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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses. For details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
Titre original
Open Bite Sem [Recovered] / orthodontic courses by Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses. For details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses. For details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
www.indiandentalacademy.com O www.indiandentalacademy.com DEFINITIONS CLASSIFICATIONS ETIOLOGY DIAGNOSIS TREATMENT FINISHING & RETENTION www.indiandentalacademy.com INTRODUCTION; Open bite mal occlusion has long held fascination in orthodontics. It is difficult to treat and relapse tendencies are strong. - Young H. Kim AO 1987 www.indiandentalacademy.com
Normal bite: It is defined as vertical overlap of the incisors. The lower incisal edges in relation to the lingual surface of the upper incisors present at or above the cingulam (normally there is 1-2 mm overbite)
DEFINITIONS; www.indiandentalacademy.com OPEN BITE; www.indiandentalacademy.com ANTERIOR OPEN BITE; www.indiandentalacademy.com POSTERIOR OPEN BITE; www.indiandentalacademy.com SIMPLE OPEN BITE; www.indiandentalacademy.com COMPLEX OPEN BITE; www.indiandentalacademy.com COMPOUND OPEN BITE; www.indiandentalacademy.com IATROGENIC OPEN BITE; Open bite as a consequence of orthodontic treatment.
www.indiandentalacademy.com Classificaton; It used to visualize the problem, diagnosis and treatment plan. www.indiandentalacademy.com Classified on developmental; Primary; Mixed; Permanent; Gum pads Temporary Persistent habits www.indiandentalacademy.com Depend on site; Anterior open bite; Posterior open bite; www.indiandentalacademy.com Depend on position; Intra arch The tooth itself is malpositioned within arch creating open bite - infraversion / inclination abnormally without root. www.indiandentalacademy.com Inter arch; -No vertical overlap -abnormality in upper/lower or both - Ant/post segment www.indiandentalacademy.com Ankerman profit; vertical relation Anterior open bite Posterior open bite dental skeletal dental www.indiandentalacademy.com Depend on etiology; Lateral open bite Compound open bite Iatrogenic open bite www.indiandentalacademy.com ETIOLOGY OF OPEN BITE; WHY OPEN BITE ? - ENVIRONMENTAL FACTORS - HABITS - EPIGENETIC FACTORS www.indiandentalacademy.com Pre disposing factors; Skeletal Dental Mandible Excess eruption of posteriors Decreased eruption of anteriors maxilla www.indiandentalacademy.com Various factors influencing open bite; a) Disturbances in embryonic development; 1) Muscle dysfunction 2) Hemi mandibular hypertrophy www.indiandentalacademy.com 1) Muscle dysfunction; - defect in the uterus. - Etiology; - Pathology - affect the particular muscle Bone formation in the origin of muscle Loss of musculature Kiliaridis s, mejersjo c - Ejo 1989 www.indiandentalacademy.com Underdevelopment of face www.indiandentalacademy.com Muscular dystropy. & Muscle weakness syndrome. Muscle tonicity Open bite www.indiandentalacademy.com Mandible drops downwards away from maxilla www.indiandentalacademy.com Anterior open bite due to increased eruption of posterior teeth. www.indiandentalacademy.com 2) Hemi mandibular hypertrophy Bilateral www.indiandentalacademy.com - unilateral www.indiandentalacademy.com b) Genetic influence; - A strong influence of inheritence on facial features is obvious at a glance. - mal occlusion produced by inherited characteristic in 2 ways; What it has to do with open bite ? www.indiandentalacademy.com Long face pattern; King L, Harris EF, Tolley EA - AJO 1993 Long face syndrome; www.indiandentalacademy.com Genetic inheritence Skeletal influence Dental influence Open bite Ackerman, Isacson, Shapiro - AJO 1970 www.indiandentalacademy.com c) Environmental influence; The open bite can be produced by 1) equilibrium forces 2) Functional forces www.indiandentalacademy.com 1) Equilibrium forces; It states that object subject to unequal forces will be accelerated and there by move to different space. Proffit WR; AO 1978 Hence the equilibrium has to be maintained. www.indiandentalacademy.com Altered equilibrium due to increased tonque pressure. www.indiandentalacademy.com a) Juvenile equilibrium; The teeth that are in