t&e dor#um
i# in contact wit& t&e #o!t "alate.
T&e li"# are not in contact and t&e teet& are not occluding
Tran!portin) !ta)e I!t part of &ove&ent(
During t&e #econd "&a#e o! #wallowing7 i.e. t&e tran#"orting
#tage7 t&e ti" o! t&e tongue !ir#t mo%e# u"ward and t&e
anterior #ection o! t&e dor#um i# de"re##ed <according to
>ra-er7 .GD1=.
Transporting stage 2nd part of movement0 Transporting stage 2nd part of movement0
T&e entire anterior #ection o! t&e tongue t&en mo%e#
u"ward and t&e central #ection o! t&e dor#um i#
de"re##ed.
T&i# "eri#tal#i# tran#"ort# t&e -olu# rearward.
Tran!portin) !ta)e 5rd part of &ove&ent( Tran!portin) !ta)e 5rd part of &ove&ent(
At t&e end o! t&e tran#"orting #tage7 t&e #o!t "alate i#
di#"laced u"ward and rearward.
T&e li" mu#culature contract# #imultaneou#ly7 t&e li"# are
toget&er7 t&e mandi-le i# rai#ed and t&e teet& come into
contact.
T,ird Swallowin) Sta)e(
T&e dor#um o! t&e tongue i# de"re##ed e%en !urt&er during
t&e t&ird #tage #o t&at t&e -olu# can "a## t&roug& t&e
oro"&aryngeal i#t&mu#L #imultaneou#ly t&e anterior "art o!
t&e tongue i# "re##ed again#t t&e &ard "alate7 t&u# !orcing
more !ood rearward.
a##a%antJ# "ad and #o!t "alate !orm t&e "alato"&arygeal
#eal and clo#e t&e na#o"&aryn(. T&e teet& are in !ull
occlu#ion and t&e li"# in contact.
Fo$rt, Swallowin) Sta)e( Fo$rt, Swallowin) Sta)e(