function parallels the rate of vertical growth of mandibular ramus www.indiandentalacademy.com The rate of eruption is controlled by forces opposing direction, not those promoting it. www.indiandentalacademy.com 2) Functional forces; Biting force and eruption Downward growth of mandible Open bite Masticatory muscle gains strength at puberty. www.indiandentalacademy.com HABITS Definition; It is the tendency towards an act of repeated performance relatively fixed or consistent and ease to perform by an individual. We are just beginning to realize how common and varied the vicious habits of lip and tongue, and how power full and persist to overcome - Angle. www.indiandentalacademy.com Earliest writings; - causes of irregularities through habits that pushes teeth forward. - Lefoulon 1839 - balance of force to retain teeth in position. - Desirabode 1843 - lateral pressure theory - Bridgeman 1859 - Sim Wallace theory - Bennett
www.indiandentalacademy.com Classify; 1) useful harmful Tongue thrusting When persists 2) Pressure Sucking ( lip, thumb) Non pressure Mouth breathing www.indiandentalacademy.com Thumb sucking; Definition; It is defined as the placement of thumb or one/more fingers in varying depths into the mouth. Klein AJO 1979 www.indiandentalacademy.com Physiological condition; -It is considered normal till 3 4 yrs. - It is an non nutritive sucking habit - Recent studies indicate that thumb sucking is practised even during the intra uterine life. www.indiandentalacademy.com Pathological condition; & Clinical features It occurs through altered equilibrium not just pressure through fingers. Open bite www.indiandentalacademy.com Sucking habits; www.indiandentalacademy.com Theories; 1) Freudan theory; 1- 3 years oral and anal phase. 2) Oral drive theory of sears and wise; 1950 Prolonged habit leads to thumbsucking. 3) Benjamins theory; Thumbsucking develops in infants due to the rooting reflex/placing reflex. www.indiandentalacademy.com 4) Psychological aspects; Children develop this habit as a feeling of insecurity, when they are deprived of love, care and affection. www.indiandentalacademy.com Phases of thumbsucking; Phase 1; - First three years of life. - sub clinically significant. Phase - 2; - 3 6 yrs of life. - clinically significant. www.indiandentalacademy.com Phase - 3; - beyond 5 yrs. - intractable sucking. - Its an alert to an dentist. www.indiandentalacademy.com DIAGNOSIS; - Check for childs emotional status. - feeding habits - Intra oral examination; - incissors - open bite - Clean nails www.indiandentalacademy.com TREATMENT; 1) Psychological approach; Beta hypothesis theory by Dunlop Consious purposeful repeatation. 2) Mechanical aids; Basically reminders 3) Chemical approach; www.indiandentalacademy.com TONGUE THRUSTING DEFINITION; It is defined as the forward movement of the tongue tip between the teeth to meet the lower lip in deglutition and in sounds of speech so that the tongue becomes interdental. Tulley AJO 1969 www.indiandentalacademy.com Classification; According to moyers; Simple complex - To establish lip seal - Anterior open bite - abnormal mentalis - Contraction of circum oral muscles. - diffuse open bite. - poor occlusion. www.indiandentalacademy.com Simple tongue thrust. www.indiandentalacademy.com According to James s. Braner and holt Type 1 - Non deforming tongue thrust. Type 2 Deforming anterior tongue thrust. Type 3 Deforming lateral tongue thrust Type 4 Deforming ant; & lat; tongue thrust www.indiandentalacademy.com Etiology ; According to fletcher; 1) Genetic factors; Neuromuscular variations in oro facial region. 2) Learned behaviour; Prolonged action & gum tenderness. 3) maturational; Age swallow pattern. www.indiandentalacademy.com 4) Mechanical restrictions; - macroglossia. - arch constricted. 