During t&e !ourt& #age o! t&e #wallowing act7 t&e dor#um o!
t&e tongue i# mo%ed !urt&er u"ward and rearward again#t
t&e #o!t "alate and #,uee8e# t&e remaining !ood -olu# out
o! t&e oro"&aryngeal area.
Final Sta)e Of Swallowin) C*+le(
Once t&e #wallowing act &a# -een com"leted7 t&e
mandi-le return# to it# re#t "o#ition.
$i#ceral <In!antile= Swallow In T&e Neonate
$i#ceral <In!antile= Swallow In T&e Neonate
T&e 4aw# are a"art during #wallowing. T&e
tongue i# "u#&ed !orward and "laced -etween
t&e gum "ad#. T&e ti" o! t&e tongue "rotrude#.
T&e mandi-le i# #ta-ili8ed -y t&e contraction o!
t&e tongue and t&e oro)!acial mu#culature a#
well a# -y t&e tongue contact wit& t&e li"#.
Swallowing i# triggered o!! and7 to a large
e(tent7 carried out -y #en#ory interc&ange
-etween t&e li"# and t&e tongue. eri#tal#i#
already commence# in t&e %e#ti-ule.
T&e tran#%er#e #ection #&ow# t&at t&e tongue
i# "o#itioned low in t&e mout& and t&at t&e
central !urrow i# de"re##ed <according to
>ra-er7 .GD1=.
Somatic S!allo!
Somatic S!allo!
A# #wallowing i# triggered o!! -y contraction o! t&e
mandi-ular ele%ator# <ma##eter mu#cle=7 t&e teet&
occlude momentarily during t&e #wallowing act and t&e
ti" o! t&e tongue i# enclo#ed in t&e oral ca%ity.
T&e tran#%er#e #ection #&ow# t&at t&e dor#um o! t&e
tongue i# le## conca%e and a""roac&e# t&e "alate
during #wallowing <according to >ra-er7 .GD1=.
Tongue -Thrust
Tongue)t&ru#t &a# an im"ortant e!!ect on t&e
etio "at&ogene#i# o! malocclu#ion#
Tongue)T&ru#t
rimary
#econdary
Anterior
Lateral
com"le(
Endogenou#
Ha-itual
ada"ti%e
T&e t&ru#t may ta+e "lace in t&e anterior or lateral
region# or can -e com"le(. In t&e !ir#t ca#e7 t&e
dy#!unction i# #igni!icant during t&e de%elo"ment o! an
anterior o"en -ite and in t&e #econd ca#e during t&e
de%elo"ment o! a lateral o"en -ite or a dee" o%er-ite.
In ca#e o! a com"le( tongue)t&ru#t7 t&e occlu#ion i#
#u""orted only in t&e molar region.
Ca#e# wit& an anterior o"en -ite during c&ild&ood are
o!ten #el!)com"en#ating. Com"le( or #+eletal o"en
-ite# do not regulate t&em#el%e# #"ontaneou#ly7 -ut
rat&er "er#i#t.
.rimar+ 3 Secondar+ D+sfunctions
.rimar+ 3 Secondar+ D+sfunctions
Etiologic "oint o! %iew7 tongue)t&ru#t may -e
con#idered "rimary or #econdary.
rinci"ally #"ea+ing7 all dy#!unction# can -e di%ided
into "rimary7 i.e. cau#al or #econdary7 i.e. ada"ti%e
mal!unction#
Cau#e# o! dy#!unction
rimary #econdary
E
Endogenou# !actor#
E
Heredity
E
Limitation
E
Ada"ti%e
rimary tongue dy#!unction in
con4unction wit& &y"er"la#tic ton#il#
A retracted tongue would touc&
in!ected7 #wollen ton#il# i! t&e#e were
to "rotrude !ar out o! t&e #urrounding
#tructure#. In order to a%oid "ain!ul
#en#ation# and to +ee" t&e oral
airway o"en t&e mandi-le i# dro""ed
and t&e tongue "o#ture# !orward
<according to Moyer#=.
Hy"er"la#tic ton#il#
Moderately #wollen "alatine
ton#il# w&ic& "rotrude
#igni!icantly !rom t&e ton#illar
#inu#.
Adaptive ton)$e d*!f$n+tion
Ada"ti%e tongue dy#!unction wit& toot& mal"o#ition.
A!ter lo## o! teet&7 t&e tongue i# u#ed to !ill t&e ga"#7 t&u#
#ealing t&e oral ca%ity7 i.e. com"en#atory dy#!unction.
In ca#e# wit& "remature e(traction o! deciduou# teet&7 t&i#
"rimarily "&y#iologic di#"lacement o! t&e tongue may
"er#i#t a# a !unctional a-normality e%en a!ter t&e "ermanent
teet& &a%e eru"ted.
Enamel &y"o"la#ia o! t&e u""er and lower anterior teet& Enamel &y"o"la#ia o! t&e u""er and lower anterior teet&
a# well a# o! t&e !ir#t molar# re#ult# !rom a %itamin D a# well a# o! t&e !ir#t molar# re#ult# !rom a %itamin D
de!iciency w&ic& occurred at t&e age o! a-out . year. de!iciency w&ic& occurred at t&e age o! a-out . year.
T&e #+eletal and dentoal%eolar o"en -ite i# aggra%ated -y T&e #+eletal and dentoal%eolar o"en -ite i# aggra%ated -y
t&e ada"ti%e tongue dy#!unction. t&e ada"ti%e tongue dy#!unction.
Open ite Due To &ickets
Open ite Due To &ickets
#outh reathing
#outh reathing
C&ornically di#tur-ed na#al re#"iration re"re#ent# a
dy#!unction o! t&e oro!acial mu#culatureL it can re#trict
de%elo"ment i! t&e dentition and &inder# t&e ort&odontic
treatment.
T&e e(traoral a""earance o! t&e#e "atient# i# o!ten
con#"icuou#. And i# termed @adenoid !acie#A
'denoid Facies
C&ronically re#tricted na#al