5) Neurological disturbances; - motor disability 6) Psychogenic factor; - discontinuation of other habits. www.indiandentalacademy.com DIAGNOSIS; - Size of the tongue - posture of the tongue - Function of the tongue - Structure of the tongue www.indiandentalacademy.com 1) Size of the tongue; Why asses the variations ? Variations in tongue size , Reaches its adult size by the age of 8 years. True macroglossia Pseudo macroglossia www.indiandentalacademy.com Macroglossia; The whole oral cavity is filled with the tongue mass, presence of indentations on the periphery. www.indiandentalacademy.com Etiological factors; congenital Acquired - muscular hypertrophy - glandular hyperplasia - lymphangioma - Downs syndrome - Acromegaly - myxedema - amyloidosis - tertiary syphylis Cyst/tumors involving tongue. www.indiandentalacademy.com Pseudo macroglossia; Forward posture of tongue - Low palatal vault www.indiandentalacademy.com Etiological factors; - habitual posturing of the tongue. - hypertropied tonsils and adenoid tissue. - arch deficiency in all dimensions. - severe mandibular deficiency. - cyts/tumors that displaces the tongue www.indiandentalacademy.com Clinical assessment; 1) macroglossia. 2) microglossia. - Tulley AJO 1969. www.indiandentalacademy.com MACROGLOSSIA; Signs and symptoms. - Open bite (ant/post) - Diastema (mx/md) - Accentuated curve of spee in maxillary arch - Reverse curve of spee in mandibular arch. - difficulty in swallowing - mandibular prognathism. - Larry M. WOLFORD, AJO 1996 www.indiandentalacademy.com Cephalometric & Radiographic assessment. - over angulation of upper and lower anteriors. - Dispropotionately excessive mandibular growth. - increased gonial angle. - increased occlusal and mandibular plane angle. - David A. AJO 1996. www.indiandentalacademy.com Cephalometric evaluation; Lateral ceph with sufficient exposure to evaluate the soft tissue. Reference lines; I , V , M , O . www.indiandentalacademy.com Criteria for evaluation; - The greatest possible area of tongue should be above reference line. - The base line is independent of skeletal structures. - The tongue should not change with position of the mandible. www.indiandentalacademy.com Menstrual data through template; www.indiandentalacademy.com Template evaluation; www.indiandentalacademy.com 2) Posture of tongue; The posture is evaluated for various open bite tendencies. It can be flat/arched, protracted/retracted, narrow/long. www.indiandentalacademy.com ANTERIOR POSTURE; www.indiandentalacademy.com LATERAL POSTURE; www.indiandentalacademy.com STRUCTURE OF TONGUE; In infancy the extrinsic suspensory muscles attach the tongue to various osseous structures largely resposible for gross movements in horrizontal plane. - It has the property of elasticity & contractility ----- tongue thrust. Acts through all / none law. www.indiandentalacademy.com FUNCTION OF TONGUE; DEGLUTATION www.indiandentalacademy.com According to moyers; Depend on the characteristic; 1) Infantile swallow ---- 12 - 18 mnths. 2) Mature swallow ----2 - 4 yrs www.indiandentalacademy.com INFANTILE SWALLOW; www.indiandentalacademy.com Central furrow & gum pads. www.indiandentalacademy.com MATURE SWALLLOW; www.indiandentalacademy.com SHALLOW TONGUE; www.indiandentalacademy.com Do tongue thrust cause open bite ? Pressure on teeth by swallow - 1 secs Individual swallow 800/dy - & few in sleep. Total 1000/dy www.indiandentalacademy.com Treatment; - habit breaking appliance. - muscle exercise through elastics. Defect in posture; Defect in size; - Glossectomy.. - surgical correction. www.indiandentalacademy.com Glossectomy; Pseudo macroglossia True macroglossia Procedures; - Midline wedge resection with base in the anterior tongue. - Midline elliptical excision. - Marginal excision. - Keyhole or combined technique. www.indiandentalacademy.com Keyhole technique; Midline elliptical incision Anterior wedge resection - AJO -96 www.indiandentalacademy.com SEQUENCE OF PROCEDURES; STAGE I : GLOSSECTOMY ORTHOGNATHIC SURGERY - Psychological approach. - No IMF - No air way obstruction. www.indiandentalacademy.com STAGE 2 : ORTHOGNATHIC SURGERY. GLOSSECTOMY - If occlusal stability is a concern. www.indiandentalacademy.com STAGE 3 : COMBINED - Both the procedures combined together at a same surgical stage. www.indiandentalacademy.com MOUTH BREATHING; Definition; It is defined as the the pattern of breathing totally / partially through oral cavity due to anatomical / functional variations. www.indiandentalacademy.com Classify; a) Obstructive. b) Habitual. c) Anatomical. www.indiandentalacademy.com ETIOLOGY; Mouth breathing primarily has effect on - posture of jaws. - Position of tongue - posture of head. Altered equilibrium Tooth position Growth www.indiandentalacademy.com