re#"iratory !unction.
Occlu#al and dental !inding# in ca#e o! orona#al
re#"iration
T&e u""er 4aw i# mar+edly
con#tricted7 t&e mandi-ular
arc& i# well !ormed. /idt& a
-ilateral cro##)-ite
T&e &ig& "alate and narrow
u""er arc&
T,e A!!o+iation Between Anterior Open.
T,e A!!o+iation Between Anterior Open.
ite And A&elo)ene!i!
ite And A&elo)ene!i!
.. Amelogene#i# im"er!ecta were in%e#tigated clinically7
and wit& ce"&alometric radiogra"&y in order to
determine t&e "re%alence and nature o! t&e anterior
o"en)-ite
1. It i# #ugge#ted t&at t&e !re,uent a##ociation o! anterior
o"en)-ite and amelogene#i# im"er!ecta i# cau#ed -y a
genetically determined anomaly o! cranio!acial
de%elo"ment7 rat&er t&an -y local !actor# in!luencing
al%eolar growt&.
3. T&i# anomaly c&aracteri8ed -y an anterior
in!raocclu#ion or anterior o"en)-ite.
5. @He and I##el -elie%e t&at t&e co)e(i#tence o! t&e two
condition# may -e attri-uted to a "leiotro"ic action o!
t&e amelogene#i# im"er!ecta gene#7 in!luencing t&e
growt& o! t&e cranio!acial #+eleton.
D. /it+o" and &i# co)wor+er#7 "o#tulated t&at roug& and
#en#iti%e teet& lead to a-normal tongue acti%ity w&ic&7
di#"lace# t&e anterior teet& to "roduce a o"en)-ite7
I. Locally inter!ere wit& t&e growt& o! t&e al%eolar
"roce##e#7 and could alter t&e mor"&ology o! t&e
cranio!acial com"le(
BIO - MECHANICAL
BIO - MECHANICAL
CONSIDERATION IN OPEN BITE
CONSIDERATION IN OPEN BITE
Presented by
Presented by
Dr.Rajashekar
Dr.Rajashekar
CONTENTS
CONTENTS
Introduction.
De!inition.
Ty"e# O! $ertical Malocclu#ion.
O%er%iew O! O"en Bite.
Etiologic Con#ideration.
E#t&etic Con#ideration.
'unctional Con#ideration
Clinical Con#ideration
Ce"&alometric Critera
E(amination o! Oro)'acial Dy#!unction
*
Swallowing
*
Tongue)t&ru#t
*
C&ee+ Dy#!unction
*
Mout& Breat&ing
E,uili-rium T&eory
In!luence O! Na#o)re#"iratory 'unction
Long 'ace Syndrome
Treatment In rimary Dentition
Treatment In Mi(ed Dentition
Treatment In ermanent Dentition
Conclu#ion.
TREATMENT IN T%E
TREATMENT IN T%E
/ECI/UOUS /ENTITION
/ECI/UOUS /ENTITION
TREATMENT IN T%E /ECI/UOUS /ENTITION
TREATMENT IN T%E /ECI/UOUS /ENTITION
.. Control o! a-normal &a-it# and elimination o!
dy#!unction #&ould -e gi%en to" "riority in t&e deciduou#
dentition.
1. T&e anterior o"en -ite im"ro%e# a# #oon a# t&e &a-it i#
#to""ed.
2. Autonomou# im"ro%ement can -e e("ected only i! t&e
de!orming mu#cle acti%ity i# terminated and t&e o"en
-ite i# not com"licated -y crowding or cro## -ite o! t&e
u""er arc&.
3. Treatment wit& #creening a""liance# i# indicated in
#uc& o"en) -ite ca#e#.
5. A #+eletal o"en -ite i# #eldom o-#er%ed in t&e
deciduou# dentition. Ha-it control i# o! only #econdary
con#ideration in t&e#e ca#e#7 retarding t&e increa#ing
#e%erity o! t&e dy#"la#ia.
B. E(tra oral ort&o"edic a""liance# #uc& a# c&in ca"# can
-e u#ed e!!ecti%ely to redirect growt&.
Screening A""liance
Screening A""liance
.. Screening a""liance# interce"t and eliminate all
a-normal "erioral mu#cle !unction in ac,uired
malocclu#ion# re#ulting !rom a-normal &a-it#7 mout&
-reat&ing7 and na#al -loc+age.
1. O"en -ite created -y !inger #uc+ing and retained
%i#ceral deglutition)"attern7 tongue !unction can -e
&el"ed wit& %e#ti-ular #creen#.
Mi(ed Dentition)treatment
Mi(ed Dentition)treatment
Ton)$e Cri
Ton)$e Cri

.. A remo%al or !i(ed a""liance can in&i-it tongue t&ru#t.
1. T&e cri- u#ed wit& a remo%a-le a""liance !or an
anterior o"en -ite con#i#t# o! a "alatal "late wit& a
&or#e#&oe)#&a"ed wire cri-.
2. T&e cri- i# "laced in t&e area o! local tongue
dy#!unction and re#ultant malocclu#ion.
5. T&e acrylic al#o can -e inter"o#ed -etween t&e teet&7
co%ering t&e occlu#al #ur!ace# o! t&e u""er molar#7 to
"re%ent eru"tion o! t&e#e teet& and en&ance anc&orage
o! t&e "late. T&i# i# e#"ecially -ene!icial in o"en)-ite
"ro-lem#.
B. T&e -ite)-loc+ing &ere can -e 2 to 3 mm7 w&ic& i#
u#ually -eyond t&e "o#tural %ertical dimen#ion in o"en)
-ite "atient#.
D. In #uc& ca#e# a #tretc& re!le( i# elicited !rom t&e
clo#ing mu#cle# t&at en&ance# t&e de"re##ing action
on t&e -uccal #egment# and &el"# clo#e t&e anterior
o"en -ite.
A+tivator
A+tivator

.. T&e -ite i# o"ened 3 to 5 mm to de%elo" a #u!!icient
ela#tic de"re##ing !orce and load t&e molar t&at are in
"remature contact.
1. ro"erly con#tructed acti%ator# t&at !ollow t&i# "rinci"le
can in!luence t&e %ertical growt& "attern in t&e#e
ca#e#.
3. To @clo#e t&e $A -etween u""er and lower ma(illary
-a#e#7 de"re##ing t&e "o#terior ma(illary #egment# wit&
t&e acti%ator in a manner analogou# to t&at o!
ort&ognat&ic #urgery
5. In #urgical o"en)-ite ca#e# t&e "o#terior #egment# are
im"acted7 allowing autorotation o! t&e mandi-le.
Bionator
Bionator

.. 6#ed to in&i-it a-normal "o#ture and !unction ?! t&e
tongue.
1. T&e con#truction -ite i# a# low a# "o##i-le7 -ut a #lig&t
o"ening allow# t&e inter"o#ition o! "o#terior acrylic -ite
-loc+# !or t&e "o#terior teet&7 to "re%ent t&eir e(tru#ion.
2. To in&i-it tongue mo%ement#7 t&e acrylic "ortion o! t&e
lower lingual "art e(tend# into t&e u""er inci#or region
a# a lingual #&ield. Clo#ing t&e anterior #"ace wit&out
touc&ing t&e u""er teet&.
3. T&e "alatal -ar &a# t&e #ame con!iguration a# t&e
#tandard -ionator7 wit& t&e goal o! mo%ing t&e tongue
into a more "o#terior or caudal "o#ition.
5. T&e la-ial -ow di!!er# !rom t&e #tandard a""liance7 t&at
t&e wire run# a""ro(imately -etween t&e inci#al edge#
o! t&e u""er and lower inci#or#.
B. T&e la-ial "art o! t&e -ow i# "laced at t&e &eig&t o!
correct li" clo#ure t&u# #timulating7 t&e li"# to ac&ie%e a
com"etent #eal and relation#&i".
D. T&e %ertical #train on t&e li"# tend# to encourage t&e
e(tru#i%e mo%ement o! t&e inci#or#7 a!ter eliminating t&e
ad%er#e tongue "re##ure#.
'R I$
'R I$
.. Normally7 anterior o"en -ite "ro-lem# #&ow "rotracted
tongue "o#ture wit& incom"etence o! li"#. T&e tongue
toot& contact re"lace# t&e li" #eal during deglutition to
create negati%e atmo#"&eric "re##ure.
1. 'R I$ along wit& li" e(erci#e# cau#e li" contact7
reducing tongue "rotru#ion and cau#e t&e tongue to
mo%e -ac+ into it# normally rai#ed "o#ition in "ro(imity
wit& "alate7 during deglutition.
2. T&e "alatal -ow i# li+e t&at o! t&e 'R)2 and i# alway#
"laced -e&ind t&e la#t molar to "ermit t&e a""liance to
#&i!t in a "o#terior direction.
3. T&i# allow# t&e mandi-le to clo#e u" and !orward into a
more !a%ora-le growt& direction reducing t&e
mandi-ular "lane angle.
Llo*d E Pear!on
Llo*d E Pear!on
DESCRIBES SE$EN DI''ERENT ROCED6RES
'OR TREATMENT O' OEN BITE/ITH BACK/ARD
ROTATIN> MANDIBLE
.. In t&e mi(ed dentition o"en)-ite "atient we could intrude
t&e u""er !ir#t "ermanent molar# and t&en remo%e t&e
remaining deciduou# teet&7 "ermitting o"en)-ite
clo#ure.
1. occi"ital &eadgear wit& a tran#"alatal arc& to control t&e
inclination o! t&e molar# a# t&ey are intruded.
2. A!ter t&e molar# &a%e -een intruded "er&a"# 2 mm t&e
deciduou# teet& are remo%ed7 t&e mandi-le i# &inged
clo#ed7 and t&e anterior o"en)-ite i# clo#ed.
Pro+ed$re .. I
Pro+ed$re .. I
3. T&e lower molar# will o!ten tend to e(trude in t&i# ty"e
o! #ituation. 6nle## mec&anic# are de#igned to control
t&eir eru"tion.
5. An addition o! a %ertical "ull)c&in cu" to t&e occi"ital
&eadgear and tran#"alatal arc& would intrude t&e u""er
molar#7 w&ile "re%enting t&e eru"tion o! t&e lower
molar#.
B. A# t&e o"en -ite clo#e# t&e mandi-le &inge# u"ward7
reducing t&e &eig&t o! t&e lower !ace.
$ertical "ull c&in cu"
$ertical "ull c&in cu"
Pro+ed$re .. II
Pro+ed$re .. II
.. E(traction o! !ir#t "remolar# and u#e a %ertical "ull)c&in
cu" wit& <.B ounce# o! !orce#=
1. T&i# can clo#e t&e mandi-ular "lane angle7 reduce t&e
lower !acial &eig&t and clo#e anterior o"en -ite#.