Mouth breathing Mandible lowered Tilted head lowered tongue LFH Change of 5 degree cranio vertebral angle Mandible rotated Open bite Obstruction relieved www.indiandentalacademy.com Mandible lowered; Ant; open bite. www.indiandentalacademy.com Change in cranio vertebral angle; www.indiandentalacademy.com Physiological variations; All humans are some mouth breathers. Average breathing air flow ------ 20 25/L/mnt Partial mouth breathing --------- 40 45 L/mnt Transitional stage ----------- 80 - Mintz S, Shepard RJ. www.indiandentalacademy.com Pathological variations; It becomes a habit when the breathing persists even when the obstruction is removed. Opposing principles; Total nasal obstruction Increased LFH Battgel J BJO - 1996 www.indiandentalacademy.com Clinical features; Malocclusion associated with the mouth breathing. Long face syndrome/classical adenoid facies; www.indiandentalacademy.com DIAGNOSIS; - Nasal obstruction. - Adenoids. - hyoid triangle analysis. www.indiandentalacademy.com NASAL OBSTRUCTION - AJO 1998 www.indiandentalacademy.com
Choanal atresia & treacher collins syndrome in infants ----- tracheostomy www.indiandentalacademy.com How much obstruction has to occur for effect on growth ? - It depends on location of the obstruction. - nasal function Anterior Middle portion posterior www.indiandentalacademy.com Methods in assessing the nasal obstruction. - Cross sectional area. - Peak nasal air flow - Nasal resistance. - Respiratory mode (oral/nasal air flow ratio) -AJO 1998 www.indiandentalacademy.com Rhinomanometric studies; Study of air flow with flow meters, and pressure gauges. Cleft lip and palate patients increase tendency of mouth breathing ? - AJO 1998 Posterior nasal obstruction by pharyngeal flaps. www.indiandentalacademy.com ADENOIDS; Enlargement of adenoids relation to mouth breathing. www.indiandentalacademy.com Hyoid bone position; - AJO 1984. In 1981 Bibby and Preston. Hyoid bone is not fixed to a space by any bony articulations. Hyoid bone is determined by muscles and ligaments attached to structures above and below it. www.indiandentalacademy.com - It is influenced by the tongue posture and mandibular position. it signifies www.indiandentalacademy.com TREATMENT; - Removal of the cause. - Interception of the habit. - Rapid maxillary expansion. - orthodontic + surgery www.indiandentalacademy.com Nasal obstruction; - AJO 1998 - vertically repositioning of maxilla predictably reduce the nasal resistance. Not nasal air flow The highest correlation between these parameters are 0.24 %---- 0.74% Breathing mode is behavioral determined than structurally determination www.indiandentalacademy.com Adenoids; - Adenoidectomy. - AJO -94 Ten yr old www.indiandentalacademy.com No change in breathing pattern; www.indiandentalacademy.com Rapid maxillary expansion; For maxillary deficiency Increase nasal air flow Reduction in nasal resistance was frequently measured. Rhinometric studies; No change in breathing mode. www.indiandentalacademy.com DIAGNOSIS; Early detection of symptoms is recommended, so that treatment can be provided in time whatever the cause may be. - Subtenly, AO 1954 - Ricketts, AO 1968 www.indiandentalacademy.com How to decide for open bite ? It is the ability to recognize vertical growth in routine treatment mechanics. Commonly clinicians evaluate Mandibular plane for open bite. www.indiandentalacademy.com DIAGNOSIS; - SKELETAL OPEN BITE - DENTAL OPEN BITE. - ANTERIOR OPEN BITE. - POSTERIOR OPEN BITE. www.indiandentalacademy.com Skeletal open bite; www.indiandentalacademy.com Posterior open bite; - Failure of posterior tooth to erupt fully in occlusion producing lateral open bite. Mechanical interference. Disturbance of eruption mechanism. www.indiandentalacademy.com GROWTH PATTERN ; Its purpose was to assess skeletal factors associated with development of vertical facial disproportions. Horrizontal facial planes tends to be steeper and more divergent with lower facial height. www.indiandentalacademy.com Steeper planes; www.indiandentalacademy.com 1) Mandibular plane; Favoured --- Nanda. Not favoured --- Skiller/Bjork. 2) Gonial angle; 3) Palatal plane; 4) Occlusal plane; 5) Cranial base; Larger cranial base and corresponding positional deviations of mandible associated with open bite.