2. A""ro(imately 3
?
o! clo#ure o! t&e mandi-ular "lane
angle wa# !ound in &i# #tudy.
3. 'our "o##i-le mec&ani#m# o! <action at wor+=
a= ma(illary #uture# are "re##ure #en#iti%e and #ome
intru#ion o! t&e ma(illa could occur.
-= T&e "o#terior teet& tend to mo%e !orward me#ially.
c= A #lig&t c&ange in t&e #&a"e o! t&e condylar nec+7
wit& many tending to -e cur%ed more !orward t&an
"re%iou#ly.
d= A retardation o! eru"tion o! t&e "o#terior teet&.
Pro+ed$re .. III
Pro+ed$re .. III
.. Mandi-ular -ite) -loc+ t&era"y7 augmented wit& %ertical
"ull)c&in cu" t&era"y7 can "roduce a !a%ora-le &olding
o! t&e %ertical &eig&t t&roug&out t&e growt& "eriod7
intru#ion o! "o#terior teet&
1. T&e &inging o! t&e mandi-ular "lane in a
countercloc+wi#e direction and clo#ure o! anterior o"en
-ite#.
Pro+ed$re .. IV
Pro+ed$re .. IV
.. Magnetic -ite -loc+#.
1. Alt&oug& we get ra"id re#ult#7 two di!!icultie# ari#e wit&
-ite -loc+#
a. E(treme mout& o"ening and "atience to
tolerate t&e a""liance.
-. lateral mo%ement o! t&e mandi-le7 t&at can
cau#e #ome tem"oromandi-ualr 4oint #train.
Pro+ed$re .. V
Pro+ed$re .. V
.. Intru#i%e !orce# wit& !ully -anded a""liance# can -e
de%elo"ed in a num-er o! way#.
1. Occi"ital &eadgear &a# "ro%ed u#e!ul and generally
#eem# e!!ecti%e in controlling t&e %ertical dimen#ion in
t&e ma(illa.
2. Mandi-ular control a""ear# to -e more di!!icult to
manage.
2. T&e lower molar normally increa#e# it# &eig&t a#
mea#ured to t&e mandi-ular "lane -y a-out ..5 mm
o%er a two) year "eriod
3. To reduce e(tru#ion o! t&e mandi-ular arc& include a
lower cer%ical &eadgear wit& a %ery lig&t !orce t&roug&
t&e center o! re#i#tance
Pro+ed$re .. VI
Pro+ed$re .. VI
.. Anot&er u#e!ul treatment modality i# %ertical reduction
genio"la#ty.
1. One ad%antage7 i# t&at it doe# not in%ol%e t&e
tem"oromandi-ualr 4oint#7
2. It can -e done a!ter non)#urgical treatment a# an
ad4unct to -ring t&e c&in u" and !orward7 to im"ro%e
!acial -alance7 and to ac&ie%e com"etency
3. A %ertical reduction genio"la#ty mig&t -e more u#e!ul in
"atient# wit& t&e correct amount o! e("o#ed gingi%a in
t&e ma(illa -ecau#e it doe# not "ro%ide ma(illary
anterior intru#ion.
Pro+ed$re .. VII
Pro+ed$re .. VII
.. Ma(illary im"action N %ertical reduction genio"la#ty7
#&ould al#o -e con#idered.
1. T&i# can -e a great -ene!it to "atient# wit&
i. elongated u""er "o#terior teet&7
ii. elongated u""er anterior teet&7
iii. a gummy #imile7
i%. a tall lower !ace7
%. anterior ma(illa wit& a ma(illary im"action.
Brac+et o#ition
Brac+et o#ition
.. T&e "lacement "oint !or inci#or -rac+et# may %ary in
ca#e# o! in!raocclu#ion.
1. In ca#e# o! o"en -ite7 "lacing anterior -rac+et# I mm
more toward# t&e gingi%al #ide.
In%er#e Anc&orage Tec&ni,ue
Modi!ication# To Standard
Modi!ication# To Standard
Se,uence
Se,uence
.. T&e only two c&ange# !rom t&e #tandard #e,uence are
in -rac+et "lacement and t&e clo#ing loo" ga-le -end.
1. On t&o#e teet& in occlu#ion7 t&e -rac+et# are "laced a#
clo#e to t&e occlu#al #ur!ace a# "o##i-le.
2. On all t&e teet& out o! occlu#ion7 t&e -rac+et# are
"laced more gingi%ally.
R.>. @/ic+A Ale(ander
Triangle Ela#tic#
Triangle Ela#tic#
.. Triangle ela#tic# aid in t&e im"ro%ement o! cla## I
cu#"id intercu#"ation and increa#ing t&e o%er-ite
relation#&i" anteriorly -y clo#ing o"en -ite# in t&e range
o! ?.5 to ..5 mm.
1. T&ey e(tend !rom t&e u""er cu#"id to t&e lower cu#"id
and !ir#t -icu#"id teet&.
Anterior $ertical Ela#tic#
Anterior $ertical Ela#tic#
Cla## II orientation.
Cla## III orientation
Avoid Inter&a'illar* Ela!ti+!
Avoid Inter&a'illar* Ela!ti+!

.. Interma(illary ela#tic# !rom t&e "o#terior teet& &a%e a
%ertical !orce %ector w&ic& e(trude# t&e#e teet& and can
!urt&er o"en t&e "o#terior %ertical dimen#ion.
1. Cla## II ela#tic# !rom B ) B #&ould not -e utili8ed until
t&e#e teet& are well anc&ored in -uccal cortical -one .
How To 6#e Cla## II Or Cla## III
How To 6#e Cla## II Or Cla## III
Ela#tic#
Ela#tic#
.. I! cla## II or III ela#tic# are re,uired7 t&ey #&ould -e
attac&ed "o#teriorly to "remolar# rat&er t&an molar#.
1. T&e#e C#&ort ela#tic# minimi8e t&e e(tru#i%e e!!ect on
t&e -ac+ o! t&e arc&
ACTI$E $ERTICAL CORRECTOR
ACTI$E $ERTICAL CORRECTOR
.. A$C i# a #im"le remo%a-le or !i(ed ort&odontic
a""liance t&at intrude# t&e "o#terior teet& o! -ot& t&e
ma(illa and mandi-le -y reci"rocal !orce#.
1. By e!!ecti%e intru#ion o! "o#terior teet&7 t&e mandi-le i#
allowed to rotate in u"ward and !orward direction#.
2. T&e uni,uene## o! t&i# a""liance i# t&at7 it correct#
anterior o"en -ite "ro-lem# -y actually reducing
anterior !acial &eig&t.
3. ro-lem# !ormerly t&oug&t to re,uire ort&ognat&ic
#urgery7 can now -e treated #ucce##!ully wit& A$C.
Met,od of A+tion (.
.. 'orce #y#tem )) generated -y re"elling magnet#7
1. A$C i# con#idered #u"erior to a #tatic -ite -loc+
a""liance energi8ed only -y t&e intermittent !orce !rom
t&e mu#cle# o! ma#tication.
2. T&e con#tant !orce #y#tem o! t&e A$C re#ult# in greater
ra"idity o! toot& mo%ement.
Tooth
Tooth
.ositioner
.ositioner
.. In o"en)-ite ca#e#7 a toot& "o#itioner may -e u#ed !or B
to I wee+# o! nig&t)time wear
1. T&i# a""liance# "lace# ela#tic !orce# to t&e teet& and
-ring# t&em into a "redetermined ideal "o#ition.
2. It &el"# to +ee"# t&e o"en -ite clo#ed a# t&e teet& are
"ulled in a %ertical direction.
Bonded !i(ed and Hawley retainer# are al#o gi%en to
t&e#e "atient# !or long)term retention.
Ma+e #ure7 t&at t&e mandi-ular anterior teet& do not
contact t&e acrylic o! t&e ma(illary7 -ecau#e t&i# would
o"en t&e -ite in t&e "o#terior and "romote toot&
e(tru#ion7 w&ic& would o"en t&e -ite !urt&er
Low tran#"alatal arc&
Low tran#"alatal arc&
.. It i# con#idered t&at t&e tran#"alatal -ar inter!ere# wit&
t&e normal %ertical de#cent o! t&e u""er molar#7 and
t&ere!ore retard# ma(illary %ertical al%eolar
de%elo"ment.
1. It &a# al#o -een #tated t&at ma(illary %ertical al%eolar
growt& contri-ute# one t&ird o! t&e total %ertical
de%elo"ment o! t&e !ace
2. It i# -elie%ed t&at7 tongue "re##ure again#t t&e
tran#"alatal arc& during #wallowing7 e#"ecially w&en
t&e tran#"alatal arc& i# "laced low in t&e "alate7 will
in&i-it ma(illary al%eolar %ertical growt&.
3. /i#e et al. a##e##ed "re and "o#t treatment
ce"&alometric radiogra"&# in t&e #tudy.
*
T&ey !ound t&at t&e tran#"alatal -ar &a# no
#tati#tically #igni!icant e!!ect on t&e amount o!
%ertical eru"tion o! t&e ma(illary teet&.
5. Howe%er #e%eral aut&or# #ugge#ted t&at !uture #tudie#
wit& an integrated acrylic -utton on a lowered
tran#"alatal arc& #&ould -e conducted.
Low Mandi-ular Li" Bum"er
Low Mandi-ular Li" Bum"er
.. Cetlin and Hoe%e ad%ocated t&e u#e o! a li" -um"er !or
t&e de%elo"ment o! t&e lower dental arc&.
1. T&ey #ugge#ted t&at i! t&e li" -um"er were ad4u#ted
low7 t&e c&ee+ and li" muco#a would re#t a-o%e t&e
a""liance7 and t&i# will in&i-it %ertical mandi-ular molar
dentoal%eolar de%elo"ment.
2. But t&ere i# no !urt&er e("lanation or e%idence t&at a
lower li" -um"er can -e u#ed to "re%ent eru"tion o! t&e
mandi-ular molar teet&.
3. Similarly7 a lower lingual arc& may -e u#ed !or
controlling %ertical molar de%elo"mentL -ut t&ere i# lac+
o! e%idence
/edge rinci"le Cou"led /it& T&e
/edge rinci"le Cou"led /it& T&e
E(traction O! Teet&
E(traction O! Teet&
Two ma4or a""roac&e# o! a""lying t&e wedge "rinci"le
-y e(traction o! teet& to control t&e %ertical dimen#ion#.
.. Lo## o! "o#terior anc&orage #o t&at t&e anc&or
teet& mo%e me#ially and are located !art&er
anteriorly in t&e arc& in an area o! greater %ertical
dimen#ion.
1. E(traction o! !ir#t or #econd molar# in -ot&
arc&e# to decrea#e t&e "o#terior dentoal%eolar
&eig&t.
>arlington and Logan !ound t&at enucleation o!
mandi-ular #econd "remolar# i# -ene!icial7
To control t&e %ertical dimen#ion.
Increa#ed in !orward rotation o! t&e mandi-le.
Signi!icant decrea#e in lower anterior !ace &eig&t.