Enlow - Posterior dips Steeper Angle. Bjork no change www.indiandentalacademy.com CEPHALOMETRIC EVALUATION; There are six specific cephalometric angular measurements for identifying the vertical dysplasia. www.indiandentalacademy.com 1) SN --- (ANS PNS); www.indiandentalacademy.com 2) SN --- MANDIBULAR PLANE; www.indiandentalacademy.com 3) GONIAL ANGLE; Resultant uprighting of the ramus. www.indiandentalacademy.com 4) PALATOMANDIBULAR ANGLE; Bimler used this angle for describing facial types. www.indiandentalacademy.com 5) SN --- OCCLUSAL PLANE; www.indiandentalacademy.com 6) CRANIAL BASE ANGLE; www.indiandentalacademy.com LINEAR PARAMETERS; GROUP 1; PFH/AFH ----- Sum of angle -Jarabak GROUP 2; UFH/LFH Average --- 0.810 Open bite ---0.686 www.indiandentalacademy.com OBJECTIVE OF OPEN BITE; - AO 1998 1) Creating sufficient overlap with molar relation; Incisal overlap 0.5 --- 4.0 mm Average 2.8mm - Kim 1974 www.indiandentalacademy.com Central incisor relative to lip line; www.indiandentalacademy.com The dentition is placed in proper three dimensional perspective to ensure stability. - Antero posterior aspect. - Vertical aspect. - Transverse aspect. www.indiandentalacademy.com Axial inclination; ------ open bite www.indiandentalacademy.com Axial inclination ----- deep bite. www.indiandentalacademy.com Eliminate Blocks: In order to eliminate blocks the molar are distally tipped. Extraction ( 1/2/3) molar Non extraction www.indiandentalacademy.com TREATMENT; It depends on etiology and location - Dento alveolar open bite. - skeletal open bite. TIMING OF TREATMENT; Not too early not too late www.indiandentalacademy.com TREATMENT DURING PRIMARY DENTITION; Dental open bite; - Habits ---- after 3 yrs. Screening therapy. Skeletal open bite; - Habit control secondary. - Growth modification not indicated www.indiandentalacademy.com TREATMENT ON EARLY MIXED DENTITION; Dento alveolar open bite; - Screening therapy - Behavior modification. www.indiandentalacademy.com Screening appliances; Vestibular screen ------------ digit sucking Vestibular screen ------ Its modifications. Tongue crib ------ tongue thrust. Posterior tongue crib -------- lateral tongue thrust Activator ----------- Tongue thrust and finger sucking ( work as a interceptor). www.indiandentalacademy.com BEHAVIOR MODIFICATION; COUNSELLING; A straight forward discussion with the child during eruption of permanent incisors. REWARD; For not engaging in the habit. www.indiandentalacademy.com REMINDER; For the child who wants to quit. www.indiandentalacademy.com QUAD HELIX; Maxillary lingual arch with crib; www.indiandentalacademy.com OPEN BITE IN LATE MIXED DENTITION; Skeletal parameters; - Major diagnostic criteria is either, KEY maxilla mandible or both Palatal plane Ramus www.indiandentalacademy.com GROWTH MODIFICATION; It varies depends on horrizontal/vertical growth; www.indiandentalacademy.com www.indiandentalacademy.com High pull head gear to molars; www.indiandentalacademy.com High pull head gear with maxillary splint; www.indiandentalacademy.com Bite blocks with functional appliance; www.indiandentalacademy.com Head gear with functional appliance and bite blocks; www.indiandentalacademy.com Functional appliance; Head gear with activator www.indiandentalacademy.com Bite registration; www.indiandentalacademy.com TREATMENT IN ADULT; Correction of vertical relation maxilla mandible Vertical excess
anterior posterior excess www.indiandentalacademy.com Maxillary excess; Le Forte I Reduce the nasal septum www.indiandentalacademy.com Anterior open bite; Anterior segment is moved more than posterior www.indiandentalacademy.com Posterior open bite; Segmental osteotomy www.indiandentalacademy.com Mandibular surgery; Surgery in the ramal part is done only to the secondary aspect to the maxillary osteotomy for the auto rotation of the mandible. Advancement genioplasty www.indiandentalacademy.com GENIOPLASTY; Long face pts has excess eruption of lower anterior which is flared and unstable Poor chin balance Bony cut is given upward and forward angulated to advance it. www.indiandentalacademy.com PRE SURGICAL ORTHODONTICS; allignment levelling Antero posterior incisor position www.indiandentalacademy.com LEVELLING; MAY OR MAY NOT BE DONE; - Depend on facial type. Stabilizing arch wire; 18 slot ------- 17 x 25 22 slot ------ 21 x 25 www.indiandentalacademy.com POST SURGICAL ORTHODONTICS; Until stabilizing arch wire is removed the teeth are held in tight position. - four weeks Light vertical elastics www.indiandentalacademy.com RETENTION Removable Appliance with high pull head gear www.indiandentalacademy.com Appliance with the bite block. www.indiandentalacademy.com Force Amplified Retention 1997 JCO Sheridan Low profile lingual caplin hooks Canine to canine intra oral elastics. www.indiandentalacademy.com Conclusion; www.indiandentalacademy.com THANK U www.indiandentalacademy.com