T&e criteria #election F)
a. Minimal lower arc& di#cre"ancy <B to .?mm=.
-. A mandi-ular "lane angle greater t&an 2I
?.
c. A &y"erdi%ergent #+eletal "attern.
d. Increa#ed lower anterior !acial &eig&t.
ear#on #tated t&at a!ter t&e e(traction o! "remolar
teet&7 t&ere i# #ome me#ial dri!t o! t&e "o#terior teet&
<out o! t&e wedge= and t&i# "ermit# t&e mandi-le to
&inge clo#ed.
9amaguc&i and Nanda concluded t&at t&e c&ange# in
&ori8ontal and %ertical "o#ition o! t&e molar# were
de"endent on t&e ty"e o! !orce a""lication and not on
t&e e(traction or non)e(traction #trategy.
T&e E(tru#ion Arc&
T&e E(tru#ion Arc&
.. T&e e(tru#ion arc& i# a term coined to de#cri-e t&e
re%er#e action o! already e(i#ting and well e#ta-li#&ed
intru#ion arc&.
1. Anterior o"en -ite can -e addre##ed wit& arc& wire
mec&anic# u#ing a#ymmetrical $ -end# in t&e wire.
2. /ire u#ed i#
.B ( 11 SS or .D O15 TMA wit& G?

?
o!!#et
-end at t&e molar.
E(tru#i%e !orce o! .?? gm# !or 3 inci#or#.

Mode O! Action
Mode O! Action
AT THE MOLARF)
.. A #econd order cou"le i# generated at t&e molar wit&
crown ti""ing me#ially and root ti""ing di#tally.
1. T&e e,uili-rium i# ac&ie%ed -ecau#e t&e anterior end o!
t&e wire e(trude# t&e inci#or# and "o#terior end
intrude# t&e molar#.
2. Relati%ely %ery minimal -uccal !laring o! t&e molar i#
#een.
AT THE INCISORSF)
.. E(tru#ion can in%ol%e #ingle teet& or grou" o! teet&.
1. /&en a grou" o! teet& are to -e e(truded 7a #egment o!
&ea%y arc& wire may -e u#ed in t&e -rac+et# o! t&e
anterior teet&7 and t&e teet& are e(truded a# i! t&ey
were one -ig toot&.
2. /&et&er t&e e(tru#ion arc& i# tied #egmentally or to
continuou# arc& wire or "laced directly into t&e
-rac+et# t&e e!!ect i# t&e #ame
Hig& ull Headgear
Hig& ull Headgear
Multiloo" Edgewi#e Arc& /ire
Multiloo" Edgewi#e Arc& /ire
.. Multiloo" Edgewi#e Arc& /ire wa# de%elo"ed -y Kim to
ac&ie%e t&e#e goal# F)
a. Correcting t&e inclination o! t&e occlu#al "lane#.
-. Aligning t&e ma(illary inci#or# relati%e to t&e li"
line.
c. 6"rig&ting t&e a(ial inclination# o! t&e "o#terior
teet&.
.. T&e MEA/ contain# &ori8ontal and %ertical loo"#
!a-ricated !rom a .B ( 11 ## wire in an L ) #&a"e
!a#&ion
1. T&e %ertical loo"# act a# a -rea+ -etween t&e teet&7
lower# t&e load de!lection rate and "ro%ide# &ori8ontal
control.
2. T&e &ori8ontal loo"# !urt&er reduce# t&e load de!lection
rate and "ro%ide# %ertical control.
3. Ty"ical ti" -ac+ -end# o! 2)5degree# are gi%en on eac&
toot&.
5. Ela#tic# are "laced -etween t&e loo"# t&at lie me#ial to
o""o#ing cu#"id#.
B. Recommended ela#tic #i8e i# 2;.B inc& &ea%y7 wit& a
!orce a""ro(imately 5? gm# w&en t&e 4aw i# clo#ed.
KIMS tec&ni,ue wa# later modi!ied -y A9HAN
ENACAR et.al7 u#ing .B ( 11 re%er#e cur%e NiTi arc&
wire# wit& &ea%y interma(illary ela#tic# a""lied in t&e
canine region
Hig& Angle Begg Ca#e#
Hig& Angle Begg Ca#e#
.. In &ig& angle -egg ca#e# we a%oid cla## II ela#tic# to
a%oid o"en -ite and accentuation o! "re#ent cla## II .
1. /e gi%e mild cla## I ela#tic# in #uc& ca#e#.
Skeletal 'nchorage S+stem
Skeletal 'nchorage S+stem
.. S+eletal anc&orage #y#tem wa# de%elo"ed !or toot&
mo%ement#.
1. SAS con#i#t# o! titanium mini"late#7 t&at are
tem"orarily im"lanted in t&e ma(illa or t&e mandi-le a#
an immo-ile anc&orage.
2. T&e#e mini"late# are !i(ed at t&e -uccal cortical -one
around t&e a"ical region# o! t&e lower !ir#t and #econd
molar# on -ot& t&e #ide#.
3. Ela#tic t&read# are u#ed a# a #ource o! ort&odontic
!orce to reduce e(ce##i%e molar &eig&t.
5. T&e lower molar# were intruded a-out 2 to 5 mm7 and
o"en)-ite wa# #igni!icantly im"ro%ed wit& little i! any
e(tru#ion o! t&e lower inci#or#7 wit& counter cloc+wi#e
rotation o! t&e occlu#al "lane .
SAS i# an e!!ecti%e ad4uncti%e -iomec&anical
"rocedure !or correction o! #+eletal o"en)-ite
malocclu#ion wit& out un!a%ora-le #ide)e!!ect.
Care Regarding u#e o! a""ro"riate
Care Regarding u#e o! a""ro"riate
!orce #y#tem
!orce #y#tem
.. Lig&t !orce# and "re"aration o! anc&orage may "re%ent
e(tru#ion o! t&e "o#terior teet&.
1. T&e #egmented arc& tec&ni,ue to -e #u"erior in
"re%enting "o#terior dental e(tru#ion during inci#or
intru#ion
2. It i# "re!era-le to include #econd molar# in t&e "o#terior
#egment# to di#tri-ute t&e !orce# o! occlu#ion o%er a
larger area7 t&ere-y counteracting t&e e(tru#i%e !orce#
on t&e -uccal #egment#
Conclu#ion
Conclu#ion
Indeed it i# a daunting and c&allenging 4o- to treat o"en
-ite ca#e# -y now you will agree on t&at "oint I t&in+.
@A t&ing #tarted nicely i# &al! wor+ doneA #o ta+ing t&i#
guideline and "utting meticulou# attention to
-iomec&anic#7 I t&in+ we can %ery #ucce##!ully treat t&e
%ery di!!icult o"en -ite ca#e# .
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Etiologic !actor# Etiologic !actor# related to o"en)-ite mu#t "recede any

6n!a%ora-le growt& 6n!a%ora-le growt& or genetic determinant# genetic determinant# o! a

To control t&e %ertical dimen#ion.

Increa#ed in !orward rotation o! t&e mandi-le.

Signi!icant decrea#e in lower anterior !ace &eig&t.

.B ( 11 SS or .D O15 TMA wit& G?

E(tru#i%e !orce o! .?? gm# !or 3 inci#or#.

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